Velopharyngeal dysfunction and speech-related characteristics in craniofacial microsomia: a retrospective analysis of 223 patients

This study aimed to document the prevalence, severity, and risk factors of velopharyngeal dysfunction (VPD) in craniofacial microsomia (CFM) and to analyse differences in VPD-related speech characteristics between CFM patients without cleft lip and/or palate (CL/P), CFM patients with CL/P, and CL/P patients without CFM (control). A total of 223 patients with CFM were included, of whom 59 had a CL/P. Thirty-four CFM patients had VPD, including 20 with a CL/P. VPD was significantly more prevalent in CFM with CL/P than in CFM without CL/P (odds ratio (OR) 4.1, 95% confidence interval (CI) 1.9-8.7; P < 0.001). Multivariate logistic regression showed a significant association between CL/P and VPD in CFM patients (OR 7.4, 95% CI 2.1-26.3; P = 0.002). The presence of VPD was not associated with sex, the laterality or severity of CFM. Speech problems related to VPD appeared to be similar among the different groups (CFM without CL/P, CFM with CL/P, CL/P without CFM). As 15.2% of all CFM patients and 8.5% of CFM patients without CL/P had VPD, it is proposed that all patients with CFM, with or without CL/P, should be assessed by a speech and language therapist for the potential risk of VPD.

Extracraniofacial anomalies in Treacher Collins syndrome: A multicentre study of 248 patients

Treacher Collins syndrome (TCS) is a congenital malformation of the craniofacial structures derived from the first and second pharyngeal arches. The craniofacial deformities are well described in the literature. However, little is known about whether there are associated extracraniofacial anomalies. A retrospective study was conducted using data from four craniofacial units. Medical charts were reviewed for the presence and type of extracraniofacial anomalies, as well as age at diagnosis. A possible correlation between the severity of the phenotype and the presence of extracraniofacial anomalies was assessed using the Hayashi classification. A total of 248 patients with TCS were identified; 240 were confirmed to have TCS, of whom 61 (25.4%) were diagnosed with one or more extracraniofacial anomalies. Ninety-five different extracraniofacial anomalies were found; vertebral (n=32) and cardiac (n=13) anomalies were most frequently seen, followed by reproductive system (n=11), central nervous system (n=7), and limb (n=7) anomalies. No correlations between tracts were found. Extracraniofacial anomalies were more prevalent in these patients with TCS compared to the general population (25.4% vs 0.001-2%, respectively). Furthermore, a positive trend was seen between the severity of the syndrome and the presence of extracraniofacial anomalies. A full clinical examination should be performed on any new TCS patient to detect any extracraniofacial anomalies on first encounter with the craniofacial team.

Vitamin D metabolism and regulation in pediatric MSCs

Vitamin D is crucial for mineral homeostasis and contributes to bone metabolism by inducing osteoblast differentiation of marrow stromal cells (MSCs). We recently reported that MSCs from adults demonstrate 1α-hydroxylase activity in vitro and express vitamin D-related genes; this raises a possible autocrine/paracrine role for D activation in pre-osteoblasts. In this studies, we tested the hypotheses that pediatric MSCs have 1α-hydroxylase activity and express vitamin D-related genes. With IRB approval, we isolated MSCs from discarded excess iliac marrow graft from 6 male and 6 female subjects (age 8-12 years) undergoing alveolar cleft repair. 1α-hydroxylation of substrate 25(OH)D₃ was measured by ELISA for 1α,25(OH)₂D. RT-PCR was used for gene expression. Pediatric MSCs showed a range of 1α-hydroxylase activity in vitro. There was constitutive expression of vitamin D receptor (VDR), megalin, d-hydroxylases (CYP27B1, CYP27A1, CYP2R1, and CYP24A1), and estrogen receptor (ER). There was 2.6-fold greater expression of CYP27B1 and 3.5-fold greater expression of CYP24A1 in MSCs from boys compared with girls. There was 2.4-fold greater expression of ERα and 3.2-fold greater expression of megalin in MSCs from boys. In preliminary studies, treatment of female pediatric MSCs with 10nM 17β-estradiol resulted in upregulation of CYP27B1 and CYP24A1, as well as VDR, megalin, ERα, and ERβ. Treatment with 25(OH)D₃ upregulated CYP27B1, VDR, and ERα. Expression and regulation of vitamin D related genes in pediatric hMSCs reinforces an autocrine/paracrine role for vitamin D in hMSCs. Finding striking gender differences in MSCs from children was not seen with MSCs from adults and adds insight to the metabolic environment of bone and presents a research approach for investigating and optimizing pediatric bone health.

The prevalence of obstructive sleep apnea in symptomatic patients with syndromic craniosynostosis

The reported prevalence of obstructive sleep apnea (OSA) in patients with syndromic craniosynostosis (SCS) varies due to inconsistent definitions of OSA, lack of uniform diagnostic testing, and different mixes of syndromic diagnoses. The purpose of this study was to determine the prevalence of OSA in symptomatic patients with SCS, and to determine whether this differs by phenotypic diagnosis. A retrospective cohort study of children with SCS was conducted. The primary outcome was presence of OSA diagnosed by polysomnography. The prevalence of OSA was calculated and stratified by diagnosis to compare differences in prevalence and severity (mild, moderate, or severe). The prevalence of OSA in symptomatic patients was 74.2%. Patients with Apert syndrome had the highest prevalence (80.6%), followed by Pfeiffer, Crouzon with acanthosis nigricans, and Crouzon syndromes (72.7%, 66.7%, and 64.7%, respectively). Severe OSA was most common in patients with Pfeiffer syndrome (45.5%), while patients with Apert and Crouzon syndromes were more likely to have moderate OSA (29.0% and 23.5%, respectively). Given that 56.4% of patients with SCS are symptomatic and that 74.2% of these symptomatic patients have OSA, it is recommended that a screening level I polysomnography be part of the clinical care for all patients with SCS.

Facial infiltrating lipomatosis

Facial infiltrating lipomatosis is a rare congenital disorder in which mature lipocytes invade adjacent tissue. The phenotypic features include soft-tissue and skeletal hypertrophy, premature dental eruption, and regional macrodontia. There is a high risk for regrowth after resection that is, perforce, subtotal. The etiology, natural history, optimal management, and relationship to other disorders of fatty overgrowth are unclear. In this study, the clinical features, radiographic findings, histopathology, and postoperative results were analyzed in 13 patients with facial infiltrating lipomatosis. The condition was diagnosed in infancy (eight male subjects, five female subjects) and characterized by enlargement of the cheek (n = 12) or chin (n = 1). Other findings included cutaneous capillary blush (n = 9), ipsilateral macroglossia (n = 8), and mucosal neuromas (n = 6). Most patients had early eruption of ipsilateral deciduous and permanent teeth (n = 12). Computed tomography and magnetic resonance imaging showed an infiltrated soft-tissue mass of fatty density (n = 13) and skeletal overgrowth (n = 9). Multiple resection was performed on six patients (mean number of operations per patient, 2.5; range, one to six operations); regrowth and/or worsening of the capillary stain occurred in all six patients. Because surgical removal of the mass is usually unsuccessful, specific management of this condition will require insight into its etiopathogenesis. Given the presence of mucosal neuromas and lipomatosis, this study included testing for the known mutations in three entities that are associated with these soft-tissue findings (Cowden syndrome, Bannayan-Riley-Ruvalcava syndrome, and multiple endocrine neoplasia type 2B). Results of DNA analyses for these germline mutations were negative. It is more likely that this disorder is caused by a somatic mutation involving a local increase in growth factor(s).

Progression of facial asymmetry in hemifacial microsomia

Hemifacial microsomia is a common craniofacial anomaly, variably affecting structures derived from the first and second pharyngeal arches. Correction of the skeletal deformity in children has been advocated to improve growth potential and reduce secondary deformity. However, contrary reports have suggested that facial asymmetry in hemifacial microsomia does not increase with growth; therefore, skeletal correction can be postponed, even until adolescence. The purpose of this study was to test the hypothesis that facial asymmetry in hemifacial microsomia is progressive. This is a retrospective evaluation of 67 patients with untreated hemifacial microsomia. The patients were categorized as: group I (mandible type I, IIa), n = 38, and group II (mandible type IIb, III), n = 29. Pretreatment posterior-anterior cephalometric radiographs were used to analyze asymmetry by measuring the angle between the true horizontal and the following planes: piriform rim, maxillary occlusal plane, and intergonial angle. Angular measurements were averaged for patients in the deciduous (<6 years), mixed (> or =6<13 years), and permanent dentition (> or =13 years). In group I, angle piriform rim, maxillary occlusal plane, and intergonial angle increased from 7.0, 4.3, and 4.4 to 8.4, 6.6, and 6.1 degrees, respectively [mean age, 4.1 (deciduous) to 8.6 (mixed) to 21.0 (permanent) years]. In group II, angle piriform rim, maxillary occlusal plane, and intergonial angle increased from 9.5, 6.2, and 5.3 to 11.7, 7.6, and 8.0 degrees, respectively [mean age, 3.4 (deciduous) to 8.0 (mixed) years]. These data demonstrate that hemifacial microsomia is progressive and underscores the importance of early surgical correction of mandibular asymmetry in this disorder.

Children with repaired bilateral cleft lip/palate: effect of age at premaxillary osteotomy on facial growth

This study compared facial growth in three groups of patients with bilateral complete cleft lip/palate: those who had (1) no premaxillary osteotomy, (2) premaxillary osteotomy before age 8 years, and (3) premaxillary osteotomy after age 8 years. Of 24 children with bilateral complete cleft lip/palate, 7 had early premaxillary osteotomy (mean age, 6.1; range, 3.7 to 7.6 years), 10 had late osteotomy (mean age, 11.2; range, 8.3 to 20.7 years), and 7 did not require premaxillary repositioning and served as controls (mean age, 12.4; range, 6.4 to 17.8 years). Presurgical and postsurgical lateral cephalograms were digitized using the Dentofacial Planner software; most current lateral cephalograms comprised the control group. Forty-one bony and 25 soft-tissue landmarks were digitized, and 8 angles were measured: SNA, (sella-nasion-A point), SNPg (sella-nasion-pogonion), ANB (A point-nasion-B point), NAPg (nasion-A point-pogonion), ST convexity (glabella-subnasale-soft-tissue pogonion), Sn-G vertical (line perpendicular to the horizontal plane dropped from glabella and distance measured from subnasale to this vertical), Cm-Sn-Ls (columella-subnasale-abial superioris), and Sn-Gn-C (subnasale-soft-tissue gnathion-chin point). Statistical difference in mean preoperative and postoperative values were measured with analysis of variance. Tests of significance were adjusted for multiple comparisons using the Bonferroni correction. Mean age at follow-up for early, late, and control groups was 11.8, 14.0, and 12.4 years, respectively. Mean follow-up for early and late groups was 5.7 and 2.8 years. There was a significant preoperative difference among the three groups for mean SNA (p < 0.01), ANB (p < 0.01), and NAPg (p < 0.01). Bonferroni analyses revealed that the early group had significantly greater SNA, ANB, and NAPg angles than the late (p < 0.01) and control groups (p < 0.05). There was a significant postoperative difference among groups for ANB (p < 0.05); Bonferroni analyses also showed that the control group had a significantly greater ANB than the late group (p < 0.05). The t test for equity of means established postoperative change for SNA (p < 0.01), ANB (p< 0.01), NAPg (p < 0.01), and ST convexity (p < 0.01) for the early group was significantly greater than for the late group. Children who required early premaxillary positioning had more significant preoperative deformity; however, this group's postoperative profile was not, on average, significantly different from either the late or control groups. Our findings that the early group had more significant change with premaxillary osteotomy than the late group suggest that premaxillary positioning can be done before completion of facial growth without compromise.

State of the art in oral and maxillofacial surgery: treatment of maxillary hypoplasia and anterior palatal and alveolar clefts

As the new millennium approaches, it seems appropriate to look back at where we have been and where we are going with the care of patients with facial deformities. None of us can deny that although changes have been made, many current treatment modalities are no more than modifications of old techniques. We are, however, poised to make dramatic improvements in the management of facial abnormalities as we enter the new century and millennium. Biotechnology, genetic manipulation, and new surgical technology will become pervasive, and perhaps we will move from "modification" of the old into a completely new era of therapeutic approaches to the care of dentofacial deformities. "Opportunities multiply as they are seized" (from Sun Tzu), and the time of opportunity is approaching. This review will attempt to look at the state of the art in cleft care and in oral and maxillofacial surgery: where we have been and where we are going. It will be clear that there is overlap between specialties and that these overlaps will become greater as new regimens in the care of facial deformities come to the forefront.

Simultaneous maxillary and mandibular distraction osteogenesis with a semiburied device

Distraction osteogenesis is a technique utilizing natural healing mechanisms to generate new bone; it is commonly used to lengthen the hypoplastic mandible. Distraction of the maxilla and mandible as a unit is an obvious extension of the technique. We describe the application of a semiburied distractor to simultaneously lengthen the mandible and maxilla and level a canted occlusal plane in three cases. The indications for bimaxillary distraction are reviewed, including its advantages, disadvantages and limitations.

Sensory abnormalities associated with mandibular fractures: incidence and natural history

PURPOSE

The aims of this study were to determine the incidence of inferior alveolar nerve (IAN) abnormalities in patients with mandibular fractures and to document the natural history and spontaneous recovery rate in patients with a sensory disturbance.

PATIENTS AND METHODS

This was a retrospective evaluation of patients (n = 150) with mandibular fractures at risk for IAN injury admitted to the Oral and Maxillofacial Surgery Service between 1985 and 1995. The inclusion criteria were: 1) fractures between the mandibular and mental foramina, 2) availability of the results of a post-injury, preoperative sensory examination, and 3) at least 1 year follow-up. Fracture characteristics, physical examination findings, hospital course, operative treatment, and follow-up were documented. Patient interviews were conducted to determine the incidence of long-term sensory disturbance and associated morbidity. The results were evaluated with chi-square analysis.

RESULTS

Fifty-six percent of patients (84 of 150) had a post-injury/pretreatment IAN abnormality. Patients with sensory disturbance had a significantly higher frequency of displaced fractures than those without sensory disturbance (P < .001). Sixteen of 24 patients (66.7%) with an abnormal post-injury/ pretreatment sensory examination reported a permanent sensory deficit (mean follow-up, 74.3 months); 55% of these patients complained of impairment.

CONCLUSIONS

The incidence of postinjury IAN deficits in patients with mandibular fractures was greater than 50% and was related to fracture displacement. One third of these patients regained normal sensation; the remaining two thirds reported a persistent sensory deficit. A significant number of these patients complained of discomfort and impairment after a mean follow-up of greater than 6 years.

Midfacial growth after costochondral graft construction of the mandibular ramus in hemifacial microsomia

PURPOSE

The purpose of this study was to document vertical midfacial growth after costochondral graft mandibular ramus construction in children with type IIB and type III hemifacial microsomia (HFM).

METHODS

This is a retrospective study of 33 children who underwent costochondral graft (CCG) construction for mandibular type IIB (abnormal, small, and medially displaced ramus, n = 19) and mandibular type III (absent ramus and glenoid fossa, n = 14) HFM, between 1980 and 1990. Types I and IIA patients were not included because their milder mandibular deformities were lengthened by osteotomy. Mean age at operation was 6.2 (2 to 10) years, and the mean follow-up period was 5.5 (1 to 13.5) years. Occlusal cant, piriform angle, and intergonial angle were measured on the most current posteroanterior (PA) cephalogram. The ratio of unaffected to affected ramus length was determined on the most current panoramic radiograph. Patient outcomes were classified based on the occlusal cant at the latest follow-up: group 1, successful result with a symmetrical maxilla (occlusal cant of <5 degrees); group 2, acceptable result (occlusal cant > or =5 degrees but <8 degrees), and Group 3, failure (occlusal cant > or = 8 degrees). OMENS scores were calculated for each patient: each of the five major anatomic deformities of HFM (orbital, mandibular, auricular, neural, and soft tissue) were graded 0 to 3 and summed. The mean differences in age at operation and OMENS scores between groups were calculated (ANOVA).

RESULTS

At the end of follow-up, patients defined as having a successful result (group 1) had a mean occlusal cant of 2 degrees, a mandibular length ratio of 1.0, and an intergonial angle of 2 degrees. However, the final piriform angle was 7 degrees, indicating less vertical midfacial growth than maxillary alveolar growth. These patients were older at the time of operation (mean age, 6.7 years), and their mean OMENS score (6.3) was significantly lower (P = .004) than in patients in group 2 (mean age at operation, 6.3 years; mean OMENS score, 6.8) and group 3 (mean age at operation, 5.8 years; mean OMENS score, 7.8). In group 2, the occlusal cant, mandibular length ratio, and intergonial and piriform angles did not improve. In group 3, the occlusal cant and piriform angle became worse during the follow-up period.

CONCLUSIONS

The results of this study indicate that after construction of the ramus and condyle in type IIB and III HFM patients, vertical midface growth is secondary to a combination of midfacial and alveolar growth. Patients operated on at an older age were more likely to have a successful long-term result. Finally, the severity of the overall deformity, as reflected in a higher OMENS score, appeared to be an important factor in the response to early correction.

Synostotic frontal plagiocephaly: anthropometric comparison of three techniques for surgical correction

Surgical correction of synostotic frontal plagiocephaly ("unilateral coronal synostosis") focuses on distortions of the forehead and orbits. Technical variations include unilateral versus bilateral fronto-orbital positioning. Surgical alignment of the deviated nasal root was introduced in our unit. Anthropometry was used to assess anatomic outcome, and results were compared in 22 children with synostotic frontal plagiocephaly who had either (1) unilateral fronto-orbital advancement ("canthal advancement") (n = 8), (2) bilateral fronto-orbital advancement/ modeling without nasal straightening (n = 7), or (3) bilateral fronto-orbital advancement/modeling with closing wedge nasal osteotomy (n = 7). Postoperative fronto-orbital asymmetry was most marked in the group I patients wherein the ipsilateral supraorbital rim was retruded 3.9 mm and elevated 2.6 mm, on average relative to the corneal apex, compared with the normal side. Group II children averaged 2-mm orbital retrusion and 2.2-mm elevation. Group III patients averaged 1.4-mm orbital retrusion and 2.9-mm elevation. These differences in orbital rim measurements among the three groups were not statistically significant. Postoperative nasal root angulation of 4 degrees or more was found in more than 50 percent of children who had either a unilateral or a bilateral procedure, without nasal correction. In contrast, primary nasal osteotomy resulted in a nasal cant of 3 degrees or less in all children. This difference in nasal angulation among the three groups was statistically significant (p = 0.035). Group III had a straighter nasal angle than groups II and I (in that order). Measurement of the distances from nasion to inner and to outer canthi also reflected persistent deviation of the nasal root. Group III children had a more central radix than either group I or II (p = 0.05). The data in this study support an operative strategy of bilateral (parallelogrammic) positioning of the forehead/ superior orbits with primary correction of nasal root angulation.

Occlusal cant in the frontal plane as a reflection of facial asymmetry

PURPOSE

The purpose of this study was to compare subjective evaluation of occlusal canting in frontal photographs with objective radiographic measurements to determine the threshold at which a cant is recognized as abnormal.

PATIENTS AND METHODS

Standardized frontal photographs (at rest and smiling) of two groups of orthognathic surgery patients were evaluated. Group 1 consisted of patients with a documented occlusal cant (n = 21), and group 2 consisted of patients with no cant (n = 22). Four untrained and five trained observers independently, and blind to the diagnoses, assessed patient photographs to judge the presence or absence of canting. These subjective results were compared with objective measurements of the angle of the occlusal plane to the true horizontal on each patient's posteroanterior (PA) cephalogram.

RESULTS

The mean occlusal cant was 5.0 degrees +/- 1.6 degrees for group 1 and 1.4 degrees +/- 0.9 degree for group 2. The difference between groups was statistically significant (P < .01). Cants greater than 4 degrees were detected clinically with greater than 90% frequency by both untrained and trained observers.

CONCLUSIONS

The results of this study indicate that 4 degrees is the threshold for recognition of an occlusal cant by 90% of observers. This information has significant implications for three-dimensional planning and outcome assessment in orthognathic and craniofacial surgery.

OMENS-Plus: analysis of craniofacial and extracraniofacial anomalies in hemifacial microsomia

This review of 121 patients with hemifacial microsomia (HFM) revealed that 67 (55.4%) had extracraniofacial anomalies. Sixteen patients (13%) had one extracraniofacial anomaly and 51 patients (42.4%) had anomalies of multiple organ systems. There was no gender or side predominance in the cohort with the HFM "expanded spectrum." Central nervous system (CNS), cardiac, and skeletal anomalies were "associated" (i.e., had frequencies of 10% or more). Pulmonary, gastrointestinal, and renal deformities were equivocally associated. Statistical analysis indicated significant associations between several orbital, mandibular, ear, neural, and soft tissue (OMENS) variables and extracraniofacial anomalies. Patients with extracraniofacial structural defects had higher OMENS grades for individual craniofacial anatomic categories. Furthermore, patients with expanded spectrum had higher total OMENS scores. The frequency of cardiac anomalies (26%) supports the model of neural crest involvement in the pathogenesis of both hemifacial microsomia and conotruncal defects. The majority of the heart defects in this study were of either the outflow or septal type. We propose that the OMENS classification system for craniofacial anomalies of HFM be expanded to OMENS-Plus (+) to designate the presence of associated extracraniofacial anomalies.

Cervicofacial lymphatic malformation: clinical course, surgical intervention, and pathogenesis of skeletal hypertrophy

This is a retrospective review of the clinical course and long-term soft-tissue/skeletal problems in 17 patients with large cervicofacial lymphatic malformations. Morbidity included infection (71 percent), airway compromise requiring tracheostomy (65 percent), poor dental health with aggressive caries (53 percent), abnormal articulatory patterns (47 percent), and episodic bleeding (35 percent). All patients underwent soft-tissue excision (mean four procedures per patient). Damage to facial nerve (76 percent) and hypoglossal nerve (24 percent) were common postoperative sequelae. Contour resection did not alter the progression of skeletal hypertrophy. Overgrowth most commonly occurred in the mandibular body, manifesting as anterior open bite deformity and class III occlusion (65 percent). Early mandibular body ostectomy was done in four children with grotesque hypertrophy. Jaw osteotomy was required in 71 percent of the patients to improve the maxillary/mandibular relationship. Histologic examination revealed intraosseous lymphatic malformation in areas of skeletal overgrowth in two-thirds of surgical specimens. The complexity of managing cervicofacial lymphatic malformation underscores the need for an interdisciplinary program in every major referral center.

Association between "plagiocephaly" and hemifacial microsomia

Fifteen of 155 patients with hemifacial microsomia were noted to have frontal plagiocephaly. These patients were examined to determine whether the frontal flattening was either secondary to deformation, the result of unilateral coronal synostosis, or part of the spectrum of hemifacial microsomia. The patients were categorized as having deformational versus synostotic frontal plagiocephaly by documenting position of the supraorbital rims, nasal root, ears, malar eminences, chin point, and the palpebral fissure height. Other extracraniofacial anomalies were also noted. Fourteen of 15 (93%) patients had characteristic deformational abnormalities. Only 1/15 (7%) had an elevated orbit, suggestive of unilateral coronal synostosis, but this diagnosis was not radiographically confirmed. Frontal deformational plagiocephaly was ipsilateral to the side predominantly affected by hemifacial microsomia in all but one patient. Patients with hemifacial microsomia-deformational frontal plagiocephaly often had ipsilateral torticollis, cervical spine abnormalities, and anomalies outside the craniofacial region. This was in contrast to patients with deformational frontal plagiocephaly, in the absence of hemifacial microsomia, who frequently had ipsilateral torticollis but no other anomalies. This study also underscores possible confusion in differentiating hemifacial microsomia from deformational hemifacial hypoplasia on physical examination. The association of deformational frontal plagiocephaly and hemifacial microsomia belies a rigid etiologic label of deformational versus malformative anomaly.

Psychosocial adjustment in children with hemifacial microsomia and other craniofacial deformities

Psychosocial adjustment was evaluated in different groups of children with craniofacial deformities in order to examine the relationships between symmetry, functional impairments, and social adaptation. Thirty patients, ages 6 through 16 years, were assessed using a battery of standard psychologic measures including Human Figure Drawing, Tasks of Emotional Adjustment, and Children's Depression Inventory. Parents and teachers also provided ratings of the children's functioning using the Child Behavior Checklist (parent and teacher forms). Scores on the outcome measures were summarized with descriptive statistics and then multivariate analyses of variance were conducted to determine the differences in psychosocial development between children with symmetric versus asymmetric craniofacial deformities and between the presence or absence of a functional impairment in children with craniofacial deformities. The results indicate that children with symmetric craniofacial deformities score poorer on measures of psychosocial adjustment than children with asymmetric deformities (F = 3.20, p less than 0.015); however, differences among the groups with or without functional impairments were not significant.