Faculty Bibliography

BACKGROUND: : A multidisciplinary meeting was held from March 4 through 6, 2010, in Atlanta, Georgia, to conceptualize, map out, and operationalize the variables most relevant to the care of patients with craniosynostosis. In this article, the authors highlight the development of the craniofacial and neurologic surgery parameters of care. METHODS: : Fifty-two conference attendees, representing a broad range of expertise in craniosynostosis care and 16 professional societies, participated in this working group. Literature and expert opinion were used to identify the variables important for the care of patients with craniosynostosis. In an iterative manner, specialty-specific data were compiled into draft recommendations and presented to all conference attendees. Cross-discipline analysis was used to assess the completeness of the data, facilitate exchange of ideas, and achieve consensus. RESULTS: : Consensus was reached among the 52 conference attendees and two post hoc reviewers in 18 areas of craniosynostosis care. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the specialty areas of care, from prenatal evaluation to completion of care in adulthood. CONCLUSIONS: : To our knowledge, this is the first multidisciplinary effort to develop parameters of care and best practices for craniosynostosis. In conjunction with patient input, these parameters may help to heuristically develop core outcome sets that are important not only to patients and their families, but also to health care providers and health services and outcome researchers. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Osteoradionecrosis (ORN) of the mandible is a potentially catastrophic complication of external beam radiation therapy for head and neck malignancies. A 55-year-old man treated with chemoradiation for base-of-tongue cancer presented with a necrotic left mandibular body and underwent left mandibulectomy with right free fibula osteocutaneous flap reconstruction. Two and a half years later, he presented with right mandibular body ORN and underwent a second mandibular resection and subsequent reconstruction with a left fibula osteocutaneous free flap fixed in the midline to the previously placed contralateral fibula. He recovered well from all procedures. To the best of our knowledge, we report the first case of a patient with metachronous ORN of the mandible requiring resection and subsequent reconstruction with sequential free fibula flaps. Even in the presence of prior microvascular reconstructions, patients can successfully undergo additional reconstructive procedures to restore their function, appearance, and quality of life.

Objectives: To investigate the effect of Si addition on a nanometer-scale roughness Ca and P implant surfaces in a canine tibia model by biomechanical and histomorphometric evaluations. Material and methods: The implant surfaces comprised a resorbable media CaP microblasted (control) and a CaP resorbable media+silica-boost microblasted (experimental) surfaces. Surfaces were characterized by scanning electron microscopy (SEM), X-ray photoelectron spectroscopy (XPS), and optical interferometry (IFM) down to the nanometric level. The animal model involved the bilateral placement of control (n=24) and experimental surface (n=24) implants along the proximal tibiae of six dogs, remaining in vivo for 2 or 4 weeks. After euthanization, half of the specimens were torqued-to-interface failure, and the other half was subjected to histomorphologic and bone-to-implant contact (BIC) evaluation. Torque and BIC statistical evaluation was performed by the Friedman test at 95% level of significance, and comparisons between groups was performed by the Dunn test. Results: IFM and SEM observations depicted comparable roughness parameters for both implant surfaces on the micrometer and nanometer scales. XPS analysis revealed similar chemical composition, except for the addition of Si on the experimental group. Torque-to-interface failure and BIC mean values showed no significant differences (P=0.25 and 0.51, respectively) at both 2- and 4-week evaluation points for experimental and control groups. Early bone healing histomorphologic events were similar between groups. Conclusions: The experimental surface resulted in not significantly different biomechanical fixation and BIC relative to control. Both surfaces were biocompatible and osseoconductive. To cite this article: Coelho PG, Granato R, Marin C, Jimbo R, Lin S, Witek L, Suzuki M, Bonfante EA. Effect of Si addition on Ca- and P-impregnated implant surfaces with nanometer-scale roughness: an experimental study in dogs. Clin. Oral Impl. Res. 23, 2012; 373-378. doi: 10.1111/j.1600-0501.2010.02150.x.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is often found in children affected by congenital or acquired craniomaxillomandibular malformations. This disease carries different levels of risk, ranging from attention problems at school to growth problems and serious disorders, such as cor pulmonale or sudden infant death. The examination that is most commonly used to evaluate the severity of OSAS is polysomnography, and the therapeutic course is often determined by the disease state. Considering the discrepancy between clinical history and polysomnographic findings, we felt the need to identify an instrument for evaluating OSA to be used as a support for polysomnography. MATERIALS AND METHODS: This study was carried out on pediatric patients affected by congenital or acquired craniomaxillofacial malformations. We selected 34 pediatric patients, including 15 boys and 19 girls, aged between 1 and 16 years, with a mean age of 7.3 years. The study consisted of individuation of common clinical history data obtained from each patient and associating those data with the level of OSA severity identified by polysomnography. We were able to isolate certain symptoms and signs that can be predictive of OSA from research in the literature and our clinical experience with pediatric patients. In the clinic, we have found that the clinical history, given by the parents, often differs significantly from the instrumental findings obtained with polysomnography. From the previously expressed considerations and comparison of clinical history data and questionnaires, we have extracted the most significant questions for our questionnaire, which are present in the literature but formulated for adults. RESULTS AND CONCLUSIONS: The obstructive airway child test was found to be a very efficient method to evaluate and diagnose OSA. In all patients, it consistently revealed the pathology and never underestimated OSA severity. The examination focuses on clinical signs and symptoms because, in our opinion, clinical history, reported by the parents, can be more accurate than any instrumental examination.

The present investigation hypothesized that the reliability of reduced-thickness monolithic lithium disilicate crowns is high relative to that of veneered zirconia (Y-TZP) and comparable with that of metal ceramic (MCR) systems. CAD/CAM first mandibular molar full-crown preparations were produced with uniform thicknesses of either 1.0-mm or 2.0-mm occlusal and axial reduction, then replicated in composite for standard crown dies. Monolithic 1.0-mm (MON) and 2.0-mm CAD/CAM lithium disilicate crowns, the latter with a buccal thin veneer (BTV) of 0.5 mm, were fabricated and then sliding-contact-fatigued (step-stress method) until failure or suspension (n = 18/group). Crack evolution was followed, and fractography of post mortem specimens was performed and compared with that of clinical specimens. Use level probability Weibull calculation (use load = 1,200 N) showed interval overlaps between MON and BTV. There was no significant difference between the Weibull characteristic failure loads of MON and BTV (1,535 N [90% CI 1,354-1,740] and 1,609 N [90% CI 1,512-1,712], respectively), which were significantly higher than that of Y-TZP (370 N [90% CI 322-427]) and comparable with that of MCR (1,304 N [90% CI 1,203-1,414]), validating the study hypothesis.

BACKGROUND: : The senior author routinely performs primary nasal reconstruction with every cleft lip repair. This addresses the nasal tip asymmetry and simplifies the definitive secondary rhinoplasty in adolescence. METHODS: : A retrospective chart review was completed of all unilateral cleft secondary rhinoplasties performed by the senior author. The indications for secondary rhinoplasty were examined, anatomical features of the nose at the time of operation were documented, and the reconstructive techniques used were recorded. RESULTS: : From 2001 to 2009, the senior author performed 116 secondary rhinoplasties in patients with a previously repaired unilateral cleft lip. The senior author performed 44 of the initial cleft lip repairs (group A). A Dibbell rhinoplasty was required in 26 percent, a Potter rhinoplasty was required in 5 percent, a Tajima inverted-U incision was required in 70 percent, and an alar base resection was required in 53 percent. For those patients who did not undergo cleft lip repair with primary rhinoplasty by the senior author, 60 percent required a Dibbell rhinoplasty, Potter rhinoplasty was not used, 76 percent required a Tajima inverted-U incision, and 64 percent required an alar base resection. Group A had significantly greater dome symmetry when comparing the cleft side to the noncleft side (p = 0.001). Nostril apex height was also more symmetrical in group A (p = 0.105). CONCLUSION: : Primary nasal reconstruction performed with cleft lip repair as described by the senior author makes the nasal tip more symmetric and requires less complex intervention at the time of definitive secondary rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

BACKGROUND: The aesthetics of facial structure are used by humans to measure one's beauty, character, and overall "goodness." Individuals born with cleft lip and/or palate are often stigmatized and face much psychosocial adversity. Social attitudes and beliefs have a direct impact upon the psychological development of these individuals. Such social norms are in large part shaped by the physical representations of "good" and "attractive" in various art media including films, advertisements, and paintings. OBJECTIVE: Individuals born with a cleft have been portrayed in the artworks of different eras. The light in which they are portrayed stems from the prevalent beliefs of each period and sheds light on the social attitudes of each epoch toward clefts. Here we discuss the social and psychological ramifications of these works. We then review several artworks representing cleft lip and/or palate and propose an active role for the artist in shaping social attitudes regarding facial deformities. METHODS: Numerous articles and works of arts were examined and inspected for signs of facial deformity, with particular attention to cleft lip and/or palate. CONCLUSION: Social media have an important role in defining the norms of society. Much of the art of the past has depicted negatively individuals born with cleft lip and/or palate deformity, thus excluding them from the norm. In order to decrease the negative social stigmas of cleft lip and/or palate, it is now the responsibility of society to widen its range of norms to include individuals born with these deformities through "normal" representations in the various media.

BACKGROUND: Syndromic craniosynostosis is associated with a high incidence of elevated intracranial pressure. The most common treatment paradigm is to perform anterior cranial vault reconstruction in infancy followed later by possible expansion of the posterior cranial vault and midface advancement. Recently, however, posterior cranial vault expansion has been advocated as an initial step in treatment. We sought to quantify volumetric changes with anterior versus posterior cranial vault surgery in these patients. MATERIALS AND METHODS: We reviewed patients with syndromic brachycephalic craniosynostosis treated in our unit from 2002 to 2009 with existing preoperative fine-cut computed tomographic scans. Using computer software (Analyze; Mayo Clinic, Rochester, MN) and computed tomographic data, the senior author simulated both anterior and posterior cranial vault expansions. Expansion was simulated with a series of translational advancements of the separated segments. Volumetric data were compared for each simulated procedure. RESULTS: Thirteen patients underwent simulated cranial vault reconstructions. At 2, 10, and 20 mm of anterior advancement, the mean increase in intracranial volume was 1.8%, 8.8%, and 17.7%, respectively, whereas posterior advancements achieved 2.4%, 11.9%, and 23.9%, respectively. On average, posterior cranial vault reconstruction created 35% more relative expansion than anterior expansion at equivalent degrees of advancement (P < 0.001). In all simulations, posterior cranial vault reconstruction created greater intracranial volume changes than anterior reconstructions. CONCLUSIONS: This simulation demonstrates that, in syndromic brachycephalic craniosynostosis, posterior cranial vault advancement achieves approximately 35% greater intracranial volume expansion compared with equivalent degrees of anterior cranial vault advancement. This may help guide decisions in treatment sequencing of patients with syndromic craniosynostosis.