The pericranium

The purpose of this chapter is to present how past surgeons have viewed the pericranium and how they have reacted to its appearances. In ancient times, the membrane was considered formed by the dura through the sutures and it retained a relationship with the dura via vessels in the sutures. It was considered advisable to strip it totally from any area to be examined for fissure fractures and also for any area to be trepanned, as pericranial injury was thought to lead to fever and inflammation. In the 18th century, a new idea arose that posttraumatic spontaneous separation of the pericranium from the bone was a reliable indicator of the development of intracranial suppuration. This idea was subsequently refuted. For over two millennia, the pericranium was considered to be an important membrane requiring the close attention of the surgeon. It is no longer required to receive more than minimal attention.

Cranial surgery and the pericranium

In contemporary neurosurgery little attention is currently paid to the pericranium. The purpose of this article is to present how past surgeons have viewed this membrane and how they have reacted to its appearances. In ancient times, the pericranium was considered formed by the dura through the sutures and it retained a relationship with the dura via vessels in the sutures. It was considered advisable to strip it totally from any area to be examined for fissure fractures and also for any area to be trepanned, as pericranial injury led to fever and inflammation. In the eighteenth century, a new idea arose that posttraumatic spontaneous separation of the pericranium from the bone was a reliable indicator of the development of intracranial suppuration. This idea was subsequently refuted. The development of the osteoplastic bone flap imposed on the surgeon the need to ensure postoperative craniotomy closure included accurate apposition of the margins of the pericranium. With modern free bone flaps, this is no longer required. For over two millenia, the pericranium was considered to be an important membrane requiring the close attention of the surgeon. It is no longer required to receive more than minimal attention.

A history of the surgery of the cranial sutures

INTRODUCTION

While the calvarial sutures have a limited importance for the modern neurosurgeon, they were of considerable interest to cranial surgeons from the time of Hippocrates onwards. The reasons for this interest together with the evolution of ideas are the subjects of this paper.

MATERIALS AND METHODS

The texts of surgeons from the time of Hippocrates to the eighteenth century have been studied and analysed.

RESULTS

Hippocrates advised against trepanation through a suture without specifying why. Galen taught that the dura was only attached to the interior of the calvarium at the sutures. The first author to state that the attachment was diffuse was Berengario da Carpi, at the beginning of the sixteenth century. This teaching was subsequently ignored until the eighteenth century, from which time it has been universally accepted. It was also first emphasized in the eighteenth century that it was not dangerous to trepan at the sutures.

CONCLUSIONS

This study documents the persistence of incorrect ideas from classical times to the middle of the eighteenth century. These notions would have limited the regions available for surgical access to the skull and thereby limited the benefits to be derived from surgery.

Augmented reality navigation for minimally invasive craniosynostosis surgery: a phantom study

Purpose

In minimally invasive spring-assisted craniectomy, surgeons plan the surgery by manually locating the cranial sutures. However, this approach is prone to error. Augmented reality (AR) could be used to visualize the cranial sutures and assist in the surgery planning. The purpose of our work is to develop an AR-based system to visualize cranial sutures, and to assess the accuracy and usability of using AR-based navigation for surgical guidance in minimally invasive spring-assisted craniectomy.

Methods

An AR system was developed that consists of an electromagnetic tracking system linked with a Microsoft HoloLens. The system was used to conduct a study with two skull phantoms. For each phantom, five sutures were annotated and visualized on the skull surface. Twelve participants assessed the system. For each participant, model alignment using six anatomical landmarks was performed, followed by the participant delineation of the visualized sutures. At the end, the participants filled a system usability scale (SUS) questionnaire. For evaluation, an independent optical tracking system was used and the delineated sutures were digitized and compared to the CT-annotated sutures.

Results

For a total of 120 delineated sutures, the distance of the annotated sutures to the planning reference was \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$2.4\pm 1.2$$\end{document}2.4±1.2 mm. The average delineation time per suture was \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$13\pm 5$$\end{document}13±5 s. For the system usability questionnaire, an average SUS score of 73 was obtained.

Conclusion

The developed AR-system has good accuracy (average 2.4 mm distance) and could be used in the OR. The system can assist in the pre-planning of minimally invasive craniosynostosis surgeries to locate cranial sutures accurately instead of the traditional approach of manual palpation. Although the conducted phantom study was designed to closely reflect the clinical setup in the OR, further clinical validation of the developed system is needed and will be addressed in a future work.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11548-022-02634-y.

[A cone-beam computed tomography evaluation of three-dimensional changes of circummaxillary sutures following maxillary protraction with alternate rapid palatal expansions and constrictions]

OBJECTIVE

To assess three-dimensional (3D) changes of circummaxillary sutures following maxillary protraction with alternate rapid palatal expansions and constrictions (RPE/C) facemask protocol in maxillary retrusive children, and to investigate the relationship between the changes of circum-maxillary sutures and zygomaticomaxillary suture (ZMS) maturation, and to explore the factors of maxilla forward movement with RPE/C and facemask.

METHODS

In the study (clinical trial registration No: ChiCTR2000034909), 36 maxillary retrusive patients were recruited and block randomized to either the rapid palatal expansion (RPE) group or the RPE/C group. Patients aged 7 to 13 years, Class Ⅲ malocclusion, anterior crossbite, ANB less than 0°, Wits appraisal less than -2 mm, and A-Np less than 0 mm were included in the study. The RPE group received rapid palatal expansion, whereas the RPE/C group received alternate rapid palatal expansions and constrictions, and both with facemask protraction. Head orientations of cone-beam computed tomography (CBCT) images were implemented by Dolphin 11.7. 3D measurements of circummaxillary sutures on CBCT images were evaluated using Mimics 10.01 before (T0) and after treatment (T1). The changes were analyzed with independent t test, two-way ANOVA, Pearson correlation and regression analysis.

RESULTS

Two subjects in the RPE/C group were lost to follow-up. A total of 34 patients reached the completion criteria and were analyzed. Compared with the RPE group, sagittal changes of circummaxillary sutures were significantly increased in the RPE/C group with 1.21 mm advancement of zygomaticotemporal suture, 2.20 mm of ZMS, 1.43 mm of zygoma-ticofrontal suture (P < 0.05, respectively). Except for the zygomaticotemporal suture, the rest forward sagittal changes of other circummaxillary sutures showed no major difference in terms of the ZMS maturation. The Spearman's correlation in RPE/C indicated a strong positive correlation of sagittal changes between ZMS and point A (P < 0.01) with a regression analysis R²=42.5%.

CONCLUSION

RPE/C might be more effective on the treatment of maxillary retrusive children. As one of the major mechanical loading sutures during orthopedic therapy, ZMS showed a strong positive correlation with point A on sagittal changes.

[A cone-beam computed tomography evaluation of three-dimensional changes of circummaxillary sutures following maxillary protraction with alternate rapid palatal expansions and constrictions]

OBJECTIVE

To assess three-dimensional (3D) changes of circummaxillary sutures following maxillary protraction with alternate rapid palatal expansions and constrictions (RPE/C) facemask protocol in maxillary retrusive children, and to investigate the relationship between the changes of circum-maxillary sutures and zygomaticomaxillary suture (ZMS) maturation, and to explore the factors of maxilla forward movement with RPE/C and facemask.

METHODS

In the study (clinical trial registration No: ChiCTR2000034909), 36 maxillary retrusive patients were recruited and block randomized to either the rapid palatal expansion (RPE) group or the RPE/C group. Patients aged 7 to 13 years, Class Ⅲ malocclusion, anterior crossbite, ANB less than 0°, Wits appraisal less than -2 mm, and A-Np less than 0 mm were included in the study. The RPE group received rapid palatal expansion, whereas the RPE/C group received alternate rapid palatal expansions and constrictions, and both with facemask protraction. Head orientations of cone-beam computed tomography (CBCT) images were implemented by Dolphin 11.7. 3D measurements of circummaxillary sutures on CBCT images were evaluated using Mimics 10.01 before (T0) and after treatment (T1). The changes were analyzed with independent t test, two-way ANOVA, Pearson correlation and regression analysis.

RESULTS

Two subjects in the RPE/C group were lost to follow-up. A total of 34 patients reached the completion criteria and were analyzed. Compared with the RPE group, sagittal changes of circummaxillary sutures were significantly increased in the RPE/C group with 1.21 mm advancement of zygomaticotemporal suture, 2.20 mm of ZMS, 1.43 mm of zygoma-ticofrontal suture (P < 0.05, respectively). Except for the zygomaticotemporal suture, the rest forward sagittal changes of other circummaxillary sutures showed no major difference in terms of the ZMS maturation. The Spearman's correlation in RPE/C indicated a strong positive correlation of sagittal changes between ZMS and point A (P < 0.01) with a regression analysis R2=42.5%.

CONCLUSION

RPE/C might be more effective on the treatment of maxillary retrusive children. As one of the major mechanical loading sutures during orthopedic therapy, ZMS showed a strong positive correlation with point A on sagittal changes.

Skeletal and alveolar changes in conventional rapid palatal expansion (RPE) and miniscrew-assisted RPE (MARPE): a prospective randomized clinical trial using low-dose CBCT

Background

This prospective randomized clinical trial aimed to evaluate the immediate and short-term skeletal, dentoalveolar, and periodontal effects of rapid palatal expansion (RPE) and miniscrew-assisted RPE (MARPE) in adolescent and young adult patients.

Methods

This study followed a two-arm, parallel, randomized clinical trial design that recruited patients with transverse maxillary deficiency in a 1:1 allocation ratio. Forty patients (14 men and 26 women) requiring maxillary expansion were randomly allocated to the RPE (n = 20, age = 14.0 ± 4.5) or MARPE (n = 20, age = 14.1 ± 4.2) groups. The assignment was performed via computer-generated block randomization, with a block size of four. Upon identical (35 turns) amount of expansion, low-dose cone-beam computed tomography images were taken before treatment (T0), immediately after expansion (T1), and after a 3-month consolidation period (T2). The primary outcome of this study comprised the assessment of midpalatal suture separation. Secondary outcomes included, skeletal, dentoalveolar, and periodontal measurements, which were performed at each time point.

Results

The frequency of midpalatal suture separation was 90% (18/20) and 95% (19/20) for the RPE and MARPE groups, respectively. A greater increase in nasal width in the molar region (M-NW) and greater palatine foramen (GPF) was observed immediately after the expansion (T1-T0) and consolidation periods (T2-T0) in the MARPE group compared to the RPE group (P < 0.05). The MARPE and RPE groups showed similar dentoalveolar changes except for the maxillary width (PM-MW, M-MW). The MARPE group presented greater bilateral first premolar (PM-MW) and molar (M-MW) maxillary width in relation to the RPE group (P < 0.05). Through the expansion and consolidation periods (T2-T0), lesser buccal displacement of the anchor teeth was observed in the MARPE group (PM-BBPT, PM-PBPT, M-BBPT [mesial and distal roots], and M-PBPT)( P < 0.05).

Conclusions

Midpalatal suture separation was observed in 90% and 95% of patients in the RPE and MARPE groups, respectively. Both RPE and MARPE groups exhibited significant triangular basal bone expansion and skeletal relapse during consolidation. Under identical amounts of expansion, the MARPE group showed lower decrease in the skeletal, dentoalveolar and periodontal variables after consolidation. The reinforcement of RPE with miniscrews contributes to the maintenance of the basal bone during consolidation period.

Trial registration WHO Institutional Clinical Trials Registry Platform (IRB No. KCT0006871 / Registration date 27/12/2021).

FollowTheSutures: Piloting a new way to administer onabotulinumtoxinA for chronic migraine

Background

Anatomical and experimental data indicate that onabotulinimtoxin A could be more efficient and cost-effective for treating chronic migraine with injections targeting the cranial sutures, where collaterals from the meninges penetrate the skull.

Methods

A new injection paradigm (FollowTheSutures) was tested for safety, tolerability and feasibility in a Phase II, open-label, non-controlled, single-center pilot study. Ninety units of onabotulinimtoxin A (Botox®), were injected in 18 sites over the area of the cranial sutures. Adverse events and potential beneficial effects were recorded in a headache diary at least 4 weeks before, and for 12 weeks after the injections. A higher dilution than normal of onabotulinimtoxin A was used to get better diffusion.

Results

Nineteen (of 20 included) women with chronic migraine received the injections and were evaluable. There was only one treatment-related adverse event (reduced power of chewing for some weeks). Otherwise, the procedure was overall well tolerated. Patients improved on most efficacy parameters after the injections. There was little or no effect on glabellar or forehead lines.

Conclusions

The protocol was safe and well tolerated. Lower risk of unblinding due to the absence of cosmetic effects should make the injection procedure well suited for a large, randomized, placebo-controlled study. If efficacy is confirmed, it will be markedly less costly than the standard procedure.

Trial registration: EUDRACT (2017-002516-13), ClinicalTrials.gov (NCT03543254).

Pediatric skull fractures: could suture contact be a sign of abuse?

PURPOSE

Skull fractures in infants and young children can occur as a result of both accidental trauma and abuse. 1/3 of children with abuse-related head trauma and 1/5 of children with abuse-related fractures were overlooked during the initial evaluation. In this study, we aim to investigate the prevalence of skull fractures that come into contact with the suture in head traumas caused by accidents and abuse, and also to see if contact of the fracture line with the suture could be used as a sign for abuse in the pediatric population.

METHODS

Forry-four patients with head trauma were retrospectively assessed between January 2010 and June 2020 and were confirmed to have fractures on a brain CT. Patient age, gender, and head injury type were recorded. The fracture site, location and number, the contact of the fracture line with the suture, the name, and number of the suture it came into contact with were determined.

RESULTS

Twenty-eight skull fractures in 22 children with a diagnosis of child abuse and 25 skull fractures in 22 children due to accidental trauma were evaluated in the same age and gender range. Eighteen (64%) of 28 abuse-related skull fractures were in contact with two or more sutures. Two (8%) of 25 accident-related fractures were related to two or more sutures. Abuse-related fractures had a significantly higher suture contact rate than accident-related fractures (p = 0.007).

CONCLUSION

Contact with two or more sutures of a skull fracture is a finding related to abuse rather than accident.

The success and effectiveness of miniscrew-assisted rapid palatal expansion are age- and sex-dependent

OBJECTIVES

This study aimed to assess the success rate and the amount of suture separation after the miniscrew-assisted rapid palatal expansion (MARPE) procedure in relation to the chronological age and sex of the patients.

MATERIALS AND METHODS

The periapical radiographs of 215 subjects (95 male; 120 female; range, 6-60 years) who had undergone MARPE treatment were retrospectively analyzed. The success of suture separation was determined and, in suture-separated subjects, the amount of suture separation was evaluated by suture separation ratio calculated from the periapical radiograph obtained after active expansion. Association tests were performed using linear-by-linear association, the Jonckheere-Terpstra test, Fisher's exact test, and the Mann-Whitney U test, and linear regression models were also developed.

RESULTS

The success rate of suture separation was 61.05% in male, 94.17% in female, and 79.53% in both sexes. There was a statistically significant association between older age and suture nonseparation in male (p < 0.001), but not in female (p = 0.221). In suture-separated subjects, there was a statistically significant trend toward a low amount of suture separation with older age subgroups in both sexes (p < 0.001); however, there was no statistically significant difference in the amount of suture separation between male and female in all age subgroups.

CONCLUSIONS

Older patients treated with MARPE, particularly in male, may have a reduced likelihood of both success in suture separation and sufficient basal bone expansion.

CLINICAL RELEVANCE

This study demonstrates that clinicians should consider that the success rate of MARPE and the amount of suture separation may depend on chronological age and sex.

Diagnosis and Management of Suture-Related Concerns of the Infant Skull

The cranial fontanelles and sutures have several benign variations, including most cases of "early" or "late" closure of the anterior fontanelle, bathrocephaly, overriding sutures, and benign metopic ridging. However, recognizing true craniosynostosis and referring the patient to a craniofacial specialist in a timely fashion are imperative, as minimally invasive options can be offered to most patients younger than 6 months of age. Gaining comfort with the physical examination of an infant with an abnormal head shape is best achieved through experience and pattern recognition and will frequently facilitate an accurate diagnosis without the need for ionizing radiation.

Classification of the midpalatal suture maturation in individuals older than 15 years: a cone beam computed tomographic study

PURPOSE

The aim of this study was to classify the maturation of the midpalatal suture (MPS) in a sample of individuals aged 15 years and older.

METHODS

Tomographic images in axial sections of the MPS of 289 female individuals and 198 male individuals aged between 15 and 40 years were analyzed and classified in stages of maturation (A, B, C, D, and E), stage A represents the earliest maturation stage of the suture and in stage E the fusion of the MPS has occurred in the maxilla. The Kruskal-Wallis and Student-Newman-Kells tests were used to compare the chronological ages among different maturation stages. Spearman's correlation coefficient was used to assess the correlation between patient's age and the maturation stages of the MPS.

RESULTS

Stage A was not observed in the sample. Stages B and C represent, respectively, 1.03% and 34.09% of the sample, stage D was found in 16.63% of the sample while stage E was the most prevalent stage found (48.25%). For females, it was revealed no statistically significant difference in the mean ages among stages C, D and E (p = 0.4753). For males, a statistically significant difference was observed, with the mean age of individuals in stages D and E of the MPS maturation higher than in other stages (p = 0.0001). There was a significant, but weak, correlation between patient's age and the maturation stages of the suture (rs = 0.11/p = 0.01).

CONCLUSION

No individuals in stage A of suture maturation were found and stage B was identified in only 1% of the sample. The majority of the patients (64.88%) presented at least partial fusion of the MPS (stages D and E).

Late presenting bilateral squamosal synostosis

Premature fusion of one or other of the minor sutures can subtly influence the shape of the human skull. Although infrequently reported or not clinically recognized, it can such contribute to a variety of craniofacial dysmorphisms. We herein report a case of late presenting, isolated bilateral synostosis of the squamosal suture dysmorphologies whose presentation mimics aspects of sagittal synostosis.

Crouzon Syndrome in a Ten-week-old Infant: A Case Report

Crouzon syndrome is a rare genetic disorder. We report a rare case of Crouzon syndrome in a very young infant with distinct features of craniofacial malformations. A 10-week-old male child presented with features of craniofacial dysostosis with abnormal shape of the skull, proptosis, hypertelorism, curved nose and frontal bossing. Radiological findings revealed a predominant premature fusion of sagittal sutures. The infant had airway obstruction. Features of hydrocephalus, papilledema and optic atrophy were not evident. We chose to manage the symptoms and prevent complications, and the surgery was deferred for later, depending on the degree of malformation and psychological needs. Diagnosis of this rare condition at an early stage can help in preventing the development of complications. A careful follow-up and appropriate surgical intervention can improve the prognosis of this condition, which carries the risk of respiratory complications, poor vision and, in some cases, mental retardation as the age advances.

Exome sequencing reveals a novel splice site variant in HUWE1 gene in patients with suspected Say-Meyer syndrome

Say-Meyer syndrome is a rare and clinically heterogeneous syndrome characterized by trigonocephaly, short stature, developmental delay and hypotelorism. Nine patients with this syndrome have been reported thus far although no causative gene has yet been identified. Here, we report two siblings with clinical phenotypes of Say-Meyer syndrome with moderate to severe intellectual disability and autism spectrum disorder. Cytogenetics and array-based comparative genomic hybridization did not reveal any chromosome abnormalities or copy number alterations. Exome sequencing of the patients revealed a novel X-linked recessive splice acceptor site variant c.145-2A > G in intron 5 of HUWE1 gene in both affected siblings. RT-PCR and sequencing revealed the use of an alternate cryptic splice acceptor site downstream, which led to deletion of six nucleotides resulting loss of two amino acids p.(Cys49-Glu50del) in HUWE1 protein. Deletion of these two amino acids, which are located in a highly conserved region, is predicted to be deleterious and quite likely to affect the function of HUWE1 protein. This is the first report of a potential candidate gene mutation for Say-Meyer syndrome, which was initially described four decades ago.

Structural Genome Variations Related to Craniosynostosis

Craniosynostosis refers to a condition during early development in which one or more of the fibrous sutures of the skull prematurely fuse by turning into bone, which produces recognizable patterns of cranial shape malformations depending on which suture(s) are affected. In addition to cases with isolated cranial dysmorphologies, craniosynostosis appears in syndromes that include skeletal features of the eyes, nose, palate, hands, and feet as well as impairment of vision, hearing, and intellectual development. Approximately 85% of the cases are nonsyndromic sporadic and emerge after de novo structural genome rearrangements or single nucleotide variation, while the remainders consist of syndromic cases following mendelian inheritance. By karyotyping, genome wide linkage, and CNV analyses as well as by whole exome and whole genome sequencing, numerous candidate genes for craniosynostosis belonging to the FGF, Wnt, BMP, Ras/ERK, ephrin, hedgehog, STAT, and retinoic acid signaling pathways have been identified. Many of the craniosynostosis-related candidate genes form a functional network based upon protein-protein or protein-DNA interactions. Depending on which node of this craniosynostosis-related network is affected by a gene mutation or a change in gene expression pattern, a distinct craniosynostosis syndrome or set of phenotypes ensues. Structural variations may alter the dosage of one or several genes or disrupt the genomic architecture of genes and their regulatory elements within topologically associated chromatin domains. These may exert dominant effects by either haploinsufficiency, dominant negative partial loss of function, gain of function, epistatic interaction, or alteration of levels and patterns of gene expression during development. Molecular mechanisms of dominant modes of action of these mutations may include loss of one or several binding sites for cognate protein partners or transcription factor binding sequences. Such losses affect interactions within functional networks governing development and consequently result in phenotypes such as craniosynostosis. Many of the novel variants identified by genome wide CNV analyses, whole exome and whole genome sequencing are incorporated in recently developed diagnostic algorithms for craniosynostosis.

Centile charts for cranial sutures in children younger than 1 year based on ultrasound measurements

BACKGROUND

Cranial US allows for the evaluation of premature closure (synostosis) or abnormal widening of the cranial sutures. An understanding of the normal anatomy is required to help define the presence or absence of abnormality.

OBJECTIVE

To provide reference for normal ultrasound measurements of cranial sutures during the child's first year.

MATERIALS AND METHODS

We included children ages 0 to 12 months who were referred to the hospital during 2011-2013 for radiographic evaluation of cranial sutures. Cranial US study was focused on evaluating the sagittal, coronal, lambdoid and metopic sutures. We measured the hypoechoic gap between the bones (patent suture). Two readers performed the measurements, blinded to clinical indications and previous reports. Estimates of the 10^th, 25^th, 50^th, 75^th and 90^th percentiles were achieved for ages 1-12 months.

RESULTS

Of 129 children whose families consented to cranial US, 11 were excluded because of craniosynostosis and 3 for suboptimal quality of cranial US images. In 115 patients measurements of normal cranial sutures were obtained (75 boys [65%], ages 0.26-11.27 months). For each suture, the suture size decreased significantly with age (P<0.001). Only the metopic suture was noted to close completely toward the end of the first year of age. There were no statistically significant differences in age-related suture size by gender.

CONCLUSION

The current patient series represents a reference of percentiles of normal ultrasound measurements of cranial sutures during the first year of age.

A new method for sex estimation from maxillary suture length in a Thai population

Sex estimation is one of the crucial procedures in the biological profile identification of human skeletal remains. Knowing sex of unknown case can lead to accurate and appropriate methods for predicting age, stature, ancestry, or even personal identification. Skull is one of the most reliable one among other skeletons and it is usually retained for both archaeological and forensic contexts. Although many morphological features and metric measurements of skull have been studied for sexing, but to the best of our knowledge is no study on maxillary suture length for sex estimation. Therefore, this study aims to develop a new sex estimation method for a Thai population by determining three maxillary suture lengths: anterior, transverse, and posterior maxillary suture, by computerizing amount of pixel obtained from photographs of these sutures. The present study was conducted on 190 Thai bone samples of which 96 were males and 94 were females. Independent t test revealed statistically significant difference (P<0.01) between males and females in all maxillary suture measurements. Equations derived from prediction model, which required three maxillary suture lengths gave 76.8421% accuracy from the leave-one-out cross validation in estimating sex percentage accuracies in predicting sex from these equations, which were relatively moderate. This study provides a novel and objective sex estimation method for Thais. It suggests that maxillary suture length can be applied for sex estimation. The new computerized technique will contribute basis knowledge and method for sex estimation, especially when only base of skull is available in forensic circumstance.

Effectiveness of screening for craniosynostosis with ultrasound: a retrospective review

BACKGROUND

Minimizing the ionizing radiation dose to children is fundamental to pediatric radiology. The most widely accepted imaging examination for evaluating craniosynostosis is computed tomography (CT) of the head, an examination that involves ionizing radiation.

OBJECTIVE

To determine if sonography of the cranial sutures is an adequate screening examination for the diagnosis of craniosynostosis in patients with abnormal skull shape.

MATERIALS AND METHODS

A retrospective review of all cranial suture ultrasound (US) examinations performed during the course of a 3-year period (July 2012 - September 2015) was undertaken. Results were compared with clinical follow-up and/or head CT to evaluate the accuracy of this modality as a screening tool to determine the presence or absence of craniosynostosis. Fifty-two sonographic exams were adequate for inclusion.

RESULTS

Forty-five of the examinations did not reveal synostosis. In each of these instances, follow-up physical exam findings and/or CT imaging confirmed that no abnormal premature suture closure was present. US findings demonstrated synostosis in seven cases. CT exam or operative reports of these cases confirmed all seven findings of premature suture closure. Statistical analysis demonstrated a sensitivity of 100% (95% confidence interval [CI]: 56.1-100.0%), a specificity of 100% (95% CI: 90.2-100.0%), and a negative predictive value of 100% (95% CI: 90.2-100.0%).

CONCLUSION

Cranial US is a reliable screening tool to rule out craniosynostosis in patients with abnormal head shape.

Evaluation of the palatal split pattern in surgically rapid maxillary expansion-comparison of two techniques

PURPOSE

Surgically assisted rapid maxillary expansion is performed to correct transverse deficiencies of the maxilla, and it is indicated in specific clinical situations. The literature presents different opinions in several aspects, mainly regarding the effect of disjunction of the pterygoid plates. The aim of this study was to evaluate the pattern of maxillary expansion obtained with two surgical techniques, with and without disjunction of the pterygoid plates.

METHODS

Twenty patients treated with surgically assisted rapid maxillary expansion for correction of transversal discrepancies were included in this retrospective study and divided into two groups: (G1) patients operated without disjunction of pterygoid plates and (G2) patients treated with release of the pterygoid plates.

RESULTS

There were seven male and 13 female patients, and the mean age was 29.9 years. Cone beam computed tomography images obtained after final activation of the expansion device were evaluated and complete disjunction of the midpalatal suture (type I) was present in 75 % of the patients whereas incomplete disjunction of the midpalatal suture (type II) was observed in 25 %. Chi-square test showed no statistically significant difference between groups (p = 0.606).

CONCLUSION

No difference was found in relation to the maxillary disjunction pattern irrespective of the treatment given to pterygoid plates.

Development and Growth of the Normal Cranial Vault : An Embryologic Review

Understanding the development of a skull deformity requires an understanding of the normal morphogenesis of the cranium. Craniosynostosis is the premature, pathologic ossification of one or more cranial sutures leading to skull deformities. A review of the English medical literature using textbooks and standard search engines was performed to gather information about the prenatal development and growth of the cranial vault of the neurocranium. A process of morphogenic sequencing begins during prenatal development and growth, continues postnatally, and contributes to the basis for the differential manner of growth of cranial vault bones. This improved knowledge might facilitate comprehension of the pathophysiology of craniosynostosis.

Craniosynostosis : Updates in Radiologic Diagnosis

The purpose of this article is to review imaging findings and to discuss the optimal imaging methods for craniosynostosis. The discussion of imaging findings are focused on ultrasonography, plain radiography, magnetic resonance imaging and computed tomography with 3-dimensional reconstruction. We suggest a strategy for imaging work-up for the diagnosis, treatment planning and follow-up to minimize or avoid ionized radiation exposure to children by reviewing the current literature.

The Development of the Calvarial Bones and Sutures and the Pathophysiology of Craniosynostosis

The skull vault is a complex, exquisitely patterned structure that plays a variety of key roles in vertebrate life, ranging from the acquisition of food to the support of the sense organs for hearing, smell, sight, and taste. During its development, it must meet the dual challenges of protecting the brain and accommodating its growth. The bones and sutures of the skull vault are derived from cranial neural crest and head mesoderm. The frontal and parietal bones develop from osteogenic rudiments in the supraorbital ridge. The coronal suture develops from a group of Shh-responsive cells in the head mesoderm that are collocated, with the osteogenic precursors, in the supraorbital ridge. The osteogenic rudiments and the prospective coronal suture expand apically by cell migration. A number of congenital disorders affect the skull vault. Prominent among these is craniosynostosis, the fusion of the bones at the sutures. Analysis of the pathophysiology underling craniosynostosis has identified a variety of cellular mechanisms, mediated by a range of signaling pathways and effector transcription factors. These cellular mechanisms include loss of boundary integrity, altered sutural cell specification in embryos, and loss of a suture stem cell population in adults. Future work making use of genome-wide transcriptomic approaches will address the deep structure of regulatory interactions and cellular processes that unify these seemingly diverse mechanisms.

Molecular basis of cranial suture biology and disease: Osteoblastic and osteoclastic perspectives

The normal growth and development of the skull is a tightly regulated process that occurs along the osteogenic interfaces of the cranial sutures. Here, the borders of the calvarial bones and neighboring tissues above and below, function as a complex. Through coordinated remodeling efforts of bone deposition and resorption, the cranial sutures maintain a state of patency from infancy through early adulthood as the skull continues to grow and accommodate the developing brain's demands for expansion. However, when this delicate balance is disturbed, a number of pathologic conditions ensue; and if left uncorrected, may result in visual and neurocognitive impairments. A prime example includes craniosynostosis, or premature fusion of one or more cranial and/or facial suture(s). At the present time, the only therapeutic measure for craniosynostosis is surgical correction by cranial vault reconstruction. However, elegant studies performed over the past decade have identified several genes critical for the maintenance of suture patency and induction of suture fusion. Such deeper understandings of the pathogenesis and molecular mechanisms that regulate suture biology may provide necessary insights toward the development of non-surgical therapeutic alternatives for patients with cranial suture defects. In this review, we discuss the intricate cellular and molecular interplay that exists within the suture among its three major components: dura mater, osteoblastic related molecular pathways and osteoclastic related molecular pathways.

An assessment of the maxilla after rapid maxillary expansion using cone beam computed tomography in growing children

INTRODUCTION

With the advent of cone beam computed tomography (CBCT), it is now possible to quantitatively evaluate the effects of rapid maxillary expansion (RME) on the entire maxillary complex in growing patients.

OBJECTIVE

The purpose of this study is to use three-dimensional images to evaluate the displacement that occurs at the circummaxillary sutures (frontonasal, zygomaticomaxillary, intermaxillary, midpalatal, and transpalatal sutures) following rapid maxillary expansion in growing children.

METHODS

The CBCT scans of 25 consecutively treated RME patients (10 male, 15 female) with mean age of 12.3±2.6 years, were examined before expansion and immediately following the last activation of the expansion appliance.

RESULTS

Statistically significant (P<0.05) amounts of separation were found for the displacement of the bones of the frontonasal suture, the intermaxillary suture, the zygomaticomaxillary sutures, and the midpalatal suture. The change in angulation of the maxillary first molars due to RME was also statistically significant. There was no statistically significant displacement of the transpalatal suture.

CONCLUSIONS

Rapid maxillary expansion results in significant displacement of the bones of circummaxillary sutures in growing children.