Associations between the Cervical Vertebral Column and Craniofacial Morphology. Int J Dent. 2010;2010:295728. [PMID: 20628592 PMCID: PMC2901616 DOI: 10.1155/2010/295728]

The Verification of the Degree of Concordance of the SMI/CVMS Indexes in Evaluating the Pubertal Growth Stages—Longitudinal Study

The research aims to verify the concordance between the skeletal maturity index (SMI) measured on the hand and wrist X-rays using Fishman method and the cervical vertebral maturation stage (CVMS), measured on the lateral cephalometric X-rays using Baccetti method. The concordance of the two indexes (SMI and CVMS) has been statistically verified with the help of the Cohen’s kappa coefficient, by relating them to the growth stages, within a longitudinal study done upon a group of 38 patients, 22 female and 16 male, aged between 8–18 y, the analyzed investigations being done in series, along the orthodontic treatment. The research showed a strong correlation between the SMI and CVMS indexes within the analyzed group, confirmed by the obtained values (k = 0.84 for female and k = 0.85 for male).

Assessment of maturation stages and the accuracy of age estimation methods in a Turkish population: A comparative study

Purpose

This study assessed the associations between chronological age, dental maturation (DM), cervical vertebrae maturation (CVM), and hand-wrist maturation (HWM) in individuals aged 9-19 years. In addition, this study aimed to derive practical methods to evaluate the skeletal age using DM, CVM, or HWM for orthodontic, medical, and forensic purposes and to compare which of these 3 developmental parameters is more accurate for estimating the age of individuals in a Turkish population.

Materials and Methods

Panoramic, lateral cephalometric, and hand-wrist radiographs of 284 patients aged 9-19 years were used in this study. The DM, CVM, and HWM stages were determined. The Kolmogorov-Smirnov, kappa, Wilcoxon, Kruskal-Wallis, chi-square, and Spearman correlation tests and simple linear regression analysis were used for statistical analysis. The significance level was 0.05.

Results

Statistically significant differences were found between chronological age and DM, chronological age and CVM, and chronological age and HWM in both sexes (P<0.05). DM did not show statistically significant differences according to sex (P>0.05), but CVM and HWM were statistically different between males and females (P<0.05). The DM-estimated age yielded more accurate values than the other methods.

Conclusion

All correlations between skeletal and dental stages were statistically significant. Our results showed that there was no statistically significant difference between chronological age and DM-estimated age. Therefore, it can be concluded that DM stages have the potential to be used for legal purposes.

Three-dimensional craniofacial characteristics associated with obstructive sleep apnea severity and treatment outcomes

OBJECTIVES

This study aims to assess craniofacial dimensions in obstructive sleep apnea (OSA) patients treated with a mandibular advancement device (MAD) and to identify anatomic influences on OSA severity and MAD therapy outcomes.

MATERIALS AND METHODS

Twenty patients with OSA were prospectively treated with MAD. Clinical, cone-beam computed tomography, and polysomnography exams were performed before treatment and 4-6 months after achieving the MAD therapeutic position. Polysomnographic exams and three-dimensional maxillary, mandibular, and upper airway (UA) measurements were evaluated. Pearson's correlation and t-tests were applied.

RESULTS

Before MAD treatment, the transverse width measured at the frontomaxillary suture and the angle between the mandibular ramus and Frankfurt horizontal were statistically correlated with apnea and the hypopnea index (AHI), while the gonial angle was correlated with therapeutic protrusion. After MAD treatment, all patients showed a significant AHI reduction and an improvement in minimum oxyhemoglobin saturation. The UA total volume, superior and inferior oropharynx volume, and area were statistically correlated with MAD therapeutic protrusion. The UA total area showed a statistical correlation with the improvement in AHI, and the superior oropharynx volume and area increased significantly.

CONCLUSIONS

The transversal frontomaxillary suture width and the mandibular ramus facial angle may influence OSA severity. The gonial angle, volume, and area of all UA regions may indicate the amount of protrusion needed for successful MAD treatment.

CLINICAL RELEVANCE

The craniofacial characteristics reported as important factors for OSA severity and MAD treatment outcomes impact therapy planning for OSA patients, considering individual anatomic characteristics, prognosis, and cost benefits.

Sleep apnea and unilateral upper and lower extremity allodynia as a result of a large thoracic disc herniation: a case report

Background

Clinically significant disc herniations in the thoracic spine are rare accounting for approximately 1% of all disc herniations. In patients with significant spinal cord compression, presenting symptoms typically include ambulatory dysfunction, lower extremity weakness, lower extremity sensory changes, as well as bowl, bladder, or sexual dysfunction. Thoracic disc herniations can also present with thoracic radiculopathy including midback pain and radiating pain wrapping around the chest or abdomen. The association between thoracic disc herniation with cord compression and sleep apnea is not well described.

Case presentation

The following is a case of a young male patient with high grade spinal cord compression at T7-8, as a result of a large thoracic disc herniation. The patient presented with complaints of upper and lower extremity unilateral allodynia and sleep apnea. Diagnosis was only made once the patient manifested more common symptoms of thoracic stenosis including left lower extremity weakness and sexual dysfunction. Following decompression and fusion the patient’s allodynia and sleep apnea quickly resolved.

Conclusions

Thoracic disc herniations can present atypically with sleep apnea. We recommend taking into consideration that sleep symptoms may resolve when planning treatment for thoracic disc herniation.

Integration between the cranial boundaries of the nasopharynx and the upper cervical vertebrae in Homo and Pan

The nasopharynx is an important anatomical structure involved in respiration. Its bony boundaries, including the basicranium and upper cervical vertebrae, may be subject to selective pressures and constraints related to respiratory function. Here, we investigate phenotypic integration, or covariation, between the face, the basicranial boundaries of the nasopharynx, and the atlas and axis to understand constraints affecting these structures. We collected three-dimensional coordinate data from a sample of 80 humans and 44 chimpanzees, and used two-block partial least squares to assess RV (a multivariate generalization of Pearson's r² ), r_PLS , the covariance ratio, and effect size for integration among structures. We find that integration is significant among some of these structures, and that integration between the basicranial nasopharynx and vertebrae and between the face and vertebrae is likely independent. We also find divergences in the pattern of integration between humans and chimpanzees suggesting greater constraints among the human face and nasopharynx, which we suggest are linked to divergent developmental trajectories in the two taxa. Evolutionary changes in human basicranial anatomy, coupled with human-like developmental trajectories, may have required that the face grow to compensate any variation in nasopharyngeal structure. However, we were unable to determine whether the nasopharynx or the face is more strongly integrated with the vertebrae, and therefore whether respiration or biomechanical considerations related to positional behavior may be more strongly tied to vertebral evolution. Future work should focus on greater sample sizes, soft tissue structures, and more diverse taxa to further clarify these findings.

Comparison of cervical vertebral anomalies and sella turcica bridging in different growth stages with various vertical skeletal growth patterns

PURPOSE

To compare cervical vertebral anomalies and sella turcica bridging (STB) in different growth stages in orthodontic patients with different vertical skeletal growth patterns.

METHODS

Lateral cephalometric radiographs (LCR) of 270 patients in the preadolescent, adolescent, or postadolescent periods and having low angle [LA], normal angle [NA], or high-angle [HA] vertical skeletal growth patterns were evaluated retrospectively. STB was visualized using LCRs while evaluating the deficiency of ponticulus posticus (PP) and atlas posterior arch (PAA) associated with the atlas bone. The Pearson chi-square and Fisher's exact tests were used for categorical data and one-way ANOVA for numerical data.

RESULTS

The prevalence of fully calcified PP and STB increased from the preadolescent (PP, 10.0%; STB, 11.1%) to the postadolescent period (PP, 24.4; STB, 21.1%); they did not differ from vertical skeletal growth patterns (p > 0.05). The prevalence of PAA deficiency is significantly higher in individuals with LA (46.7%) than with other angles (NA, 27.8%; HA, 26.7%). The vertical skeletal growth pattern was significantly related to STB in the preadolescent period and PAA in the postadolescent period.

CONCLUSIONS

Different anomalies during different growth periods correlate with the vertical skeletal growth pattern. It will be useful to evaluate a different anomaly according to the relevant growth period.

Exploring copy number variants in deceased fetuses and neonates with abnormal vertebral patterns and cervical ribs

Background

Cervical patterning abnormalities are rare in the general population, but one variant, cervical ribs, is particularly common in deceased fetuses and neonates. The discrepancy between the incidence in the general population and early mortality is likely due to indirect selection against cervical ribs. The cause for the co‐occurrence of cervical ribs and adverse outcome remains unidentified. Copy number variations resulting in gain or loss of specific genes involved in development and patterning could play a causative role.

Methods

Radiographs of 374 deceased fetuses and infants, including terminations of pregnancies, stillbirths and neonatal deaths, were assessed. Copy number profiles of 265 patients were determined using single nucleotide polymorphism array.

Results

274/374 patients (73.3%) had an abnormal vertebral pattern, which was associated with congenital abnormalities. Cervical ribs were present in 188/374 (50.3%) and were more common in stillbirths (69/128 [53.9%]) and terminations of pregnancies (101/188 [53.7%]), compared to live births (18/58, 31.0%). Large (likely) deleterious copy number variants and aneuploidies were prevalent in these patients. None of the rare copy number variants were recurrent or overlapped with candidate genes for vertebral patterning.

Conclusions

The large variety of copy number variants in deceased fetuses and neonates with similar abnormalities of the vertebral pattern probably reflects the etiological heterogeneity of vertebral patterning abnormalities. This genetic heterogeneity corresponds with the hypothesis that cervical ribs can be regarded as a sign of disruption of critical, highly interactive stages of embryogenesis. The vertebral pattern can probably provide valuable information regarding fetal and neonatal outcome.

Thoracic-lumbar-sacral spine sagittal alignment and cranio-mandibular morphology in adolescents

PURPOSE

The relationship between thoracic-lumbar-sacral spine sagittal alignment and craniofacial morphology is still controversial. Evidence-based results are difficult to obtain and scientific studies are inhomogeneous. The aim of this study was to investigate the difference of thoracic-lumbar-sacral spine posture and cephalometric values comparing two groups of subjects with different cranial structure in the sagittal plane.

METHODS

Eighty-one subjects were consecutively selected and divided into two groups, according to the orientation of the condyle-orbital plane (CoOr) with respect to the superior maxilla (SpP): Group1: 49 subjects 11.6 (2.1) years showing posterior-rotation of CoOr: SpP^CoOr ≤ -2°, -4.1°(2.1°); Group2: 32 subjects 12.9 (2.3)years showing anterior-rotation of CoOr: SpP^CoOr ≥ 2°, 3.7°(1.9°). Each patient underwent in blinding, Spinal Mouse recording and cephalometry of the skull.

RESULTS

Group1 showed a significant forward tilting of the spine 4.4°(1.8°) with respect to Group2 2.4°(1.3°) (p < 0.0001) and higher values related to the vertical dimension of the skull: higher maxillary divergency (p < 0.0001), steep occlusal plane (p < 0.0007), higher gonial angle (p < 0.001).

DISCUSSION

The results of this study showed a difference in the thoracic-lumbar-sacral spine inclination between groups with different craniofacial morphology. The achievement of this outcome is important to improve our multidisciplinary evaluation and treatment planning.

Morphologic Anomalies of Upper Cervical Vertebrae in Swedish Children Born with Nonsyndromic Cleft Lip and/or Palate Compared to Swedish Children without Cleft

OBJECTIVE

To examine and compare the prevalence of morphologic anomalies of the upper cervical vertebrae in Swedish children with nonsyndromic cleft lip and/or palate to Swedish children without cleft.

DESIGN

Retrospective study on lateral cephalograms.

SETTING

Division of Orthodontics, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.

PATIENTS

The cleft group consisted of 325 children (150 girls and 175 boys) born with nonsyndromic cleft lip and/or palate (mean age: 11.1 years). The control group consisted of 325 children without cleft, matched for age and gender.

MAIN OUTCOME MEASURES

Lateral cephalograms exposing upper cervical vertebrae (C1-C3) were examined regarding morphologic anomalies such as posterior arch deficiencies, fusion of vertebrae, odontoid anomalies, and deviations of the vertebral artery canal.

RESULTS

The prevalence of children with morphologic anomalies of the upper cervical vertebrae was 24.3% (n = 79) in children with cleft and 12.6% (n = 41) in children without cleft. Posterior arch deficiency and vertebral fusion were significantly more frequent in children with cleft (P < .001). No statistically significant differences were found between the 2 groups regarding odontoid and vertebral artery canal anomalies.

CONCLUSIONS

Morphologic anomalies of the upper cervical vertebrae in Swedish children with nonsyndromic cleft lip and/or palate were significantly more frequent compared to similar anomalies in Swedish children without cleft.

Pre-optimization of spinal surgery patients: Development of a neurosurgical enhanced recovery after surgery (ERAS) protocol

OBJECTIVE

Despite surgical, technological, medical, and anesthetic improvements, patient outcomes following elective neurosurgical procedures can be associated with high morbidity. Enhanced recovery after surgery (ERAS) protocols are multimodal care pathways designed to optimize patient outcomes by addressing pre-, peri-, and post-operative factors. Despite significant data suggesting improved patient outcomes with the adoption of these pathways, development and implementation has been limited in the neurosurgical population.

METHODS/RESULTS

This study protocol was designed to establish the feasibility of a randomized controlled trial to assess the efficacy of implementation of an ERAS protocol on the improvement of clinical and patient reported outcomes and patient satisfaction scores in an elective inpatient spine surgery population. Neurosurgical patients undergoing spinal surgery will be recruited and randomly allocated to one of two treatment arms: ERAS protocol (experimental group) or hospital standard (control group). The experimental group will undergo interventions at the pre-, peri-, and post-operative time points, which are exclusive to this group as compared to the hospital standard group.

CONCLUSIONS

The present proposal aims to provide supporting data for the application of these specific ERAS components in the spine surgery population and provide rationale/justification of this type of care pathway. This study will help inform the design of a future multi-institutional, randomized controlled trial.

RESULTS

of this study will guide further efforts to limit post-operative morbidity in patients undergoing elective spinal surgery and to highlight the impact of ERAS care pathways in improving patient reported outcomes and satisfaction.

A practical formula for determining growth

PURPOSE

We aimed to establish a practical method to evaluate skeletal age using cervical vertebrae.

METHODS

The study consisted of hand-wrist and cephalometric radiographs of 324 subjects (167 girls, 157 boys; age range, 7.3-17.2 years). Skeletal ages of the subjects were calculated from hand-wrist radiographs, and cervical vertebral bodies were measured using cephalometric radiographs. A single formula based on C3 and C4 vertebral body heights with different coefficients for each gender was derived using ridge regression analysis.

RESULTS

The correlation coefficients for vertebral and hand-wrist bone age were 0.825 and 0.856 for girls and boys, respectively. The correlations among vertebral bone age and C3 and C4 vertebral body heights were also found to be significant. The intraclass correlation (ICC) score was found to be 0.914, which shows high consistency between the two measurements of the same investigator for each C3 and C4 vertebral body height result.

CONCLUSION

The formula derived for evaluating skeletal age in cephalometric radiographs is reliable and can be applied to both girl and boy subjects for legal requirements or therapeutic needs of age estimation.

Fusion of axis with third cervical vertebra: a case report

Introduction: Fusion of one or more contiguous vertebral segments is usually the result of embryological failure of normal spinal segmentation. It may be associated with syndromes such as Klippel-Feil. Fused cervical vertebrae (FCV) may also be acquired or pathologic. FCV is generally associated with disease like tuberculosis, other infections, juvenile rheumatoid arthritis and trauma. The commonest site of involvement is C2-C3. In condition of fusion the two vertebrae appear not only structurally as one but also function as one. This anomaly may be asymptomatic; however, it may also manifest in the form of serious clinical features such as myelopathy, limitation of the neck movement, muscular weakness, atrophy or neurological sensory loss.

Case report: We observed the fusion of axis with 3rd cervical vertebra. Body, laminae and spines of C2 and C3 were completely fused on both anterior and posterior aspects, whereas the pedicles and transverse processes were not fused. Foramen transversarium was present on both the vertebrae bilaterally.

Conclusion: This variation is noteworthy to neurosurgeons and radiologists in studying computed tomography (CT) and magnetic resonance imaging (MRI) scans.

Tooth agenesis and craniofacial morphology in pre-orthodontic children with and without morphological deviations in the upper cervical spine

AIM: To analyze differences in prevalence and pattern of tooth agenesis and craniofacial morphology between non syndromic children with tooth agenesis with and without upper cervical spine morphological deviations and to analyze associations between craniofacial morphology and tooth agenesis in the two groups together.

METHODS: One hundred and twenty-six pre-orthodontic children with tooth agenesis were divided into two groups with (19 children, mean age 11.9) and without (107 children, mean age 11.4) upper spine morphological deviations. Visual assessment of upper spine morphology and measurements of craniofacial morphology were performed on lateral cephalograms. Tooth agenesis was evaluated from orthopantomograms.

RESULTS: No significant differences in tooth agenesis and craniofacial morphology were found between children with and without upper spine morphological deviations (2.2 ± 1.6 vs 1.94 ± 1.2, P > 0.05) but a tendency to a different tooth agenesis pattern were seen in children with morphological deviations in the upper spine. In the total group tooth agenesis was associated with the cranial base angle (n-s-ba, r = 0.23, P < 0.01), jaw angle (ML/RLar, r = 0.19, P < 0.05), mandibular inclination (NSL/ML, r = -0.21, P < 0.05), mandibular prognathia (s-n-pg, r = 0.25, P < 0.01), sagittal jaw relationship (ss-n-pg, r = -0.23, P < 0.5), overjet (r = -0.23, P < 0.05) and overbite (r = -0.25, P < 0.01).

CONCLUSION: Etiology of tooth agenesis in children with upper spine morphological deviations was discussed. The results may be valuable for the early diagnosis and treatment planning of non syndromic children with tooth agenesis.

Klippel-feil: A syndrome in the occipital-cervical spine field and its dentofacial manifestations

Klippel-Feil syndrome (KFS) is defined by congenital cervical vertebral spine fusion and is seen with a wide spectrum of dental manifestations and craniofacial profiles. Previous studies on lateral cephalograms have documented an association between fusion of the cervical vertebrae and deviations in the craniofacial profile in non-syndromic patients with severe malocclusion. To our knowledge, no previous studies have described the craniofacial profile including the cranial base of KFS patients on lateral cephalograms. Therefore KFS and its craniofacial and dental manifestations were described according to existing literature and additionally the craniofacial profile and cranial base was analysed on lateral cephalograms of two patients with KFS. According to the literature the dental manifestations of KFS-patients included oligodontia, overjet, cross bite, open bite and deep bite. The craniofacial profile was clinically described as reduced lower facial height, midfacial hypoplasia, and mandibular prognathia. The analyses of the two lateral cephalograms showed increased mandibular inclination, increased vertical jaw-relationship, increased jaw angle and maxillary retrognathia. The cranial base was normal in both cases. The sagittal jaw relationship and mandibular prognathia varied between the two cases. The literature review and the analyses of the two lateral cephalograms have shown that deviations in the occipital and cervical spine field as KFS were associated with deviations in the teeth and craniofacial profile.

Reduced mandibular range of motion in Duchenne Muscular Dystrophy: predictive factors

Patients with Duchenne muscular dystrophy (DMD) experience negative effects upon feeding and oral health. We aimed to determine whether the mandibular range of motion in DMD is impaired and to explore predictive factors for the active maximum mouth opening (aMMO). 23 patients with DMD (mean age 16.7 ± 7.7 years) and 23 controls were assessed using a questionnaire about mandibular function and impairments. All participants underwent a clinical examination of the masticatory system, including measurement of mandibular range of motion and variables related to mandibular movements. In all patients, quantitative ultrasound of the digastric muscle and the geniohyoid muscle and the motor function measure (MFM) scale were performed. The patients were divided into early and late ambulatory stage (AS), early non-ambulatory stage (ENAS) and late non-ambulatory stage (LNAS). All mandibular movements were reduced in the patient group (P < 0.001) compared to the controls. Reduction in the aMMO (<40 mm) was found in 26% of the total patient group. LNAS patients had significantly smaller mandibular movements compared to AS and ENAS (P < 0.05). Multiple linear regression analysis for aMMO revealed a positive correlation with the body height and disease progression, with MFM total score as the strongest independent risk factor (R(2) = 0.71). Mandibular movements in DMD are significantly reduced and become more hampered with loss of motor function, including the sitting position, arm function, and neck and head control. We suggest that measurement of the aMMO becomes a part of routine care of patients with DMD.

The effects of a temporarily manipulated dental occlusion on the position of the spine: a comparison during standing and walking

BACKGROUND CONTEXT

The relationship between dental occlusion and body posture or even the spine position is often analyzed and confirmed. However, this relationship has not been systematically investigated for standing and walking.

PURPOSE

To examine whether a symmetric or asymmetric dental occlusion block, using 4 mm thick silicon panels, can significantly change the spine position (cervical, thoracic, or lumbar region) during standing and walking.

STUDY DESIGN

The following study is a cross-sectional study.

PATIENT SAMPLE

This study was carried out with 23 healthy subjects (18 women, 5 men) without discomfort in the temporomandibular system or body movement apparatus.

OUTCOME MEASURES

Position changes (millimeter) of the spine (cervical, thoracic, lumbar) in frontal, sagittal, and transverse planes of motion.

METHODS

The upper spine position was quantified with an ultrasonic distance measurement system (sonoSens Monitor). Every subject placed the 4 mm thick silicon panel systematically between the left/right premolars or the front teeth. Differences between the habitual and manipulated occlusion positions were determined by the Friedman test, followed by pairwise comparisons with applied Bonferroni-Holm correction.

RESULTS

During standing and walking there were significant (p≤.05) differences between the occlusion block conditions and the habitual dental position in all body planes except in the right lumbar region during walking. In addition, differences within the manipulated occlusion position could be detected. Significant differences were also shown between the standing and walking trials in the frontal, sagittal, and transverse planes, particularly with respect to the lumbar region (p≤.001).

CONCLUSIONS

Symmetrical and asymmetrical occlusion blocks in the premolar region can be associated with changes in all three spine regions during standing and walking. The results showed highly similar reaction patterns in all spine positions, regardless of the location of the silicon panel. Between standing and walking, the main differences were in the lumbar spine. The results suggest a relationship between the chewing and the movement system. However, it must be stated that this study has no direct clinical impact. The study design cannot determine the causality of the observed associations; also the clinical significance of the small postural changes remains unknown.

Sleep apnea and cervical spine pathology

PURPOSE

Sleep apnea is a multi-factorial disease with a variety of identified causes. With its close proximity to the upper airway, the cervical spine and its associated pathologies can produce sleep apnea symptoms in select populations. The aim of this article was to summarize the literature discussing how cervical spine pathologies may cause sleep apnea.

METHODS

A search of the PubMed database for English-language literature concerning the cervical spine and its relationship with sleep apnea was conducted. Seventeen published papers were selected and reviewed.

RESULTS

Single-lesion pathologies of the cervical spine causing sleep apnea include osteochondromas, osteophytes, and other rare pathologies. Multifocal lesions include rheumatoid arthritis of the cervical spine and endogenous cervical fusions. Furthermore, occipital-cervical misalignment pre- and post-cervical fusion surgery may predispose patients to sleep apnea.

CONCLUSIONS

Pathologies of the cervical spine present significant additional etiologies for producing obstructive sleep apnea in select patient populations. Knowledge of these entities and their pathophysiologic mechanisms is informative for the clinician in diagnosing and managing sleep apnea in certain populations.