Anaesthetic consideration of a child with concomitant craniovertebral junction anomaly and arrested hydrocephalus

Congenital malformations of various sorts account for a large percentage of childhood hydrocephalus but associated Craniovertebral junction (CVJ) anomaly has not been reported earlier. Though the anaesthetic concerns for isolated arrested hydrocephalus and CVJ anomaly has been reported but the concomitant occurrence of both and its anaesthetic implications is not mentioned in literature. Here we present the anaesthetic management of a child with arrested hydrocephalus along with CVJ anomaly leading to compression of cervicomedullary junction and myelopathy scheduled for decompression and fixation of craniovertebral junction.

The ubiquitin E3 ligase NOSIP modulates protein phosphatase 2A activity in craniofacial development

Holoprosencephaly is a common developmental disorder in humans characterised by incomplete brain hemisphere separation and midface anomalies. The etiology of holoprosencephaly is heterogeneous with environmental and genetic causes, but for a majority of holoprosencephaly cases the genes associated with the pathogenesis could not be identified so far. Here we report the generation of knockout mice for the ubiquitin E3 ligase NOSIP. The loss of NOSIP in mice causes holoprosencephaly and facial anomalies including cleft lip/palate, cyclopia and facial midline clefting. By a mass spectrometry based protein interaction screen we identified NOSIP as a novel interaction partner of protein phosphatase PP2A. NOSIP mediates the monoubiquitination of the PP2A catalytic subunit and the loss of NOSIP results in an increase in PP2A activity in craniofacial tissue in NOSIP knockout mice. We conclude, that NOSIP is a critical modulator of brain and craniofacial development in mice and a candidate gene for holoprosencephaly in humans.

[DEFINITION OF INTERRELATION BETWEEN AMINOACID COMPOSITION OF URINE AND BONE TISSUE DENSITY AT CHILDREN WITH ACUTE LEUKAEMIA FOR ONCOHEMATOLOGICAL PATHOLOGY RISK GROUP FORMATION]

Age and sexual indexies of densitometry at patients with acute leukemia (AL) and healthy children are presented. 31% of children with AL during the initial period of disease had manifestations of the osteopenic syndrome. At patients with AL more often than at healthy children anomalies of development of front part of skull are defined. The partial contribution of free and peptides-connencted oxyproline in urine at AL patients differs in comparison with control group that is caused by modification or deficiency of the corresponding enzymes. 30% of patients with AL had raised concentration of free oxyproline in urine, and lowered glycine concentration that testifies to the increased disintegration of collagen and deficiency of tile plastic material necessary for collagene-forming processes. The obtained data should be considered for forming of risk group on oncohematological pathology at children.

The effect of conditional inactivation of beta 1 integrins using twist 2 Cre, Osterix Cre and osteocalcin Cre lines on skeletal phenotype

Skeletal development and growth are complex processes regulated by multiple microenvironmental cues, including integrin-ECM interactions. The β1 sub-family of integrins is the largest integrin sub-family and constitutes the main integrin binding partners of collagen I, the major ECM component of bone. As complete β1 integrin knockout results in embryonic lethality, studies of β1 integrin function in vivo rely on tissue-specific gene deletions. While multiple in vitro studies indicate that β1 integrins are crucial regulators of osteogenesis and mineralization, in vivo osteoblast-specific perturbations of β1 integrins have resulted in mild and sometimes contradictory skeletal phenotypes. To further investigate the role of β1 integrins on skeletal phenotype, we used the Twist2-Cre, Osterix-Cre and osteocalcin-Cre lines to generate conditional β1 integrin deletions, where Cre is expressed primarily in mesenchymal condensation, pre-osteoblast, and mature osteoblast lineage cells respectively within these lines. Mice with Twist2-specific β1 integrin disruption were smaller, had impaired skeletal development, especially in the craniofacial and vertebral tissues at E19.5, and did not survive beyond birth. Osterix-specific β1 integrin deficiency resulted in viable mice which were normal at birth but displayed early defects in calvarial ossification, incisor eruption and growth as well as femoral bone mineral density, structure, and mechanical properties. Although these defects persisted into adulthood, they became milder with age. Finally, a lack of β1 integrins in mature osteoblasts and osteocytes resulted in minor alterations to femur structure but had no effect on mineral density, biomechanics or fracture healing. Taken together, our data indicate that β1 integrin expression in early mesenchymal condensations play an important role in skeletal ossification, while β1 integrin-ECM interactions in pre-osteoblast, odontoblast- and hypertrophic chondryocyte-lineage cells regulate incisor eruption and perinatal bone formation in both intramembranously and endochondrally formed bones in young, rapidly growing mice. In contrast, the osteocalcin-specific β1 integrin deletion had only minor effects on skeletal phenotype.

A clinical, radiologic, and immunopathologic study of five periorbital intraosseous cavernous vascular malformations

PURPOSE

To correlate the clinical, radiographic, histopathologic, and immunohistochemical features of 5 primary periorbital intraosseous cavernous vascular malformations.

DESIGN

Retrospective interventional case series.

METHODS

Clinical and operative records and radiographic images were reviewed. Histopathologic slides were evaluated with hematoxylin-eosin, trichrome, and elastin stains. Immunohistochemical studies were performed with a spectrum of monoclonal antibodies directed at antigens of vascular cells.

RESULTS

Three men and 2 women ranged in age from 36 to 64 years. Vision was unaffected and there was no proptosis or globe displacement. The slow-growing lesions measured 13-25 mm in greatest diameter (mean 16.4 mm). Computed tomographic studies revealed that 2 lesions were situated in the maxillary bone, 2 in the frontal, and 1 in the zygoma, all anteriorly and with circumscribed, lucent, honeycombed, or sunburst characteristics. Histopathologically the lesions were composed of cavernous or telangiectatic channels; 1 showed advanced fibrotic vascular involution. Immunohistochemistry demonstrated CD31/34 positivity for vascular endothelium and D2-40 negativity for lymphatic endothelium. A typically thin mural myofibroblastic cuff was smooth muscle actin positive, weakly calponin positive, and desmin negative. Glucose transporter-1 and Ki-67 were negative in the endothelium.

CONCLUSIONS

Intraosseous vascular lesions resemble orbital cavernous venous malformations (not true hemangiomas), except that their vascular walls are thinner owing to the constraints imposed by neighboring bone spicules, which limit the amount of interstitium from which mural myofibroblasts can be recruited. The bony trabeculae conferred the honeycomb or sunburst appearances observed radiographically. En bloc excision of these lesions was successful and avoided complications (mean follow-up, 46 months).

Cephalic index in the evaluation of surgical treatment of children with sagittal synostosis. Preliminary report

AIM OF THE STUDY

To analyze changes of the cephalic index (CI) values in patients with sagittal synostosis operated on in the Department of Surgery of Children and Adolescents of the Institute of Mother and Child in Warsaw.

MATERIAL AND METHODS

The study group consisted of 14 consecutive cases (11 boys and 3 girls). In 8 patients younger than 3 months of age (1st subgroup) the modified reversed-pi technique (craniotomy in the shape of the reversed Greek π letter) was utilized. In 6 older infants and in patients with severe head deformity - the radical cranial vault reconstructions were performed (2nd subgroup). The statistical analysis of the preoperative (preop) and postoperative (postop) cephalic index (CI) values was done.

RESULTS

For the entire study group the preop CI values ranged from 61 to 77 (mean 68.14, median 68.5) and postop CIs from 73 to 89 (mean 77.64, median 76). In the 1st subgroup the preop CIs ranged from 63 to 77 (mean 69.625, median 69) whereas the postop CIs from 69 to 89 (mean 78.125, median 76.5). In the 2nd subgroup the preop CI values ranged from 61 to 72 (mean 66.1667, median 66) and postop from 73 to 81 (mean 77, median 77). All the differences were statistically significant.

CONCLUSION

The values of cephalic index increased after both types of procedures. It signifies the correction of dolichocephaly in both subgroups of the patients. However, because of the small number of operated children, further studies are necessary.

[Bicortical reconstruction of a large calvarial bone defect with Hydroset® osteoconductive cement and titanium mesh. A preliminary study]

INTRODUCTION

Bi-cortical calvarial bone loss is a very frequent issue for neurosurgery and craniofacial surgery. Several techniques can be used to reconstruct the skull, with variable difficulty and costs. The purpose of our study was to assess the use of Hydroset® osteoconductive cement for large size bicortical cranioplasties.

MATERIALS AND METHODS

Three patients presented with extensive loss of calvarial bone bi-cortical substance (>25 cm(2)), between 2010 and 2012. The 3 patients underwent cranioplasty with Hydroset® osteoconductive cement and titanium mesh.

RESULTS

The esthetic results were very satisfactory, especially for the skull dome, with a completely invisible and non-palpable cement/native skull junction. Scalp adherence to the cement was natural with maintenance of skin mobility.

DISCUSSION

Bicortical calvarial bone reconstruction with Hydroset® cement is technically easy to perform, gives very good results, with an uneventful outcome, and induces lower costs.

The p38α MAPK function in osteoprecursors is required for bone formation and bone homeostasis in adult mice

BACKGROUND

p38 MAPK activity plays an important role in several steps of the osteoblast lineage progression through activation of osteoblast-specific transcription factors and it is also essential for the acquisition of the osteoblast phenotype in early development. Although reports indicate p38 signalling plays a role in early skeletal development, its specific contributions to adult bone remodelling are still to be clarified.

METHODOLOGY/PRINCIPAL FINDINGS

We evaluated osteoblast-specific deletion of p38α to determine its significance in early skeletogenesis, as well as for bone homeostasis in adult skeleton. Early p38α deletion resulted in defective intramembranous and endochondral ossification in both calvaria and long bones. Mutant mice showed reduction of trabecular bone volume in distal femurs, associated with low trabecular thickness. In addition, knockout mice also displayed decreased femoral cortical bone volume and thickness. Deletion of p38α did not affect osteoclast function. Yet it impaired osteoblastogenesis and osteoblast maturation and activity through decreased expression of osteoblast-specific transcription factors and their targets. Furthermore, the inducible Cre system allowed us to control the onset of p38α disruption after birth by removal of doxycycline. Deletion of p38α at three or eight weeks postnatally led to significantly lower trabecular and cortical bone volume after 6 or 12 months.

CONCLUSIONS

Our data demonstrates that, in addition to early skeletogenesis, p38α is essential for osteoblasts to maintain their function in mineralized adult bone, as bone anabolism should be sustained throughout life. Moreover, our data also emphasizes that clinical development of p38 inhibitors should take into account their potential bone effects.

Comparative study of chitosan/fibroin-hydroxyapatite and collagen membranes for guided bone regeneration in rat calvarial defects: micro-computed tomography analysis

This study aimed to utilize micro-computed tomography (micro-CT) analysis to compare new bone formation in rat calvarial defects using chitosan/fibroin-hydroxyapatite (CFB-HAP) or collagen (Bio-Gide) membranes. Fifty-four (54) rats were studied. A circular bony defect (8 mm diameter) was formed in the centre of the calvaria using a trephine bur. The CFB-HAP membrane was prepared by thermally induced phase separation. In the experimental group (n=18), the CFB-HAP membrane was used to cover the bony defect, and in the control group (n=18), a resorbable collagen membrane (Bio-Gide) was used. In the negative control group (n=18), no membrane was used. In each group, six animals were euthanized at 2, 4 and 8 weeks after surgery. The specimens were then analysed using micro-CT. There were significant differences in bone volume (BV) and bone mineral density (BMD) (P<0.05) between the negative control group and the membrane groups. However, there were no significant differences between the CFB-HAP group and the collagen group. We concluded that the CFB-HAP membrane has significant potential as a guided bone regeneration (GBR) membrane.

Three intragenic suppressors of a GTPase-deficient allele of GNAS associated with McCune-Albright syndrome

Gain-of-function mutations in heterotrimeric G-protein α subunits are associated with a variety of human diseases. McCune-Albright syndrome (MAS) is caused by mutations in GNAS, the gene encoding Gs. Alterations at Arg201 significantly reduce the GTPase activity of the protein, rendering it constitutively active. In this study, we have constructed a library of random mutations in a constitutively active yeast GPA1 gene carrying a mutation homologous to the McCune-Albright allele (Arg297His). Intragenic suppressors found at sites with homology to the human Gs protein were tested for their ability to suppress the constitutive activity of an Arg201His mutation in Gs. Three intragenic suppressors, at Phe142, Arg231, and Leu266, were able to suppress elevated basal cAMP responses caused by Arg201His when expressed in HEK293 cells. A range of amino acid substitutions was introduced at each of these sites to investigate the chemical requirements for intragenic suppression. The ability of Gs proteins carrying the suppressor mutations alone to mediate receptor-induced cAMP production was measured. These results offer potential sites on Gs that could serve as drug targets for MAS therapies.

Pycnodysostosis: review and case report

AIM

Aim of the present study was to present a case report of a patient suffering from pycnodysostosis and assess how it may manifest and affect the dental/ orthodontic treatment.

METHODS

An 11-year-old patient who was diagnosed with pycnodysostosis at the age of 18 months, attended the orthodontics department requiring treatment for extensive carious lesions, periodontal disease and severe crowding.

RESULTS

After an accurate radiographic, clinical and orthodontic assessment of the patient taking into consideration the severity of the condition and the patient's necessities, we have formulated a treatment plan, which was accepted by both the patient and parents. We took into consideration the risks and benefits of the options available and the requests of the patient.

CONCLUSION

We have decided to opt for the extraction of teeth to relieve the crowding as this was impeding good oral hygiene and hence increasing the risk of caries and periodontal disease. Such patients must be placed under an oral hygiene prevention scheme, a treatment plan must be accurately designed and the patient must be constantly motivated.

[Effectiveness of digital three-dimensional titanium mesh in repairing skull defect under temporalis and reconstructing temporal muscle attachment points]

OBJECTIVE

To investigate the technique and the effectiveness of digital three-dimensional (3-D) titanium mesh in repairing skull defect under the temporalis and reconstructing temporal muscle attachment points.

METHODS

Between January 2009 and December 2012, 58 patients with skull defect after decompressive craniectomy at the frontal temporal region were treated. Of 58 patients, 33 were male and 25 were female, aged 17-62 years (mean, 36.2 years). The disease duration was 15 weeks to 25 months (mean, 5.8 months). The size of skull defect ranged from 8 cm x 6 cm to 15 cm x 12 cm. The patients underwent skull impairment patch surgery with digital 3-D titanium mesh and reconstruction of the temporal muscle attachment points at titanium mesh temporal corresponding position.

RESULTS

The operation time was 60-100 minutes (mean, 87 minutes). After operation, 2 cases had slight red swelling with little exudation at skin incision margin, which was cured after symptomatic treatment; 2 cases had symptom of headache, which disappeared after incision healing; primary healing of incision was obtained in the other patients. Fifty-eight patients were followed up 6-24 months (mean, 16 months). The patients were satisfied with shaping, and had no chewing pain. Head CT after operation showed good fixation of titanium mesh and titanium nail, and satisfactory skull shape symmetry; no postoperative complication of subcutaneous effusion, intracranial bleeding, titanium mesh loosening, or titanium mesh exposure occurred.

CONCLUSION

The surgery technique of digital 3-D titanium mesh to repair skull defect in frontal temporal region and to reconstruct temporal muscle attachment points at the corresponding position of titanium mesh, basically can obtain anatomical reduction of the skull, frontal temporal, and each layer of scalp. It has the advantages of less complication, less titanium nail, and satisfactory shape.

Impact of introduction of mid-trimester scan on pregnancy outcome of open spina bifida in The Netherlands

OBJECTIVE

To examine the impact of introduction of the mid-trimester scan on pregnancy outcome in cases of open spina bifida in two regions of The Netherlands.

METHODS

This was a retrospective cohort study of 190 cases of open spina bifida diagnosed pre- or postnatally, with an estimated date of delivery between 2003 and 2011.

RESULTS

With implementation of the mid-trimester scan the percentage of cases of open spina bifida detected before the 24(th) week of pregnancy increased from 43% to 88%. The rise in prenatal detection rate was associated with a significant increase in the number of terminated pregnancies and a decrease in the rate of perinatal loss; the percentage of children born alive did not change significantly. In the subgroup that underwent a scan between 18 and 24 weeks of pregnancy, cranial signs were present in 94.4% of cases.

CONCLUSION

Introduction of the mid-trimester scan has led to an increase in early identification of pregnancies complicated by open spina bifida. Pregnancies previously destined to end in perinatal loss are now terminated whilst pregnancies with a relatively good prognosis are frequently continued; the number of children with open spina bifida who are born alive has not changed significantly. Our study confirms that prenatal diagnosis is usually triggered by visualization of a lemon-shaped skull or a banana-shaped cerebellum.

Helmet therapy in infants with positional skull deformation: randomised controlled trial

OBJECTIVE

To determine the effectiveness of helmet therapy for positional skull deformation compared with the natural course of the condition in infants aged 5-6 months.

DESIGN

Pragmatic, single blinded, randomised controlled trial (HEADS, HElmet therapy Assessment in Deformed Skulls) nested in a prospective cohort study.

SETTING

29 paediatric physiotherapy practices; helmet therapy was administered at four specialised centres.

PARTICIPANTS

84 infants aged 5 to 6 months with moderate to severe skull deformation, who were born after 36 weeks of gestation and had no muscular torticollis, craniosynostosis, or dysmorphic features. Participants were randomly assigned to helmet therapy (n=42) or to natural course of the condition (n=42) according to a randomisation plan with blocks of eight.

INTERVENTIONS

Six months of helmet therapy compared with the natural course of skull deformation. In both trial arms parents were asked to avoid any (additional) treatment for the skull deformation.

MAIN OUTCOME MEASURES

The primary outcome was change in skull shape from baseline to 24 months of age assessed using plagiocephalometry (anthropometric measurement instrument). Change scores for plagiocephaly (oblique diameter difference index) and brachycephaly (cranioproportional index) were each included in an analysis of covariance, using baseline values as the covariate. Secondary outcomes were ear deviation, facial asymmetry, occipital lift, and motor development in the infant, quality of life (infant and parent measures), and parental satisfaction and anxiety. Baseline measurements were performed in infants aged between 5 and 6 months, with follow-up measurements at 8, 12, and 24 months. Primary outcome assessment at 24 months was blinded.

RESULTS

The change score for both plagiocephaly and brachycephaly was equal between the helmet therapy and natural course groups, with a mean difference of -0.2 (95% confidence interval -1.6 to 1.2, P=0.80) and 0.2 (-1.7 to 2.2, P=0.81), respectively. Full recovery was achieved in 10 of 39 (26%) participants in the helmet therapy group and 9 of 40 (23%) participants in the natural course group (odds ratio 1.2, 95% confidence interval 0.4 to 3.3, P=0.74). All parents reported one or more side effects.

CONCLUSIONS

Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18473161.

Quantitative trait loci (QTL) study identifies novel genomic regions associated to Chiari-like malformation in Griffon Bruxellois dogs

Chiari-like malformation (CM) is a developmental abnormality of the craniocervical junction that is common in the Griffon Bruxellois (GB) breed with an estimated prevalence of 65%. This disease is characterized by overcrowding of the neural parenchyma at the craniocervical junction and disturbance of cerebrospinal fluid (CSF) flow. The most common clinical sign is pain either as a direct consequence of CM or neuropathic pain as a consequence of secondary syringomyelia. The etiology of CM remains unknown but genetic factors play an important role. To investigate the genetic complexity of the disease, a quantitative trait locus (QTL) approach was adopted. A total of 14 quantitative skull and atlas measurements were taken and were tested for association to CM. Six traits were found to be associated to CM and were subjected to a whole-genome association study using the Illumina canine high density bead chip in 74 GB dogs (50 affected and 24 controls). Linear and mixed regression analyses identified associated single nucleotide polymorphisms (SNPs) on 5 Canis Familiaris Autosomes (CFAs): CFA2, CFA9, CFA12, CFA14 and CFA24. A reconstructed haplotype of 0.53 Mb on CFA2 strongly associated to the height of the cranial fossa (diameter F) and an haplotype of 2.5 Mb on CFA14 associated to both the height of the rostral part of the caudal cranial fossa (AE) and the height of the brain (FG) were significantly associated to CM after 10 000 permutations strengthening their candidacy for this disease (P = 0.0421, P = 0.0094 respectively). The CFA2 QTL harbours the Sall-1 gene which is an excellent candidate since its orthologue in humans is mutated in Townes-Brocks syndrome which has previously been associated to Chiari malformation I. Our study demonstrates the implication of multiple traits in the etiology of CM and has successfully identified two new QTL associated to CM and a potential candidate gene.

Comparative skull analysis suggests species-specific captivity-related malformation in lions (Panthera leo)

Lion (Panthera leo) populations have dramatically decreased worldwide with a surviving population estimated at 32,000 across the African savannah. Lions have been kept in captivity for centuries and, although they reproduce well, high rates of stillbirths as well as morbidity and mortality of neonate and young lions are reported. Many of these cases are associated with bone malformations, including foramen magnum (FM) stenosis and thickened tentorium cerebelli. The precise causes of these malformations and whether they are unique to captive lions remain unclear. To test whether captivity is associated with FM stenosis, we evaluated 575 lion skulls of wild (N = 512) and captive (N = 63) origin. Tiger skulls (N = 276; 56 captive, 220 wild) were measured for comparison. While no differences were found between males and females or between subadults and adults in FM height (FMH), FMH of captive lions (17.36±3.20 mm) was significantly smaller and with greater variability when compared to that in wild lions (19.77±2.11 mm). There was no difference between wild (18.47±1.26 mm) and captive (18.56±1.64 mm) tigers in FMH. Birth origin (wild vs. captive) as a factor for FMH remained significant in lions even after controlling for age and sex. Whereas only 20/473 wild lions (4.2%) had FMH equal to or smaller than the 5^th percentile of the wild population (16.60 mm), this was evident in 40.4% (23/57) of captive lion skulls. Similar comparison for tigers found no differences between the captive and wild populations. Lions with FMH equal to or smaller than the 5^th percentile had wider skulls with smaller cranial volume. Cranial volume remained smaller in both male and female captive lions when controlled for skull size. These findings suggest species- and captivity-related predisposition for the pathology in lions.

Craniofacial fibrous dysplasia--a Morbid presentation

Fibrous dysplasia is grouped under fibro-osseous lesions with developmental anomaly of bone forming mesenchyme that manifests as a defect in osteoblastic differentiation and maturation. This paper describes a case of 28 yrs old female who presented with swelling on right side of face, nostril and intraoral swelling on right half of hard palate since 1-year. The diagnosis was based on clinico-radiological and histopathological investigations. The appropriate management of patient included surgical modality along with placement of obturator to fill the defect. Follow up was done and till date there is no recurrence.

Quantification of skull deformity for craniofacial research

Craniosynostosis, a disorder in which one or more fibrous joints of the skull fuse prematurely, causes skull malformation and may be associated with increased intracranial pressure and developmental delays. In order to perform medical research studies that relate phenotypic abnormalities to outcomes such as cognitive ability or results of surgery, biomedical researchers need an automated methodology for quantifying the degree of abnormality of the disorder. This paper addresses that need by proposing a set of features derived from CT scans of the skull that can be used for this purpose. A thorough set of experiments is used to evaluate the features as compared to two human craniofacial experts in a ranking evaluation.

Craniofacial morphology in patients with Angle Class II division 2 malocclusion

Cephalometric analysis is frequently used in orthodontics for diagnostic purposes, in order to evaluate the positional relationship of the upper and lower jaw to the cranial base, as well as to objectively asses the way dental arches relate to one another and to the skeletal base. As with other dento-skeletal anomalies, the normal growth process can induce changes in these parameters. The purpose of this study is to evaluate the skeletal and dental changes that occur in growing patients with Angle Class II division 2 malocclusion. The study also focuses on analyzing and comparing several parameters in three groups of young patients of different ages, diagnosed with Class II division 2 malocclusion, in order to determine whether the anomaly worsens or improves during the patients' growth period. A total of 25 lateral skull teleradiographs were analyzed using cephX. The patients were divided into three groups (Group 1: 6-8 years, Group 2: 9-14 years, Group 3: 15-18 years). We used the cephalometric parameters described in Björk-Jarabak and Tweed analyses, as well as the relationship of the upper and lower central incisors to the skeletal landmarks. The statistical methods used in this study were the analysis of variance (ANOVA) and the unpaired Student's t-test (p<0.05). We concluded that, during the physiological growth process, the Angle Class II division 2 malocclusion has the following cephalometric characteristics: the maxillary central incisors were in accentuated retroclination, the interincisal angle was very obtuse, the gonial angle showed lower than normal values towards the end of the growth period, the lower anterior face height was definitely decreased, the mandibular body length was shorter than normal in the early growth period and the tendency towards a hypodivergent skeletal pattern remained stable during growth.

Trigonocephaly: Lille's surgical technique

From the early beginning, in 1977, of our experience in the treatment of trigonocephaly and with the follow-up of 263 patients, we have been convinced that it was a condition related to the skull base. It is now proved thank to the comparison between patient's CT scan and normal template (normal skull of the same age) in vestibular orientation. We used to correct this condition by a frontal reshaping and a rotation of the superior and lateral orbital rim along an oblique axis. We call that movement: "valgisation."