Craniofacial polyostotic fibrous dysplasia: A rare case

Craniofacial fibrous dysplasia (FD) is one of three types of FD which can affect the craniofacial complex. It is the proliferation of cellular fibrous connective tissue intermixed with irregular bony trabecules. It is a developmental tumor-like condition that is characterized by replacement of normal bone. The purpose of this report is to present a rare case of craniofacial polyostotic FD that led to vision loss in the same affected side.

Modulation of estrogen causes disruption of craniofacial chondrogenesis in Danio rerio

Estrogen is a steroid hormone that is ubiquitous in vertebrates, but its role in cartilage formation has not been extensively studied. Abnormalities of craniofacial cartilage and bone account for a large portion of birth defects in the United States. Zebrafish (Danio rerio) have been used as models of human disease, and their transparency in the embryonic period affords additional advantages in studying craniofacial development. In this study, zebrafish embryos were treated with 17-β estradiol (E2) or with an aromatase inhibitor and observed for defects in craniofacial cartilage. Concentrations of E2 greater than 2μM caused major disruptions in cartilage formation. Concentrations below 2μM caused subtle changed in cartilage morphology that were only revealed by measurement. The angles formed by cartilage elements in fish treated with 1.5 and 2μM E2 were increasingly wide, while the length of the primary anterior-posterior cartilage element in these fish decreased significantly from controls. These treatments resulted in fish with shorter, flatter faces as estrogen concentration increased. Inhibition of aromatase activity also resulted in similar craniofacial disruption indicating that careful control of estrogen signaling is required for appropriate development. Further investigation of the phenomena described in this study could lead to a better understanding of the etiology of craniofacial birth defects and endocrine disruption of cartilage formation.

A ciliopathy with hydrocephalus, isolated craniosynostosis, hypertelorism, and clefting caused by deletion of Kif3a

Malformations of the facial midline are a consistent feature among individuals with defects in primary cilia. Here, we provide a framework in which to consider how these primary cilia-dependent facial anomalies occur. We generated mice in which the intraflagellar transport protein Kif3a was deleted in cranial neural crest cells. The Kif3a phenotypes included isolated metopic craniosynostosis, delayed closure of the anterior fontanelles, and hydrocephalus, as well as midline facial anomalies including hypertelorism, cleft palate, and bifid nasal septum. Although all cranial neural crest cells had truncated primary cilia as a result of the conditional deletion, only those in the midline showed evidence of hyper-proliferation and ectopic Wnt responsiveness. Thus, cranial neural crest cells do not rely on primary cilia for their migration but once established in the facial prominences, midline cranial neural crest cells require Kif3a function in order to integrate and respond to Wnt signals from the surrounding epithelia.

Treacher Collins Syndrome: the genetics of a craniofacial disease

OBJECTIVES

The molecular underpinnings of Treacher Collins Syndrome (TCS) are diverse. This article codifies the most recent findings in this complex area of research to further current understanding of the disease process. Elucidating the genetic causes of the disorder can be useful in earlier detection and better treatment planning.

DESIGN

Articles from 1991 to 2013 were selected and reviewed by five researchers utilizing the most recent literature of the genetics and pathophysiology of TCS.

RESULTS

Mutations in TCOF1, POLR1C and POLR1D have all been implicated in causing TCS. The association of the TCOF1 gene product, Treacle, and gene products of POLR1C and POLR1D with ribosome biosynthesis suggests that a loss of function mutation in these genes disrupts ribosome biosynthesis in constituent neural crest cells and neuroepithelium leading to apoptosis. However, recent data illustrating that P53 heterozygosity is protective against TCS, and that P53 and TCOF1 hemizygous embryos do not affect ribosomal function, implicates P53 or elements downstream of P53 as playing a role in TCS pathogenesis.

CONCLUSION

Our study codified nascent findings of the molecular determinants of TCS. These findings add to a burgeoning database of TCS-associated mutations, and as such, can be used to establish TCS diagnosis and further clarify TCS pathogenesis.

Connectivity of vertebrate genomes: Paired-related homeobox (Prrx) genes in spotted gar, basal teleosts, and tetrapods

Teleost fish are important models for human biology, health, and disease. Because genome duplication in a teleost ancestor (TGD) impacts the evolution of teleost genome structure and gene repertoires, we must discriminate gene functions that are shared and ancestral from those that are lineage-specific in teleosts or tetrapods to accurately apply inferences from teleost disease models to human health. Generalizations must account both for the TGD and for divergent evolution between teleosts and tetrapods after the likely two rounds of genome duplication shared by all vertebrates. Progress in sequencing techniques provides new opportunities to generate genomic and transcriptomic information from a broad range of phylogenetically informative taxa that facilitate detailed understanding of gene family and gene function evolution. We illustrate here the use of new sequence resources from spotted gar (Lepisosteus oculatus), a rayfin fish that diverged from teleosts before the TGD, as well as RNA-Seq data from gar and multiple teleost lineages to reconstruct the evolution of the Paired-related homeobox (Prrx) transcription factor gene family, which is involved in the development of mesoderm and neural crest-derived mesenchyme. We show that for Prrx genes, the spotted gar genome and gene expression patterns mimic mammals better than teleosts do. Analyses force the seemingly paradoxical conclusion that regulatory mechanisms for the limb expression domains of Prrx genes existed before the evolution of paired appendages. Detailed evolutionary analyses like those reported here are required to identify fish species most similar to the human genome to optimally connect fish models to human gene functions in health and disease.

Retinoic acid induced-1 (Rai1) regulates craniofacial and brain development in Xenopus

Retinoic acid induced-1 (RAI1) is an important yet understudied histone code reader that when mutated in humans results in Smith-Magenis syndrome (SMS), a neurobehavioral disorder accompanied by signature craniofacial abnormalities. Despite previous studies in mouse and human cell models, very little is known about the function of RAI1 during embryonic development. In the present study, we have turned to the model vertebrates Xenopus laevis and Xenopus tropicalis to better understand the developmental roles of Rai1. First we demonstrate that the Rai1 protein sequence is conserved in frogs, especially in known functional domains. By in situ hybridization we revealed expression of rai1 in the developing craniofacial tissues and the nervous system. Knockdown of Rai1 using antisense morpholinos resulted in defects in the developing brain and face. In particular, Rai1 morphants display midface hypoplasia and malformed mouth shape analogous to defects in humans with SMS. These craniofacial defects were accompanied with aberrant neural crest migration and reduction in the size of facial cartilage elements. Rai1 morphants also had defects in axon patterns and decreased forebrain ventricle size. Such brain defects correlated with a decrease in the neurotrophic factor, bdnf, and increased forebrain apoptosis. Our results emphasize a critical role of Rai1 for normal neural and craniofacial development, and further the current understanding of potential mechanisms that cause SMS.

[Nasal dermal sinus in children: a review based on a series of 6 cases]

INTRODUCTION

Nasal dermal sinus in children (NDSC) is a rare malformation (1/20,000 to 1/40,000). Apart from local infection, they present as median nasal lump or pit on the dorsum and their diagnosis and treatment are often delayed. Consequences of untreated NDSC are: local infection, meningitis, and empyema, due to their frequent intracranial extension.

PATIENTS AND METHODS

Six cases of NDSC were retrospectively reviewed (5 boys and one girl), all treated between 2006 and 2012 in our institution (Nancy University Hospital). All patients underwent a brain and facial CT-scan and MR imaging to check any bony lesions, skull base extension by foramen cæcum, course of the sinus and the possible associated brain malformations. Evolution, treatment and follow-up (FU) were conducted by the same multidisciplinary team (neurosurgeon, ENT surgeon, and plastic surgeon). Children were operated on by a conjoined approach (cranial and facial) for removal of the sinus and its intracranial extension.

RESULTS

Mean age at diagnosis was 12 months (birth-36 months). Initial presentation consisted of three local infections, one dorsum nasal lump, one CSF leakage, and one asymptomatic child. Five children presented with a skull base extension. There were no associated brain malformations. We observed only one surgical complication (bleeding from the anterior part of the superior sagittal sinus during dissection) leading to blood transfusion. Pathology results confirmed three dermoid cysts, one epidermoid cyst, one cyst with granulation tissue, and negative in one case. Average FU was 30.8 months (4-84 months). Two recurrences (same child) occurred, leading to two re-operations. There were no recurrences or complications at the end of FU.

CONCLUSION

NDSC are rare malformations, mostly diagnosed before the age of three years, due to an infectious complication. The aim of the treatment is complete removal to avoid recurrence, and a multidisciplinary strategy is required.

Craniofacial characteristics of successful responders to mandibular advancement splint therapy: a pilot study

Cephalometric variables that can be used to identify patients with obstructive sleep apnoea who are suitable for mandibular advancement splints and surgical maxillomandibular advancement are lacking. The aim of this pilot study was to describe the craniofacial characteristics of patients whose symptoms of obstructive sleep apnoea were successfully treated with mandibular advancement splints and who were subsequently considered for maxillomandibular advancement. We retrospectively compared the craniofacial characteristics of our patients with data from 2 previously published studies. There were significant differences between the 2 groups for ANB (p<0.000), overjet (p<0.0001), Go-Me (p<0.0002), and ANS-PNS (p<0.0009). Patients, whose symptoms improve with the use of mandibular advancement splints and are potential candidates for maxillomandibular advancement, may have unique craniofacial features consisting of bimaxillary retrusion characterised by a shorter maxilla and mandible, and a greater class II skeletal tendency. The results of this study should be viewed as a pilot. Further research is required.

Sclerosing bone dysplasias with involvement of the craniofacial skeleton

In this review we provide a complete overview of the existing sclerosing bone dysplasias with craniofacial involvement. Clinical presentation, disease course, the craniofacial symptoms, genetic transmission pattern and pathophysiology are discussed. There is an emphasis on radiologic features with a large collection of CT and MRI images. In previous reviews the craniofacial area of the sclerosing bone dysplasias was underexposed. However, craniofacial symptoms are often the first symptoms to address a physician. The embryology of the skull and skull base is explained and illustrated for a better understanding of the affected areas.

Osteomas of the craniofacial region: A case series and review of literature

Objective:

To discuss the clinical presentation, diagnosis and management of osteomas involving the craniomaxillofacial region.

Materials and Methods:

This study was conducted from June 2004 to March 2012 at our institute. A total of 12 cases between the ages of 10 and 50 years were managed with surgical excision and reconstruction. The criteria used to diagnose osteoma included radiographic and clinical features and histological confirmation of the specimen. The total follow-up period ranged from 6 to 24 months.

Results:

Out of 12 osteomas, 10 were peripheral and 2 were centrally located. Mandible involvement was seen in six patients, four involved the orbit, one the frontal bone and one the frontal bone with the skull base. All patients undergoing excision and reconstruction had a favourable aesthetic and functional outcome. There were no recurrences and no post-operative complications.

Conclusion:

Osteomas affect all age groups with no sex predilection and are usually clinically asymptomatic till they become large in size. Surgical excision and appropriate reconstruction is the mainstay of management. Surgery is indicated when lesion is symptomatic or actively growing and the surgical approach for exposure of the lesion should be case specific.

Soft tissue engineering in craniomaxillofacial surgery

Craniofacial soft tissue reconstruction may be required following trauma, tumor resection, and to repair congenital deformities. Recent advances in the field of tissue engineering have significantly widened the reconstructive armamentarium of the surgeon. The successful identification and combination of tissue engineering, scaffold, progenitor cells, and physiologic signaling molecules has enabled the surgeon to design, recreate the missing tissue in its near natural form. This has resolved the issues like graft rejection, wound dehiscence, or poor vascularity. Successfully reconstructed tissue through soft tissue engineering protocols would help surgeon to restore the form and function of the lost tissue in its originality. This manuscript intends to provide a glimpse of the basic principle of tissue engineering, contemporary, and future direction of this field as applied to craniofacial surgery.

Pattern, severity, and management of cranio-maxillofacial soft-tissue injuries in Port Harcourt, Nigeria

Background:

The pattern of craniofacial soft-tissue injuries occurring either in isolation or in association with fractures vary in different societies and is multiply influenced. The effects are enormous because of the prominence of the face; therefore, the purpose of this study was to document any changing pattern, severity and management of these craniofacial injuries in our center.

Patients and Method:

Cranio-maxillofacial region was classified into upper, middle and lower face. The cause, type, and site of the injuries were documented. Gunshot injuries were further categorized as penetrating, perforating or avulsions. Further, classification of injuries into mild, moderate, and severe was carried out based on multiple factors.

Result:

A total of 126 patients with soft-tissue injuries presented to our hospital out of which 85 (67.5%) were males and 41 (32.5) were females. The age range of the patients was between 10 months and 90 years with a mean ± SD of 26.4 ± 15.5 years. Road traffic accident was the most common etiology of which vehicular accidents constituted 50 (54.9%) and the motorcycle was 2 (2.2%). Assault contributed 16 (17.6%) while cases due to gun shots were 13 (14.3%). A total of 19 (15.1%) patients had associated head injuries, 11 (8.7%) patients had craniofacial fractures involving any of the bones while 3 (2.4%) patients had limb fractures and 2 (1.6%) patients had rib fractures. There were 51 (41.8%) cases classified as mild injuries, 37 (30.3%) cases as moderate injuries and 24 (19.7%) cases as severe injuries. Total of 126 cases managed, 121 (96.0%) received primary closure of the wounds while 5 (4.0%) received delayed closure under general anesthesia.

Cochleovestibular nerve development is integrated with migratory neural crest cells

The cochleovestibular (CV) nerve, which connects the inner ear to the brain, is the nerve that enables the senses of hearing and balance. The aim of this study was to document the morphological development of the mouse CV nerve with respect to the two embryonic cells types that produce it, specifically, the otic vesicle-derived progenitors that give rise to neurons, and the neural crest cell (NCC) progenitors that give rise to glia. Otic tissues of mouse embryos carrying NCC lineage reporter transgenes were whole mount immunostained to identify neurons and NCC. Serial optical sections were collected by confocal microscopy and were compiled to render the three dimensional (3D) structure of the developing CV nerve. Spatial organization of the NCC and developing neurons suggest that neuronal and glial populations of the CV nerve develop in tandem from early stages of nerve formation. NCC form a sheath surrounding the CV ganglia and central axons. NCC are also closely associated with neurites projecting peripherally during formation of the vestibular and cochlear nerves. Physical ablation of NCC in chick embryos demonstrates that survival or regeneration of even a few individual NCC from ectopic positions in the hindbrain results in central projection of axons precisely following ectopic pathways made by regenerating NCC.

A screen of zebrafish mutants identifies ethanol-sensitive genetic loci

BACKGROUND

Fetal alcohol spectrum disorders (FASD) are a highly variable set of phenotypes caused by fetal alcohol exposure. Numerous factors influence FASD phenotypes, including genetics. The zebrafish is a powerful vertebrate model system with which to identify these genetic factors. Many zebrafish mutants are housed at the Zebrafish International Resource Center (ZIRC). These mutants are readily accessible and an excellent source to screen for ethanol (EtOH)-sensitive developmental structural mutants.

METHODS

We screened mutants obtained from ZIRC for sensitivity to EtOH teratogenesis. Embryos were treated with 1% EtOH (41 mM tissue levels) from 6 hours postfertilization onward. Levels of apoptosis were evaluated at 24 hours postfertilization. At 4 days postfertilization, the craniofacial skeleton, peripheral axon projections, and sensory neurons of neuromasts were examined. Fish were genotyped to determine whether there were phenotype/genotype correlations.

RESULTS

Five of 20 loci interacted with EtOH. Notable among these was that vangl2, involved in convergent extension movements of the embryonic axis, interacted strongly with EtOH. Untreated vangl2 mutants had normal craniofacial morphology, while severe midfacial defects including synophthalmia and narrowing of the palatal skeleton were found in all EtOH-treated mutants and a low percentage of heterozygotes. The cell cycle gene, plk1, also interacted strongly with EtOH. Untreated mutants have slightly elevated levels of apoptosis and loss of ventral craniofacial elements. Exposure to EtOH results in extensive apoptosis along with loss of neural tissue and the entire craniofacial skeleton. Phenotypes of hinfp, mars, and foxi1 mutants were also exacerbated by EtOH.

CONCLUSIONS

Our results provide insight into the gene-EtOH interactions that may underlie EtOH teratogenesis. They support previous findings that EtOH disrupts elongation of the embryonic axis. Importantly, these results show that the zebrafish is an efficient model with which to test for gene-EtOH interactions. Understanding these interactions will be crucial to understanding of the FASD variation.

Holoprosencephaly with multiple anomalies of the craniofacial bones-an autopsy report

Holoprosencephaly (HPE), a disorder which results from a failure of cleavage or the incomplete differentiation of the forebrain structures at various levels or to various degrees, is related to hereditary factors, chromosomal anomalies, cytogenetic abnormalities, and environmental teratogenic factors. We are reporting a case of a multiparous woman who was G3,P3,L2, who delivered a full term foetus with holoprosencephaly and multiple craniofacial anomalies. An autopsy was conducted. Multiple anomalies of the craniofacial bones, which include hypoplasia and synostosis of the frontal bone, anophthalmia, absence of the anterior cranial fossa, hypoplasia of the maxillae, an absent antrum, cleft palate, a central hare lip and arrhinia which includes absence of the nostrils and hypotelorism of the eye placodes, were noted. This case is being reported for its rarity and the available literature was reviewed in this respect.

Combined function of HoxA and HoxB clusters in neural crest cells

The evolution of chordates was accompanied by critical anatomical innovations in craniofacial development, along with the emergence of neural crest cells. The potential of these cells to implement a craniofacial program in part depends upon the (non-)expression of Hox genes. For instance, the development of jaws requires the inhibition of Hox genes function in the first pharyngeal arch. In contrast, Hox gene products induce craniofacial structures in more caudal territories. To further investigate which Hox gene clusters are involved in this latter role, we generated HoxA;HoxB cluster double mutant animals in cranial neural crest cells. We observed the appearance of a supernumerary dentary-like bone with an endochondral ossification around a neo-Meckel's cartilage matrix and an attachment of neo-muscle demonstrating that HoxB genes enhance the phenotype induced by the deletion of the HoxA cluster alone. In addition, a cervical and hypertrophic thymus was associated with the supernumerary dentary-like bone, which may reflect its ancestral position near the filtrating system. Altogether these results show that the HoxA and HoxB clusters cooperated during evolution to lead to present craniofacial diversity.

Paediatric craniofacial fibrous dysplasia: the Hospital for Sick Children experience and treatment philosophy

Craniofacial fibrous dysplasia is a benign developmental anomaly in which normal bone is replaced by fibro-osseous tissue. The aim of this study was to audit the patient population at a tertiary paediatric centre and report our treatment protocols. A retrospective chart review of all patients with craniofacial fibrous dysplasia treated at the Hospital for Sick Children between 1999 and 2010 was performed. The treatment algorithm used by our centre is presented. A total of 55 patient records were reviewed; 37 patients had sufficient documentation for study; 27 (16 male, 11 female) patients underwent surgery at our institution, of these patients, 26 had post-operative follow up of greater than one year (mean 41 months; median 24 months). Mean age at presentation was 9.9 years (median 10 years) and mean age of surgery was 13 years. Ten patients underwent surgery on the fronto-orbital region, 7 of the calvarium, 2 the skull base and 8 upon tooth-bearing bones. Fourteen cases underwent debulking surgery as their primary therapy whereas 13 patients had complete resection. Nine patients experienced recurrence and all but one case of these occurred in patients that underwent debulking therapy. When age of surgery is considered, total resection and reconstruction or debulking surgery after skeletal maturity has a lower recurrence rate (1/7 cases) than earlier surgery (8/16). Complete resection at any age and debulking surgery once skeletal maturity has been reached may be associated with lower recurrence rates than incomplete resections at an earlier age. Patients with McCune-Albright syndrome may benefit from repeated debulking procedures rather than complex resections and reconstructions.

Requirement for frzb and fzd7a in cranial neural crest convergence and extension mechanisms during zebrafish palate and jaw morphogenesis

Regulation of convergence and extension by wnt-frizzled signaling is a common theme in embryogenesis. This study examines the functional requirements of frzb and fzd7a in convergence and extension mechanisms during craniofacial development. Using a morpholino knockdown approach, we found that frzb and fzd7a are dispensable for directed migration of the bilateral trabeculae, but necessary for the convergence and extension of the palatal elements, where the extension process is mediated by chondrocyte proliferation, morphologic change and intercalation. In contrast, frzb and fzd7a are required for convergence of the mandibular prominences, where knockdown of either frzb or fzd7a resulted in complete loss of lower jaw structures. Further, we found that bapx1 was specifically downregulated in the wnt9a/frzb/fzd7a morphants, while general neural crest markers were unaffected. In addition, expression of wnt9a and frzb was also absent in the edn-/- mutant. Notably, over-expression of bapx1 was sufficient to partially rescue mandibular elements in the wnt9a/frzb/fzd7a morphants, demonstrating genetic epistasis of bapx1 acting downstream of edn1 and wnt9a/frzb/fzd7a in lower jaw development. This study underscores the important role of wnt-frizzled signaling in convergence and extension in palate and craniofacial morphogenesis, distinct regulation of upper vs. lower jaw structures, and integration of wnt-frizzled with endothelin signaling to coordinate shaping of the facial form.

Craniofacial fibrous dysplasia: Surgery and literature review

Objective:

To highlight the clinical and radiologic features and management of craniofacial fibrous dysplasia with review of literature.

Materials and Methods:

A retrospective review of 6 patients who underwent surgical treatment in a tertiary healthcare centre was done using the parameters of patients' details, clinical features, radiological findings, management and postoperative review.

Results:

Of the six patients, 3 females and 2 males were in the 2^nd decade of life and 1 male in the 1^st decade of life. The disease was restricted to maxilla in 3 patients, involved the temporal and frontal bones in addition to maxilla in one, involved the frontal bone in one patient and involved frontal and parietal bones in one patient. The primary reason for seeking treatment in all the 6 cases was facial deformity. There was absence of pain in all 6 cases. For surgical treatment in all three cases involving the maxilla, the approach was intraoral while bicoronal approach was used for the other three cases. Treatment consisted of surgical contouring and reshaping the area. All cases were followed up over a period of 2 years with no signs of recurrence.

Conclusion:

Treatment of craniofacial fibro-osseous lesions is highly individualized. Most cases of craniofacial fibrous dysplasia manifest as swellings that cause facial deformity and surgical recontouring after cessation of growth seems to provide the best results.

Cornelia de-lange syndrome: a case report

Cornelia de-Lange syndrome is a congenital anomaly syndrome characterized by distinctive facial dysmorphism, primordial short stature, hirsutism, and upper limb reduction defects that range from subtle phalangeal abnormalities to oligodactyly. Craniofacial features include synophrys, arched eyebrows, long eyelashes, small widely spaced teeth and microcephaly. IQ ranges from between 30 and 102 with an average of 53. Many individuals demonstrate autistic and self-destructive tendencies. It is an autosomal dominant disorder caused by specific gene mutations and occurrence is one in 30,000 to 50,000 children. This article describes a report of a classical case of the syndrome of a 10-year-old boy and emphasizes the oral and systemic findings. The role of the pediatric dentist, with his expertize in prevention, skills of behavior management and timely referral to medical speciality, is of paramount importance in the management of children with this syndrome.

How to cite this article: Mehta DN, Bhatia R. Cornelia De-Lange Syndrome: A Case Report. Int J Clin Pediatr Dent 2013;6(2):115-118.

Accuracy of medical models made by additive manufacturing (rapid manufacturing)

BACKGROUND

Additive manufacturing (AM) is being increasingly used for producing medical models. The accuracy of these models varies between different materials, AM technologies and machine runs.

PURPOSE

To determine the accuracy of selective laser sintering (SLS), three-dimensional printing (3DP) and PolyJet technologies in the production of medical models.

MATERIAL

3D skull models: "original", "moderate" and "worse". SLS, 3DP and PolyJet models, and a coordinate measuring machine (CMM).

METHODS

Measuring balls designed for measurements were attached to each 3D model. Skull models were manufactured using SLS, 3DP and PolyJet. The midpoints of the balls were determined using CMM. The distances between these points were calculated and compared with the 3D model.

RESULTS

The dimensional error for the PolyJet was 0.18 ± 0.12% (first measurement) and 0.18 ± 0.13% (second measurement), for SLS 0.79 ± 0.26% (first model) and 0.80 ± 0.32% (second model), and for 3DP 0.67 ± 0.43% (original model, first measurement) and 0.69 ± 0.44% (original model, second measurement), 0.38 ± 0.22% (moderate model) and 0.55 ± 0.37% (worse model). Repeatability of the measurement method was 0.12% for the PolyJet and 0.08% for the 3DP.

CONCLUSION

A novel measuring technique was developed and its repeatability was found to be good. The accuracy of the PolyJet was higher when compared with SLS or 3DP.

The future in craniofacial surgery: computer-assisted planning

Advancements in computers, prototyping, and imaging, especially over the last 10 years, have permitted the adoption of three-dimensional imaging protocols in the health care field. In this article, the authors present an integrated simulation system for craniofacial surgical planning and treatment. Image fusion technology, which involves combining different imaging modalities, was utilized to create a realistic prototype and virtual image that can be manipulated in real time. The resultant data can then be shared over the Internet with distantly located practitioners.

A case report: nager acrofacial dysostosis

INTRODUCTION

Nager syndrome is a malformation resulting from problems in the development of the first and second branchial arches and limb buds. The cause of the abnormal development of the pharyngeal arches in Nager syndrome is unknown. It is also unclear why affected individuals have bone abnormalities in their arms and legs. Nager syndrome is thought to have an autosomal recessive inheritance pattern when unaffected parents have more than one affected child. The purpose of this report is to present a case of Nager syndrome where the patient exhibited upper limb shortening, an unusual feature that has been reported as coexisting in some individuals with Nager syndrome.

CASE REPORT

A 3.5-year-old girl was referred to our Department of Pediatric Otorhinolaryngology due to a cleft palate. Her craniofacial anomalies included malar hypoplasia, severe mandibular hypoplasia with retrognathia, downward slanted palpebral fissures, a high narrow hard palate, absent soft palate, small retroplaced tongue, bilateral external auditory canal atresia, and dysplastic ears. There was no evidence of mental retardation. Based on the craniofacial characteristics and the coexisting upper limb preaxial anomalies, a diagnosis of Nager syndrome was confirmed.

CONCLUSION

Nager syndrome is a rare disorder resulting from developmental abnormalities of the first and second branchial arches. It is linked to five other similar syndromes: Miller syndrome, Treacher-Collins, Pierre-Robin, Genee-Wiedemann, and Franceschetti-Zwahlen-Klein. Multidisciplinary management by a craniofacial team is needed. Early intervention, intensive education, new surgical techniques, and an emphasis on coordinated care have improved the quality of life in this patient with Nager syndrome.

Fibro-osseous Lesions of the Jaw: A Report of Two Cases

Fibro-osseous lesions of the maxillofacial bones comprise a diverse group of pathologic conditions that include developmental lesions, reactive or dysplastic diseases, and neoplasms. The concept of fibro-osseous lesions has evolved over the last several decades and now includes two major entities: fibrous dysplasia and ossifying fibroma. The less common lesions include florid osseous dysplasia, periapical dysplasia, focal sclerosing osteomyelitis, proliferative periostitis of Garre, and osteitis deformans. We report two cases, the first, a craniofacial polyostotic fibrous dysplasia, and the second, a juvenile ossifying fibroma of maxilla.

Craniofacial polyostotic fibrous dysplasia

An unusual case of fibrous dysplasia involving right craniofacial region in a female is reported. The clinical features, radiological findings, and treatment have been discussed.