Nasolabial shape and aesthetics in unilateral cleft lip and palate: an analysis of nasolabial shape using a mean 3D facial template

The aim of this study was to determine the amount of deviation in nasolabial shape in patients with a cleft compared with an average non-cleft face, and to assess whether this difference is related to nasolabial aesthetics. Three-dimensional stereophotogrammetric images of 60 patients with a unilateral cleft were used. To quantify shape differences, four average non-cleft faces were constructed from stereophotogrammetric images of 141 girls and 60 boys. Three-dimensional shape differences were calculated between superimposed cleft faces and the average non-cleft face for the same sex and age group. Nasolabial aesthetics were rated with the modified Asher-McDade Aesthetic Index using a visual analogue scale (VAS). Mean VAS scores ranged from 51.44 to 60.21 for clefts, with lower aesthetic ratings associated with increasing cleft severity. Shape differences were found between cleft faces and the average non-cleft face. No relationship was found for the VAS, age, and sex, except that a lower VAS was related to a higher nose and lip distance between the superimposed cleft and average non-cleft faces for nasal profile (P= 0.02), but the explained variance was low (R²=0.066). In conclusion, except for nasal profile, nasolabial aesthetics were not influenced by the extent of shape differences from the average non-cleft face.

Symmetry of palatal shape during the first year of life in healthy infants

Objectives

The purpose of this study was to quantify the symmetry of the alveolar process of the maxilla and palate during the first year of life in healthy infants with the help of a semiautomatic segmentation technique.

Materials and methods

Maxillary plaster models of seventy healthy babies at 0, 3, 6, 9, and 12 months were collected and digitized. A semiautomatic segmentation tool was used to extract the alveolus and palate. The resulting model was aligned within a reference frame and mirrored on its medial plane. Distance maps were created and analyzed to compare and quantify the differences between the two hemispheres. Additional hemispherical width and area measurements were performed. An ANOVA test with additional post hoc tests was performed to check if the symmetry changed during development. Finally, the results were tested on intra- and interobserver variability.

Results

The absolute mean inter-surface distance between the original and mirrored models in each age group ranged between 0.23 and 0.30 mm. Width and area analysis showed a small but significant larger left palatal hemisphere. ANOVA and post hoc tests showed no significant difference in symmetry between groups. Reliability analysis showed no significant differences between observers.

Conclusions

This study showed that in this infant population, only a small degree of palatal asymmetry was present, which can be considered as normal and clinically irrelevant.

Clinical relevance

The data from this study can be used in future comparative studies as reference data. Furthermore, modeling of these data can help in predicting the growth pattern, which may lead to improved treatment protocols for children with craniofacial anomalies.

Electronic supplementary material

The online version of this article (10.1007/s00784-020-03403-4) contains supplementary material, which is available to authorized users.

Three dimensional maxillary growth modeling in newborns

OBJECTIVES

The aim of this study was to develop an accurate and intuitive semi-automatic segmentation technique to calculate an average maxillary arch and palatal growth profile for healthy newborns in their first year of life.

MATERIALS AND METHODS

Seventy babies born between 1985 and 1988 were included in this study. Each child had five impressions made in the first year after birth that were digitalized. A semi-automatic segmentation tool was developed and used to assess the maxillary dimensions. Finally, random effect models were built to describe the growth and build a simulation population of 10,000 newborns. The segmentation was tested for inter- and intra-observer variability.

RESULTS

The Pearson correlation coefficient for each of the variables was between 0.94 and 1.00, indicating high inter-observer agreement. The paired sample t test showed that, except for the tuberosity distance, there were small, but significant differences in the landmark placements between observers. Intra-observer repeatability was high, with Pearson correlation coefficients ranging from 0.87 to 1.00 for all measurements, and the mean differences were not significant. A third or second degree growth curve could be successfully made for each parameter.

CONCLUSIONS

These findings indicated this method could be used for objective clinical evaluation of maxillary growth.

CLINICAL RELEVANCE

The resulting growth models can be used for growth studies in healthy newborns and for growth and treatment outcome studies in children with cleft lip and palate or other craniofacial anomalies.

Dentition Patterns in Different Unilateral Cleft Lip Subphenotypes

Oral clefts play an essential role in disturbed odontogenesis of the deciduous and permanent dentition, yet little is known about this relationship. We investigated, within the categories cleft lip with or without alveolus (CL ± A) and cleft lip, alveolus and palate (CLAP), whether different CL subphenotypes based on morphological severity of the cleft show different dentition patterns and whether a more detailed subdivision of the incomplete CL has clinical relevance. In this retrospective study, 345 children with nonsyndromic unilateral CL ± A and CLAP from the Dutch Association for Cleft Palate and Craniofacial Anomalies (NVSCA) registry were included to assess the association between the CL subphenotypes and lateral incisor patterns. Five different deciduous and permanent patterns of the lateral incisor were distinguished: located in normal position (pattern z/Z), in the anterior segment (pattern x/X) or in the posterior segment of the cleft (pattern y/Y), one in each segment of the cleft (pattern xy/XY), and agenesis of the lateral incisor (pattern ab/AB). Analyses were performed by using multinomial logistic regression models. Children born with a vermillion notch or a one-third to two-thirds CL were most likely to have a deciduous pattern x and a permanent pattern X, while children born with a two-thirds to subtotal CL were most likely to have deciduous pattern xy and a permanent pattern X compared to children with a complete CL that predominantly had deciduous pattern y and a permanent pattern AB. Based on the relationship of the CL morphology with the deciduous dentition, subdivision of the CL morphology into vermillion notch to two-thirds CL, two-thirds to subtotal CL, and complete CL appears to be an optimal subdivision. Our results indicate that a more detailed subdivision of the CL has clinical relevance and that critical factors in the pathogenesis of the CL are also critical for the odontogenesis.

An accuracy study of computer-planned implant placement in the augmented maxilla using osteosynthesis screws

Previous research on the accuracy of flapless implant placement of virtually planned implants in the augmented maxilla revealed unfavourable discrepancies between implant planning and placement. By using the osteosynthesis screws placed during the augmentation procedure, the surgical template could be optimally stabilized. The purpose of this study was to validate this method by evaluating its clinically relevant accuracy. Twelve consecutive fully edentulous patients with extreme resorption of the maxilla were treated with a bone augmentation procedure. Virtual implant planning was performed and a surgical template was manufactured. Subsequently, six implants were installed using the surgical template, which was only supported by the osteosynthesis screws. Implant deviations between planning and placement were calculated. A total of 72 implants were installed. Mean deviations found in the mesiodistal direction were 0.817mm at the implant tip and 0.528mm at the implant shoulder. The angular deviation was 2.924°. In the buccolingual direction, a deviation of 1.038mm was registered at the implant tip and 0.633mm at the implant shoulder. The angular deviation was 3.440°. This study showed that implant placement in the augmented maxilla using a surgical template supported by osteosynthesis screws is accurate.

Three-dimensional evaluation of the alar cinch suture after Le Fort I osteotomy

Orthognathic surgery has an influence on the overlying soft tissues of the translated bony maxillomandibular complex. Improvements in both function and facial appearance are the goals of surgery. However, unwanted changes to the soft tissues, especially in the nose region, frequently occur. The most common secondary change in the nasolabial region is widening of the alar base. Various surgical techniques have been developed to minimize this effect. The purpose of this study was to evaluate the changes in the nasal region due to orthognathic surgery, especially the alar width and nasal volume, using combined cone beam computed tomography (CBCT) and three-dimensional (3D) stereophotogrammetry datasets. Twenty-six patients who underwent a Le Fort I advancement osteotomy between 2006 and 2013 were included. From 2006 to 2010, no alar base cinch sutures were performed. From 2010 onwards, alar base cinch sutures were used. Preoperative and postoperative documentation consisted of 3D stereophotogrammetry and CBCT scans. 3D measurements were performed on the combined datasets, and the alar base width and nose volume were analyzed. No difference in alar base width or nose volume was observed between patients who had undergone an alar cinch and those who had not. Postoperatively the nose widened and the volume increased in both groups.

Postoperative socket irrigation with drinking tap water reduces the risk of inflammatory complications following surgical removal of third molars: a multicenter randomized trial

Objectives

The primary aim of the present study was to evaluate the effectiveness of postoperative irrigation of the socket with drinking tap water on inflammatory complications following lower third molar removal.

Material and methods

A multicenter randomized controlled trial was carried out from June 2013 to June 2014. In one arm of the study, patients were instructed to irrigate the tooth socket and surgical site with a Monoject® Curved 412 Tip Syringe (Tyco/healthcare-Kendall, Mansfield, MA, USA) with tap water. In a second arm of the study, the standard postoperative instructions did not include irrigation instructions. The incidences of alveolar osteitis and wound infection were recorded for each group and analyzed by the Fisher’s exact test.

Results

A total of 280 patients with 333 mandibular third molars were analyzed. According to the intention-to-treat (ITT) analysis, inflammatory complications occurred in 18 cases in the Monoject® group (11.4 %) compared to 34 cases (19.1 %) in the control group (p = 0.04). These complications were associated with significant worse outcomes regarding quality of life, pain, and trismus and caused significantly more missed days of work or study. Female gender, age >26, bone removal, deep impacted third molars, less experienced surgeons, and a high amount of debris at the surgical site were also identified as risk factors for developing inflammatory complications following lower third molar removal.

Conclusion

Irrigation of the surgical site with drinking tap water using a curved syringe following removal of third molars is effective in reducing the risk of inflammatory complications.

Clinical relevance

Water is a very accessible, cost-effective irrigant without side effects and the results from this study have proven that it can be used to reduce the risk of inflammatory complications and associated morbidity following lower third molar removal.

Clinical relevance of cone beam computed tomography in mandibular third molar removal: A multicentre, randomised, controlled trial

PURPOSE

The aims of this study were to investigate the effectiveness of cone beam computed tomography (CBCT) compared to panoramic radiography (PR), prior to mandibular third molar removal, in reducing patient morbidity, and to identify risk factors associated with inferior alveolar nerve (IAN) injury.

MATERIAL AND METHODS

This multicentre, randomised, controlled trial was performed at three centres in the Netherlands. Adults with an increased risk for IAN injury, as diagnosed from PR, were included in the study. In one arm of the study, patients underwent an additional CBCT prior to third molar surgery. In a second arm of the study, no additional radiographs were acquired. The primary outcome measure was the number of patient-reported altered sensations 1 week after surgery. As secondary outcome measures, the number of patients with objective IAN injury, with long-term (>6 months) IAN injury, the occurrence of other postoperative complications, the Oral Health Related Quality of Life-14 (OHIP-14) questionnaire responses, postoperative pain (visual analogue scale score), duration of surgery, number of emergency visits, and number of missed days of work or study were scored.

RESULTS

A total of 268 patients with 320 mandibular third molars were analysed according to the intention-to-treat principle. The overall incidence of IAN injury 1 week after surgery was 6.3%. No significant differences between CBCT and PR for temporary IAN injury (p = 0.64) and all other secondary outcomes were registered. A lingual position of the mandibular canal (MC) and narrowing, in which the diameter of the MC lumen was decreased at the contact area between the MC and the roots, were significant risk factors for temporary IAN injury.

CONCLUSION

Although CBCT is a valuable diagnostic adjunct for identification of an increased risk for IAN injury, the use of CBCT does not translate into a reduction of IAN injury and other postoperative complications, after removal of the complete mandibular third molar. In these selected cases of a high risk for IAN injury, an alternative strategy, such as monitoring or a coronectomy, might be more appropriate. (http://clinicaltrials.gov, NCT02071030).

Evaluation of the anterior mandibular donor site one year after secondary reconstruction of an alveolar cleft: 3-dimensional analysis using cone-beam computed tomography

The aim of this study was to analyse changes in the volume of the chin after harvest of a bone graft for secondary reconstruction of an alveolar cleft. Cone-beam computed tomographic (CT) scans of 27 patients taken preoperatively, and immediately and one year postoperatively, were analysed, and 3-dimensional hard-tissue reconstructions made. The hard-tissue segmentation of the scan taken one year postoperatively was subtracted from the segmentation of the preoperative scan to calculate the alteration in the volume of bone at the donor site (chin). A centrally-orientated persistent concavity at the buccal side of the chin was found (mean (range) 160 (0-500) mm(3)). At the lingual side of the chin, a central concavity remained (mean (range) volume 20 (0-80) mm(3)). Remarkably, at the periphery of this concavity there was overgrowth of new bone (mean (range) volume 350 (0-1600) mm(3)). Re-attachment of the muscles of the tongue resulted in a significantly larger central lingual defect one year postoperatively (p=0.01). We also measured minor alterations in volume of the chin at one year. Whether these alterations influence facial appearance and long term bony quality is to be the subject of further research.

Development of a three-dimensional hand model using 3D stereophotogrammetry: Evaluation of landmark reproducibility

BACKGROUND

Using three-dimensional (3D) photography, exact images of the human body can be produced. Over the last few years, this technique is mainly being developed in the field of maxillofacial reconstructive surgery, creating fusion images with computed tomography (CT) data for accurate planning and prediction of treatment outcome. However, in hand surgery, 3D photography is not yet being used in clinical settings.

METHODS

The aim of this study was to develop a valid method for imaging the hand using 3D stereophotogrammetry. The reproducibility of 30 soft tissue landmarks was determined using 3D stereophotogrammetric images. Analysis was performed by two observers on 20 3D photographs. Reproducibility and reliability of the landmark identification were determined using statistical analysis.

RESULTS

The intra- and interobserver reproducibility of the landmarks were high. This study showed a high reliability coefficient for intraobserver (1.00) and interobserver reliability (0.99). Identification of the landmarks on the palmar aspect of individual fingers was more precise than the identification of landmarks of the thumb.

CONCLUSIONS

This study shows that 3D photography can safely produce accurate and reproducible images of the hand, which makes the technique a reliable method for soft tissue analysis. 3D images can be a helpful tool in pre- and postoperative evaluation of reconstructive trauma surgery, in aesthetic surgery of the hand, and for educational purposes. The use in everyday practice of hand surgery and the concept of fusing 3D photography images with radiologic images of the interior hand structures needs to be further explored.

Three-dimensional facial analysis in acromegaly: a novel tool to quantify craniofacial characteristics after long-term remission

PURPOSE

The exact quantification of craniofacial characteristics in patients with acromegaly is important because it provides insight in the pathophysiology of the disease and offers a tool to evaluate the effects of treatment on tissue specific endpoints. However, until recently this was not feasible due to limitations of available cephalometric methods. The new technique of three-dimensional (3D) cephalometry enables the accurate quantification of facial anatomical characteristics of both soft tissue and bone. This is the first study that uses 3D cephalometry to analyze craniofacial disproportions in patients in long-term remission of acromegaly.

METHODS

Sixteen patients in remission of acromegaly for over 24 months (50% male, mean age 56.0 ± 10.7 years, mean body mass index 29.3 ± 5.5 kg/m(2)) were compared to 16 matched control subjects. A 3D cone beam computed tomography scan and 3D stereophotograph of each individual were acquired and analyzed using 3D cephalometry.

RESULTS

In addition to an accurate quantification of the classical craniofacial characteristics, 3D cephalometry, shows that many typical soft tissue deformities persist, even after long-term remission. Furthermore, we found that, compared to controls, the patients in remission of acromegaly have a wider face at the level of the zygoma and longer maxilla (p < 0.05).

CONCLUSIONS

3D cephalometry is an attractive novel imaging modality to accurately investigate craniofacial disproportions of both soft tissue and bony parts of the face in patients with acromegaly, which makes it a promising technique for future research purposes and clinical practice.

Three-dimensional changes in nose and upper lip volume after orthognathic surgery

Orthognathic surgery aims to improve both the function and facial appearance of the patient. Translation of the maxillomandibular complex for correction of malocclusion is always followed by changes to the covering soft tissues, especially the nose and lips. The purpose of this study was to evaluate the changes in the nasal region and upper lip due to orthognathic surgery using combined cone beam computed tomography (CBCT) and three-dimensional (3D) stereophotogrammetry datasets. Patients who underwent a Le Fort I osteotomy, with or without a bilateral sagittal split osteotomy, were included in this study. Pre- and postoperative documentation consisted of 3D stereophotogrammetry and CBCT scans. 3D measurements were performed on the combined datasets and analyzed. Anterior translation and clockwise pitching of the maxilla led to a significant volume increase in the lip. Cranial translation of the maxilla led to an increase in the alar width. The combination of CBCT DICOM data and 3D stereophotogrammetry proved to be useful in the 3D analysis of the maxillary hard tissue changes, as well as changes in the soft tissues. Measurements could be acquired and compared to investigate the influence of maxillary movement on the soft tissues of the nose and the upper lip.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology

OBJECTIVE

To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography.

DESIGN

During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106).

RESULTS

For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging.

CONCLUSIONS

Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology

OBJECTIVE

To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography.

DESIGN

During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106).

RESULTS

For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging.

CONCLUSIONS

Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology

OBJECTIVE

To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography.

DESIGN

During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106).

RESULTS

For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging.

CONCLUSIONS

Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

Three dimensional evaluation of facial asymmetry after mandibular reconstruction: validation of a new method using stereophotogrammetry

The scientific literature is sparse on reports that evaluate facial asymmetry after mandibular reconstructive surgery objectively. The aim of this study is to introduce and validate a new method, using three dimensional (3D) stereophotogrammetry, that quantifies soft-tissue facial asymmetry in patients who have undergone mandibular reconstruction. To validate the new method, two observers applied the method on 3D photographs of five patients and five controls. An inter-observer difference of 0.04 mm (-0.08 to 0.17) was found with a measurement error of 0.13 mm. 15 3D photographs of the mandibular reconstructed patients were compared with 24 3D photographs of healthy controls. A significant difference (1.19 mm) in asymmetry was found between patients and controls. It is concluded that this new measuring method is a valid, fast and clinically applicable technique to quantify soft-tissue facial asymmetry. It is concluded that facial symmetry in patients is not restored to the level of the control group with the mandibular reconstruction method applied.

[Sclerosis of lymfangiomas in the head and neck area: evaluation with the use of stereophotogrammetry]

Lymangiomas are congenital malformations of the lymphatic system. They can appear at any age and in any part of the body. In the head and neck area lymangiomas can give rise to functional as well as esthetic problems. Therapy consist of sclerosis, possibly followed by surgical excision. Stereophotogrammetry is a relatively new technique which, by means of superimposition of pre- and postoperative images, provides the possibility to quantify treatment results. In this paper 3 patients who underwent treatment of a lymphatic malformation and in whom treatment results were measured with stereophotogrammetry are discussed. The conclusion can be drawn that stereophotogrammetry is a promising technique for evaluation of treatment results of superficially localised lymphatic malformations that displace the skin in the head and neck area.

The clinical relevance of bifid and trifid mandibular canals

Background

Bifid mandibular canals (BMC) and trifid mandibular canals (TMC) are variations on the normal anatomy with incidences ranging from 0.08% to 65.0%. Such aberrations have an important clinical impact. For example, an extra mandibular canal may explain inadequate anesthesia, especially when two mandibular foramina are involved. Furthermore, during mandibular surgery, a second, or even third, neurovascular bundle may be damaged causing paresthesia, neuroma development, or bleeding.

Case report

Two cases are presented in this article. One patient had a BMC on both sites, and the other patient had a TMC on one site and a BMC on the other site.

Discussion

Initial screening for the presence of a BMC or TMC can be executed by conventional panoramic radiography. BMCs or TMCs are diagnosed, before executing mandibular surgery; additional CBCT scanning is indicated.

Long-term results of trismus release in noma patients

Noma, also known as cancrum oris, is an infectious disease that results in a loss of orofacial tissue, due to gangrene of soft and bony tissue. It is especially seen in young children in the sub-Saharan region. Among the sequelae of patients who survive noma, trismus is one of the most disabling. This retrospective research studied the long-term results of trismus release in noma patients. Thirty-six patients could be traced in the villages and were included in the study. The mean mouth opening in this group was 10.3mm (95% CI: 7.0; 13.6mm) and the mean period after discharge from hospital was 43 months. Better mouth opening was observed in patients who continued physiotherapy after discharge, were older, and those with a 'soft' (vs. 'hard') inner and outer cheek on palpation. The result of trismus release in noma patients in the long term was extremely poor in this study.

3D Stereophotogrammetric assessment of pre- and postoperative volumetric changes in the cleft lip and palate nose

In cleft lip and palate patients the shape of the nose invariably changes in three dimensions (3D) due to rhinoplastic surgery. The purpose of this study was to evaluate stereophotogrammetry as a 3D method to document volumetric changes of the nose in patients with a cleft lip (CL) or cleft lip and palate (CLP) after secondary open rhinoplasty. 12 patients with unilateral CL or CLP were enrolled in the study prospectively. 3D facial images were acquired using 3D stereophotogrammetry preoperatively and 3 months postoperatively. A 3D cephalometric analysis of the nose was performed and volumetric data were acquired. The reliability of the method was tested by performing an intra- and inter-observer analysis. Left, right and total nasal volumes and symmetry were compared. No statistically significant differences (p<0.05) were found within and between observers for the measured volumes and symmetry. Postoperatively, the total volume of the nose increased significantly, especially the volume at the cleft side. No significant volume difference pre- and postoperatively was found for the non-cleft side. The symmetry of the nose improved significantly. 3D stereophotogrammetry is a sensitive, quick, non-invasive method for evaluating volumetric changes of the nose in patients with cleft lip or cleft lip and palate.

Diagnostic accuracy of transabdominal ultrasound in detecting prenatal cleft lip and palate: a systematic review

OBJECTIVES

To systematically review the diagnostic accuracy of second-trimester transabdominal ultrasound in detecting orofacial clefts in low- and high-risk populations and to compare two-dimensional (2D) with three-dimensional (3D) ultrasound techniques.

METHODS

MEDLINE and EMBASE were searched for articles published in English, Dutch, French or German using the keywords 'cleft' and 'ultrasound' or 'screening' or 'sonogram' and 'prenatal' or 'antenatal' or 'fetus' to identify cohort studies and randomized trials in order to assess the detection rate by prenatal ultrasound of cleft lip and palate in high-risk and low-risk pregnant women.

RESULTS

Of 451 citations identified, 27 met the criteria for the systematic review, 21 involving unselected low-risk populations and six involving high-risk populations. In the selected studies there was diversity in the gestational age at which the ultrasound examination was performed and there was considerable variety in the diagnostic accuracy of 2D ultrasound in the low-risk women, with prenatal detection rates ranging from 9% to 100% for cleft lip with or without cleft palate, 0% to 22% for cleft palate only and 0% to 73% for all types of cleft. 3D ultrasound in high-risk women resulted in a detection rate of 100% for cleft lip, 86% to 90% for cleft lip with palate and 0% to 89% for cleft palate only.

CONCLUSIONS

2D ultrasound screening for cleft lip and palate in a low-risk population has a relatively low detection rate but is associated with few false-positive results. 3D ultrasound can achieve a reliable diagnosis, but not of cleft palate only.

[Unilateral surgically assisted rapid maxillary expansion using a transpalatal distractor]

A 46-year-old woman was referred for orthodontic surgery consultation because ofa retrognathic maxilla, unilateral cross bite and functional, aesthetic and speech problems. The maxilla was widened unilaterally by unilateral surgically assisted rapid maxillary expansion with a bone-borne transpalatal distractor. During post-operative orthodontic treatment, a temporary anchorage device was administered. With the help of composite veneers, crowns and a removable partial denture, a functionally and aesthetically satisfying result was achieved.

A comparison between 2D and 3D cephalometry on CBCT scans of human skulls

The purpose of this study was to evaluate whether measurements on conventional cephalometric radiographs are comparable with 3D measurements on 3D models of human skulls, derived from cone beam CT (CBCT) data. A CBCT scan and a conventional cephalometric radiograph were made of 40 dry skulls. Standard cephalometric software was used to identify landmarks on both the 2D images and the 3D models. The same operator identified 17 landmarks on the cephalometric radiographs and on the 3D models. All images and 3D models were traced five times with a time-interval of 1 week and the mean value of repeated measurements was used for further statistical analysis. Distances and angles were calculated. Intra-observer reliability was good for all measurements. The reproducibility of the measurements on the conventional cephalometric radiographs was higher compared with the reproducibility of measurements on the 3D models. For a few measurements a clinically relevant difference between measurements on conventional cephalometric radiographs and 3D models was found. Measurements on conventional cephalometric radiographs can differ significantly from measurements on 3D models of the same skull. The authors recommend that 3D tracings for longitudinal research are not used in cases were there are only 2D records from the past.

Prevention of thrombosis after microvascular tissue transfer in the head and neck. A review of the literature and the state of affairs in Dutch Head and Neck Cancer Centers

Free vascularized graft or free-flap reconstruction is frequently used in the reconstruction of defects in head and neck oncology patients. A common complication in free-flap surgery is thrombosis. Thrombosis occurs in 8-14% of cases and often leads to flap failure. A review of the literature on this subject was carried out and Dutch head and neck cancer centres were asked to share their guidelines concerning the prevention of thrombosis after free vascularized graft surgery. No consensus in the literature was found on how thrombosis could best be prevented. The Dutch Head and Neck Cancer Centers use routine deep venous thrombosis prophylaxis to prevent thrombosis in the anastomosis. It was also concluded that non-pharmacologic measures for preventing thrombosis, such as meticulous microvascular surgery and smoking cessation prior to the operation, are thought to play an important role in the prevention of thrombosis in microvascular free-flap reconstructions. It has not been determined which pre- and postoperative pharmacologic measure can prevent thrombosis most effectively. A pharmacologic regimen to prevent thrombosis that is customized to the patient is suggested. This should be based on an individual risk profile for the development of thrombosis.

Position of the impacted third molar in relation to the mandibular canal. Diagnostic accuracy of cone beam computed tomography compared with panoramic radiography

This study investigated the diagnostic accuracy of cone beam computed tomography (CBCT) compared to panoramic radiography in determining the anatomical position of the impacted third molar in relation with the mandibular canal. The study sample comprised 53 third molars from 40 patients with an increased risk of inferior alveolar nerve (IAN) injury. The panoramic and CBCT features (predictive variables) were correlated with IAN exposure and injury (outcome variables). Sensitivity and specificity of modalities in predicting IAN exposure were compared. The IAN was exposed in 23 cases during third molar removal and injury occurred in 5 patients. No significant difference in sensitivity and specificity was found between both modalities in predicting IAN exposure. To date, lingual position of the mandibular canal was significantly associated with IAN injury. CBCT was not more accurate at predicting IAN exposure during third molar removal, however, did elucidate the 3D relationship of the third molar root to the mandibular canal; the coronal sections allowed a bucco-lingual appreciation of the mandibular canal to identify cases in which a lingually placed IAN is at risk during surgery. This observation dictates the surgical approach how to remove the third molar, so the IAN will not be subjected to pressure.

A comparison of frontal radiographs obtained from cone beam CT scans and conventional frontal radiographs of human skulls

This study evaluated whether measurements on conventional frontal radiographs are comparable with measurements on cone beam computed tomography (CBCT)-constructed frontal cephalometric radiographs taken from dry human skulls. CBCT scans and conventional frontal cephalometric radiographs were made of 40 dry skulls. With I-Cat Vision((R)) software, a cephalometric radiograph was constructed from the CBCT scan. Standard cephalometric software was used to identify landmarks and calculate ratios and angles. The same operator identified 10 landmarks on both types of cephalometric radiographs on all Images 5 times with a time-interval of 1 week. Intra-observer reliability was acceptable for all measurements. The reproducibility of the measurements on the frontal radiographs obtained from the CBCT scans was higher than those on conventional frontal radiographs. There is a statistically significant and clinically relevant difference between measurements on conventional and constructed frontal radiographs. There is a clinically relevant difference between angular measurements performed on conventional frontal cephalometric radiographs, compared with measurements on frontal cephalometric radiographs constructed from CBCT scans, owing to different positioning of patients in both devices. Positioning of the patient in the CBCT device appears to be an important factor in cases where a 2D projection of the 3D scan is made.

[Clinical results of bone anchors for orthodontic anchorage; the indications and surgical complications]

In order to make teeth-movement possible, orthodontic anchorage is necessary. Neighbouring teeth, a headgear, dental implants and bone anchors can be used. During the period 2002-2007 158 bone anchors have been placed in 84 patients by an oral surgeon after referral by an orthodontist in order to achieve anchorage for orthodontic treatment. The bone anchor consists of a titanium osteosynthesis-plate ending in a round neck perforating the soft tissue and a cylinder attached to it. The indications for placement, results and complications were registered. 15 anchors (9,5%) were lost prematurely and in 13 cases (8,2%) complications needing surgical intervention were reported. It is concluded that zygoma-bone anchor is a good alternative for orthodontic anchorage and the number of complications is acceptable, though there is room for improvement.

[Use of root-end filling materials in a surgical apical endodontic treatment in the Netherlands]

The material to be used for closing the root canal when carrying out a retrograde surgical apical endodontic treatment continues to be a subject of discussion. The aim of the present study was to inventory which materials are being used for this purpose at this moment by Dutch O&MF surgeons. All practicing Dutch OM&F surgeons (n = 195) were sent a questionnaire. The response rate was 77%. The results showed that at this moment intermediate restoration material (IRM) is the retrograde filling material most widely used by the Dutch O&MF surgeons (47.6%) in cases of surgical apical endodontic treatment. Amalgam, with 35%, was second, especially due to its plasticity and convenience. The choice of material is just as often determined by tradition, personal preference, individual experience or scientific results. There seems to be no relationship between the dental surgeon's number of years of experience and the type of retro grade filling material which he or she uses.

[Orthodontics in general practice. 2. Treatment of eruption failures]

Since the introduction of composites and bonding in orthodontics, the possibilities of aligning impacted teeth into the dental arch after a surgical intervention, have remarkably increased. There are 4 important treatment techniques. The closed-eruption technique includes bracket-bonding to and ligating of the exposed tooth, followed by repositioning of the mucosal flap. The disadvantage of the method is the uncontrollable orthodontic force on the non-visible tooth during orthodontic extrusion. The open-eruption technique aims at keeping the exposed tooth visible, followed by spontaneous eruption. However, the exposure appears often as a radical exposure with unfavourable gingival consequences. The open-eruption technique with apical positioned mucosal flap is designed to expose teeth highly buccally impacted. The mucosal graft may cause a typical thick, stretched and not aesthetically acceptable gum after orthodontic treatment, even in case of using a split-thickness graft. The modified window technique is an open-eruption technique with minimal exposure, resulting in immediate eruption. If orthodontic treatment is required, the tooth is no longer impacted. The success rates of the 4 techniques vary from 75 until 99%. Study of the literature reveals insufficient scientific evidence in favour of 1 treatment technique. However, independent of the surgical technique applied, general practitioners play a crucial role in diagnostics of eruption failures and timely referral to an orthodontist.

[Multiple mandibular radiolucencies in an asymptomatic girl]

Routine dental radiographic examination in a 16-year-old girl revealed the presence of 3 well-defined radiolucent cystlike structures in the mandible. After clinical and radiological examination, a multiple traumatic bone cyst was diagnosed. Surgical exploration confirmed the diagnosis. Curettage of the lesions was performed. Fifteen months later, a panoramic radiograph showed almost complete ossification.

[Kabuki syndrome, a congenital syndrome with multiple anomalies]

The characteristics of a 5-years old girl, referred to a multidisciplinary team for cleft lip and palate because of speaking problems, were diagnosed as Kabuki syndrome. The Kabuki syndrome is a congenital syndrome of unknown aetiology, diagnosed based on a combination of clinical findings. It is characterised by distinctive facial features, skeletal anomalies, dermatoglyphic abnormalities, developmental delay and mild to moderate mental retardation. Children with the syndrome often have oral manifestations such as cleft palate, missing permanent teeth and conic crowns of upper incisors. The Kabuki syndrome was first described regarding the Japanese population but it is now known to occur in many other races as well. In a recent publication, 20 Dutch patients with Kabuki syndrome were described.

Hyperplasie des Processus coronoideus: Diagnose und Therapie

STUDY GOAL

As it is an unusual and infrequent clinical entity, hyperplasia of the coronoid process is often overlooked or diagnosed too late. The aim of this study was to characterize the morphology, etiology, and clinical picture of coronoid hyperplasia as well as to discuss its diagnosis and treatment.

MATERIALS AND METHODS

All cases of histologically confirmed hyperplasia of the coronoid process treated in our center between 1995 and 2004 were analyzed. Patient data were evaluated with respect to age, gender, clinical symptoms, diagnostic work-up, and treatment. The extracted data were compared to those found in the literature.

RESULTS

The study included 14 new cases and 101 cases already published: 96 with bilateral and 19 with unilateral hyperplasia. At the time of diagnosis, the subjects' mean age was 23.7 years. The patients in Bonn were all treated by coronoidectomy and appropriate physiotherapy. An improvement in mouth opening could be achieved in 86% of our patients.

CONCLUSIONS

In comparison to the somewhat disappointing results of previously published studies with regard to mouth opening and mandibular mobility, our treatment concept seems to offer the possibility for improvement. Our study emphasizes the significance of three-dimensional CT techniques for diagnosis and surgical planning, the superiority of coronoidectomy over coronoidotomy, and the importance of dynamic physiotherapy to prevent postoperative scar formation.

Steiner cephalometric analysis: predicted and actual treatment outcome compared

OBJECTIVE

To examine the accuracy and precision of the Steiner prediction cephalometric analysis.

SETTING AND SUBJECTS

The sample consisted of 275 randomly selected patients, treated between 1970 and 1995 at a university department.

METHODS

Lateral cephalograms before (T1) and after orthodontic treatment (T2) were analyzed using the Steiner analysis. A prediction of the final outcome at T2 for the variables ANB degrees, U1 to NA mm, L1 to NB mm, and Pg to NB mm was performed at T1. The difference between the actual outcome at T2 and the Steiner predicted value (SPV), which was done at T1, was calculated. Accuracy (mean difference between T2 and SPV) and precision (standard deviation of the mean prediction discrepancies) of the prediction were studied. Paired t-test was used to detect under- or overestimation of the predicted values.

RESULTS

The mean decrease in angle ANB was 1.4 +/- 2.7 degrees and for U1 to NA 2.0 +/- 2.6 mm, while L1 to NB increased 0.8 +/- 2.0 mm and Pg to NB 0.7 +/- 1.1 mm. The predicted values for the changes in ANB angle, the distance of upper incisor U1 to NA as well as the distance Pg to NB were significantly overestimated when compared with the actual outcome, while the change in the distance of lower incisor L1 to NB was underestimated.

CONCLUSION

The prediction of cephalometric treatment outcome as used in the Steiner analysis is not accurate enough to base orthodontic treatment decisions upon.

[Non ordinary radiopacity on a panoramic radiograph]

A dental panoramic radiograph of a 56-years-old Sudanese woman revealed calcifications, which could be attributed to atherosclerotic lesions of the carotid artery. The occurence of these lesions is related to the incidence of cardiovascular and cerebrovascular diseases, such as transient ischemic attack or cerebrovascular accident. Carotid calcifications can be detected in 2 to 3.8% of panoramic radiographs of patients over 50 years of age. If detected early, treatment of the disease and the underlying risk factors can significantly reduce vascular related complications. There is a significant role to be played for dentists in early referral of patients.

[Significance of prenatal diagnosis of lip-jaw-palatal clefts]

AIMS AND PATIENTS: Visualization of sonographic anatomy of the fetal face has acquired special importance, as conspicuous features in the phenotype facilitate the diagnosis of syndrome-like or chromosomally induced clinical conditions. Between 1990 and 1999, an orofacial cleft was diagnosed sonographically in 70 fetuses at the Clinic for Prenatal Diagnosis and Therapy of Bonn University Hospital. The aim of the study was to investigate whether the type of cleft correlates with the prevalence of associated anomalies or with karyotyping after amniocentesis. The types of associated anomalies and the neonatal outcome of these 70 fetuses were also reexamined.

RESULTS

We found a clearly positive correlation with the type of cleft, both for the associated anomalies and for the karyotype. The size of the cleft was much smaller with normal karyotypes than in the case of fetuses with trisomy 18. The trisomy 13 fetuses displayed the most pronounced clefts. None of the fetuses with an isolated lip cleft had an associated anomaly; all were born alive and could be treated surgically. In contrast, all the fetuses with a median cleft had severe associated anomalies that were incompatible with life. Associated anomalies occur more frequently with bilateral cleft lip and palate than with unilateral clefts. The fetuses with a unilateral cleft had a higher survival rate than those with a bilateral cleft. The most common associated anomaly in cleft fetuses is located in the region of the central nervous system.

DISCUSSION

Early sonographic information on cleft formation in combination with the karyotype can give rise to differentiated obstetric measures up to the point of termination of pregnancy in the event of an infaust prognosis.

Fetal cleft lip and palate: sonographic diagnosis, chromosomal abnormalities, associated anomalies and postnatal outcome in 70 fetuses

OBJECTIVE

The aim of this study was to determine the relationship between facial clefts, associated malformations and chromosomal abnormalities.

STUDY DESIGN

Sonograms of 70 fetuses with cleft lip with or without cleft palate were prospectively and retrospectively evaluated in our tertiary referral center for the nature of the cleft lip or palate and for the nature of the associated anomalies. Additionally, karyotyping was performed in 63 of the 70 patients (90%).

RESULTS

The frequency of additional anomalies and the mortality rate in this selected population varied with the type of cleft. None of the fetuses presenting an isolated cleft lip had additional anomalies and all survived. All fetuses presenting a median facial cleft had concurrent anomalies (particularly of the central nervous system (90%)) and a fatal outcome. Associated defects were more frequent in fetuses with bilateral clefts (72%) than in those with unilateral clefts (48%). Fetuses with a unilateral cleft lip with or without cleft palate had a better survival rate (52%) than those with a bilateral cleft lip with or without cleft palate (35%). The frequency and type of chromosomal abnormalities varied with the type of cleft. The highest rate of chromosomal abnormalities was found in fetuses with median clefts (82%).

CONCLUSIONS

Although no conclusions regarding the prevalence of chromosomal or other anomalies in patients with a cleft lip with or without cleft palate in the general population could be drawn, the study revealed a strong relationship between the type of facial cleft, associated malformations, chromosomal abnormalities and fetal outcome.

Tissue expansion using osmotically active hydrogel systems for direct closure of the donor defect of the radial forearm flap

Although widely used, the radial forearm flap has been criticized for the poor quality of its donor site. Attempts to avoid donor-site problems have concentrated on the elaboration of the split-thickness and full-thickness skin graft methods of reconstruction. Skin grafts frequently fail over the flexor carpi radialis tendon, leading to chronic skin breakdown or, at best, tendon adhesion. Tissue expansion appears to be a good alternative that allows the use of local tissues to ultimately improve the forearm donor-site appearance. To avoid the disadvantages of traditional silicone balloon expanders (such as pressure peaks, infection, the valve at a distance from the expander, postoperative fillings), an osmotically active system was used. In an 18-month prospective study, 10 osmotically active hydrogel tissue expanders were placed on the forearms of 10 patients. The radial forearm flap was performed for intraoral reconstruction after surgical resection of oral cavity malignancies. The study showed that, in nine out of 10 patients, the expanded skin achieved was sufficient to cover the donor site after raising the forearm flap. Additionally, the expansion-related swelling pressure was well tolerated by the patients, the cosmetic results were very satisfactory, and the incidence of complications was very low. By using osmotically active hydrogel tissue expanders, there is no postoperative filling and no risk of complications arising from defective balloon expanders, filling valves, or missing ports.