1
|
Hoghoughi MA, Kamran H, Shahriarirad R, Salimi M, Hosseinpour H. Posterior Positioning of Levator Veli Palatini with Intact Nasal Layer and Side-by-Side Bilateral Buccinator Flaps: Modified Approach for Palatal Lengthening. Cleft Palate Craniofac J 2024:10556656241248272. [PMID: 38676360 DOI: 10.1177/10556656241248272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVE To introduce a modified surgical method using bilateral buccinator flaps with posterior positioning of levator veli palatini muscles to treat velopharyngeal insufficiency. DESIGN Cross-sectional clinical study. PATIENTS Non-syndromic patients with velopharyngeal insufficiency. INTERVENTION We performed a modified surgical method using posterior positioning of levator veli palatini muscles and side-by-side bilateral buccinator flaps. MAIN OUTCOME MEASURES Patients' characteristics, severity of hypernasality, palatal lengthening size, and operative complications were recorded and described. The severity of hypernasality was determined by a speech therapist before and after the operation. RESULTS A total of 26 non-syndromic patients, with a median age of 8.5 years, were enrolled. All patients presented with severe hypernasality. Following the operation and during the follow-up period, 12 patients showed a complete resolution of hypernasality, while 9, 3, and 2 patients exhibited mild, moderate, and severe hypernasality, respectively. In addition, the mean palatal lengthening was measured to be 25.3 ± 3.5 mm. Overall, three patients experienced partial flap loss in one flap, which was successfully repaired with a secondary intention without the development of a fistula. In five cases, complete closure of the donor sites couldn't be achieved and thus were treated with secondary intention. Additionally, postoperative food restrictions were observed in seven cases but were resolved within one month. No other complications were noted in the remaining patients. CONCLUSION This modified palatal lengthening technique results in a significant lengthening of the palate while maintaining favorable speech outcomes. Future randomized clinical trials are warranted to validate our findings.
Collapse
Affiliation(s)
- Mohammad Ali Hoghoughi
- Burn and Wound Healing Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hooman Kamran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Salimi
- Burn and Wound Healing Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| |
Collapse
|
2
|
Esmailzade Moghimi S, Rezaei P, Sadeghi S, Feizi A, Derakhshandeh F. Outcomes of primary repair of cleft palate using sommerled intravelar veloplasty associated with velocardiofacial syndrome. Int J Pediatr Otorhinolaryngol 2024; 179:111940. [PMID: 38588634 DOI: 10.1016/j.ijporl.2024.111940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/23/2024] [Accepted: 04/01/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES Velocardiofacial syndrome, a prevalent microdeletion syndrome occurring in 1 in 2000-4000 live births, is marked by speech and language disorders, notably velopharyngeal dysfunction. This study investigates speech outcomes, nasometric and videofluoroscopic results before and after primary repair of cleft palate using the Sommerlad intravelar veloplasty (SIVV) technique within the Isfahan cleft care team for patients with velocardiofacial syndrome. METHODS Employing a quasi-experimental design, 19 participants with velocardiofacial syndrome, who underwent primary cleft palate repair by the Isfahan cleft care team, were included through convenience sampling. Perceptual and instrumental outcomes were assessed pre-and post-operatively. Statistical analysis encompassed paired t-tests and the non-parametric Wilcoxon signed-rank test (p < 0.05). RESULTS The study identified no statistically significant differences between pre-and post-surgical speech outcome parameters and nasalance scores. Nonetheless, a significant distinction emerged in the velopharyngeal closure ratio based on fluoroscopic evaluation (p = 0.038). CONCLUSION The efficacy of the SIVV technique in treating velopharyngeal dysfunction in velocardiofacial syndrome patients is inconclusive, demanding further research. Post-surgical speech outcomes are influenced by surgical technique, hypotonia, apraxia of speech, and surgery timing. Notably, an elevated velopharyngeal valve closure ratio, though anatomically indicative, does not exclusively predict surgical success.
Collapse
Affiliation(s)
- Sarah Esmailzade Moghimi
- Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Faculty of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Rezaei
- Department of Speech and Language Pathology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Saba Sadeghi
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Awat Feizi
- Department of Biostatistics, Faculty of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Derakhshandeh
- Craniofacial and Cleft Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| |
Collapse
|
3
|
Isomura ET, Matsukawa M, Yokota Y, Tanaka N, Sugiyama C, Nohara K. Clinical application of endoscopic soft palate augmentation in the treatment of velopharyngeal insufficiency. Int J Oral Maxillofac Surg 2023:S0901-5027(23)00005-X. [PMID: 36669931 DOI: 10.1016/j.ijom.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/25/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023]
Abstract
Velopharyngeal structure augmentation with the injection of autologous fat tissue into the nasal mucosa of the soft palate has been reported previously. However, as the injection points in the velopharyngeal space cannot be observed directly, these injections may be difficult to perform accurately. This report describes a new endoscope-assisted approach in which the materials for velopharyngeal structure augmentation are administered while observing the injection points directly, also enabling adjustment of the amount of material injected. A case series of five patients aged 8-16 years who underwent endoscopic soft palate augmentation under general anaesthesia is reported. Autologous fat tissue was injected into the nasal mucosa of the soft palate using a needle-type device of an endoscope, and the effects of the treatment were evaluated. The injections were performed successfully, and the velopharyngeal function was improved. This new technique of endoscopy-assisted augmentation was useful for the treatment of velopharyngeal insufficiency.
Collapse
Affiliation(s)
- E T Isomura
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan; Center for Cleft Lip and Palate Treatment, Osaka University Dental Hospital, Suita City, Osaka, Japan.
| | - M Matsukawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan; Center for Cleft Lip and Palate Treatment, Osaka University Dental Hospital, Suita City, Osaka, Japan
| | - Y Yokota
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan; Center for Cleft Lip and Palate Treatment, Osaka University Dental Hospital, Suita City, Osaka, Japan
| | - N Tanaka
- Center for Cleft Lip and Palate Treatment, Osaka University Dental Hospital, Suita City, Osaka, Japan; Division of Oral and Facial Disorders, Osaka University Dental Hospital, Suita City, Osaka, Japan
| | - C Sugiyama
- Center for Cleft Lip and Palate Treatment, Osaka University Dental Hospital, Suita City, Osaka, Japan; Division of Oral and Facial Disorders, Osaka University Dental Hospital, Suita City, Osaka, Japan
| | - K Nohara
- Center for Cleft Lip and Palate Treatment, Osaka University Dental Hospital, Suita City, Osaka, Japan; Division of Oral and Facial Disorders, Osaka University Dental Hospital, Suita City, Osaka, Japan
| |
Collapse
|
4
|
Instrum R, Dzioba A, Dworschak-Stokan A, Husein M. Surgical interventions in velopharyngeal dysfunction: comparative perceptual speech and nasometric outcomes for three techniques. J Otolaryngol Head Neck Surg 2022; 51:3. [PMID: 35120565 PMCID: PMC8815226 DOI: 10.1186/s40463-021-00548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 10/31/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate speech outcomes following surgical intervention for velopharyngeal dysfunction (VPD). Perceptual speech outcome data were subsequently analyzed in conjunction with patient factors such as congenital abnormalities, presence of cleft lip and/or palate, and age of repair. We hope to aid in the eventual creation of treatment algorithms for VPD, allowing practitioners to tailor surgical technique selection to patient factors. METHODS A retrospective analysis was performed for all patients who underwent surgical correction of VPD at London Health Sciences Centre between the years 2005 and 2018. Two hundred and two consecutive VPD patients (median age 10.6 years) were followed for an average of 20.2 months after having undergone a superiorly based pharyngeal flap (121), Furlow palatoplasty (72), or sphincteroplasty (9). Speech outcomes were measured via the American Cleft Palate-Craniofacial Association (ACPA) perceptual speech assessment, and MacKay-Kummer Simplified Nasometric Assessment Procedures Revised (SNAP-R) was used to measure nasalence. Comparisons of mean preoperative and postoperative outcomes were made, as well as analyses regarding surgical procedure, syndrome, cleft status, and age. RESULTS Mean perceptual scores improved significantly postoperatively (p < .0001), and successful perceptual resonance was identified in 86.1% patients (n = 174). Postoperative perceptual speech scores for three ACPA domains were superior with pharyngeal flap compared to both Furlow palatoplasty and sphincteroplasty ([hypernasality: p < .001, p < .02], [audible nasal emissions: p < .002, p < .05], [velopharyngeal function: p < .001, p < .05]). Success rate was higher in pharyngeal flap (94.2%) than in Furlow palatoplasty (75.0%, p < .001) or sphincter pharyngoplasty (66.7%, p < .001). No significant difference was identified in success rate based on syndrome or cleft status. CONCLUSION Operative management of VPD is highly effective in improving perceptual speech outcomes. Given proper patient selection, all three procedures are viable treatment options for VPD. For those patients identified as appropriate to undergo a pharyngeal flap, robust improvements in speech outcomes were observed.
Collapse
Affiliation(s)
- Ryan Instrum
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital, London Health Sciences Centre, Victoria Hospital, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Agnieszka Dzioba
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital, London Health Sciences Centre, Victoria Hospital, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | | | - Murad Husein
- Department of Otolaryngology-Head and Neck Surgery, Children's Hospital, London Health Sciences Centre, Victoria Hospital, Schulich School of Medicine and Dentistry, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
- Thames Valley Children's Centre, London, ON, Canada.
| |
Collapse
|
5
|
Isomura ET, Matsukawa M, Nakagawa K, Mitsui R, Kogo M. Endoscopic soft palate augmentation using injectable materials in dogs to ameliorate velopharyngeal insufficiency. PLoS One 2020; 15:e0238646. [PMID: 32886712 PMCID: PMC7473532 DOI: 10.1371/journal.pone.0238646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Velopharyngeal structure augmentation methods are used as alternatives to pharyngeal flap operations. Recently, we investigated the sites of velopharyngeal structure augmentation in dogs and reported that the most effective injection location is the soft palate. However, there have been no reports regarding the optimal materials for implantation or injection. In this study, we aimed to investigate the injectable materials used in soft palate augmentation in dogs to ameliorate velopharyngeal insufficiency (VPI). Methods Endoscopic soft palate augmentation (ESPA) was performed in dogs using purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. ESPA is an original technique developed by our group, and this is the first report of its performance. Moreover, we assessed the amount of nasal air leakage during inspiration at rest and during expiration under the rebreathing system at 1, 2, 3, 4, 5, and 6 months after injection of these materials. Results The amount of nasal air leakage during expiration under the rebreathing system was significantly decreased in all dogs injected with the ESPA materials, but neither apnea nor hypopnea was observed. Conclusions We investigated the optimal materials for use in ESPA, such as purified sodium hyaluronate, atelocollagen, or autogenic fat tissue. We found that all of them reduced nasal air leakage and only autogenic fat tissue showed significant histologic differences in dogs at 6 months. This technique may also be useful for the treatment of patients with VPI.
Collapse
Affiliation(s)
- Emiko Tanaka Isomura
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
- * E-mail:
| | - Makoto Matsukawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Kiyoko Nakagawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Ryo Mitsui
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Mikihiko Kogo
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| |
Collapse
|
6
|
Abdel-Aziz M, Talaat A, El-Tahan AR, Kamel A, Ghandour H, Abdel-Hameed A. Pharyngeal flap for a poorly repaired cleft palate with posterior palatal defect. Int J Pediatr Otorhinolaryngol 2020; 133:109977. [PMID: 32169774 DOI: 10.1016/j.ijporl.2020.109977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/28/2020] [Accepted: 03/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Posterior palatal defect after cleft palate (CP) repair is not a rare problem, it may cause velopharyngeal insufficiency (VPI). The aim of this study was to assess the effectiveness of a superiorly-based pharyngeal flap (PF) with modification of its end to accommodate the defect in treatment of post-palatoplasty VPI. METHODS Thirteen children with VPI due to posterior palatal defect after CP repair were included in this study. PF was used in treatment of all patients, the lower end of the flap was fashioned in a V-shape to accustom the shape of the defect with peeling of its overlying mucosa to enhance wound healing. The PF was inserted deeply into a tunnel created within the defect between the oral and nasal layers of the palate. Pre- and postoperative evaluation using auditory perceptual assessment (APA), nasometric assessment and velopharyngoscopy were performed. RESULTS Significant improvement of APA and nasalance score for both oral and nasal sentences was achieved. Also, velopharyngoscopy showed complete velopharyngeal closure in all patients postoperatively. CONCLUSION A modified PF is an effective treatment for VPI caused by posterior palatal defect that may be encountered after CP repair.
Collapse
Affiliation(s)
- Mosaad Abdel-Aziz
- Department of Otolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Ahmed Talaat
- Department of Otolaryngology, Suez Canal University Hospital, Ismailia, Egypt
| | | | - Ahmed Kamel
- Department of Otolaryngology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hassan Ghandour
- Department of Otolaryngology (Phoniatric Unit), Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Asmaa Abdel-Hameed
- Department of Otolaryngology (Phoniatric Unit), Cairo University, Cairo, Egypt
| |
Collapse
|
7
|
Chen AD, Kang CO, Tran BNN, Ruan QZ, Cuccolo NG, Lee BT, Ganor O. Surgical Approaches and 30-Day Complications of Velopharyngeal Insufficiency Repair Using American College of Surgeons National Surgical Quality Improvement Program-Pediatric. J Surg Res 2020; 250:102-111. [PMID: 32044506 DOI: 10.1016/j.jss.2019.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/02/2019] [Accepted: 12/28/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND This study aims to outline the 30-d complications of different velopharyngeal insufficiency (VPI) correction techniques using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric, VPI cases from 2012 to 2015 were identified. Patients were subdivided into two cohorts: (1) palatal procedures and (2) pharyngeal procedures, with the latter being subdivided into (1) pharyngeal flap and (2) sphincter pharyngoplasty. Patient characteristics and postoperative outcomes were compared using Pearson's chi-squared or Fischer's exact test for categorical variables and independent t-tests, Wilcoxon-Mann-Whitney, or analysis of variance for continuous variables. RESULTS A total of 767 VPI cases were identified: 191 (24.9%) treated with palatal procedures and 576 (75.1%) with pharyngeal procedures, of which 444 were pharyngeal flap and 132 were sphincter pharyngoplasty. Patients who underwent palatal procedure had longer anesthesia (152.41 min) and operating time (105.72 min), whereas patients who underwent pharyngeal procedure had longer length of stay (1.66 d). There were no significant differences in outcomes between the two groups, nor were there significant differences in outcomes between pharyngeal flap and sphincter pharyngoplasty subgroups. Patients who experienced complications were younger, shorter, inpatient, and having a shorter operation time, longer anesthesia time, or longer length of stay. Plastic surgeons performed the majority of palatal procedures (62.3%), whereas pharyngeal procedures were most often performed by otolaryngologists (48.8%). CONCLUSIONS As per national data, both palatal and pharyngeal procedures for repair can be performed with comparable 30-d complications. The chosen technique may be based on patient presentation and on the surgeon comfort level.
Collapse
Affiliation(s)
- Austin D Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine O Kang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bao Ngoc N Tran
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Qing Zhao Ruan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nicholas G Cuccolo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
8
|
Isomura ET, Nakagawa K, Matsukawa M, Mitsui R, Kogo M. Evaluation of sites of velopharyngeal structure augmentation in dogs for improvement of velopharyngeal insufficiency. PLoS One 2019; 14:e0212752. [PMID: 30802272 PMCID: PMC6388922 DOI: 10.1371/journal.pone.0212752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 02/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Velopharyngeal structure augmentation methods are used as alternatives to velopharyngeal plasty. Anatomic sites of implantation/injection vary widely due to a lack of standardized criteria. Here, we experimentally investigated optimal sites of velopharyngeal structure augmentation via saline injection in dogs as they naturally exhibit velopharyngeal insufficiency (VPI). Methods Velopharyngeal structure augmentation was performed on 10 beagles (age range: 20–24 months; weight range: 9–12 kg). Saline containing 1/80,000 epinephrine was injected intraorally in 1-mL increments into the nasal mucosa of the soft palate (n = 4), posterior pharyngeal wall (n = 3), or bilateral pharyngeal walls (n = 3) of each dog. Nasal air leakage was measured under rebreathing until velopharyngeal closure was achieved; the measurement was performed using flow meter sensors on both nasal apertures, and the oral cavity was filled with alginate impression material to prevent oral air leakage. Results Pre-injection, the dogs exhibited an average of 0.455 L/s air leakage from the nasal cavity. The dogs with saline injected into the nasal mucosa of the soft palate achieved steady augmentation, and nasal air leakage disappeared under rebreathing following 6-mL saline injection. Conversely, nasal air leakage remained in the dogs with saline injected in the posterior pharyngeal wall or bilateral pharyngeal walls. Conclusions During VPI treatment in dogs, augmentation was most effective at the nasal mucosa of the soft palate. Improvement in nasal air leakage was highly dependent on the saline injection volume. Although velopharyngeal structures vary between dogs and humans, velopharyngeal closure style is similar. Thus, our results may aid in the treatment of VPI patients.
Collapse
Affiliation(s)
- Emiko Tanaka Isomura
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
- Unit of Dentistry, Osaka University Hospital, Suita City, Osaka, Japan
- * E-mail:
| | - Kiyoko Nakagawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Makoto Matsukawa
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Ryou Mitsui
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| | - Mikihiko Kogo
- First Department of Oral and Maxillofacial Surgery, Osaka University, Graduate School of Dentistry, Suita City, Osaka, Japan
| |
Collapse
|