Beyond the functional matrix hypothesis: a network null model of human skull growth for the formation of bone articulations

Neuroimaging in Nonsyndromic Craniosynostosis: Key Concepts to Unlock Innovation

Craniosynostoses (CRS) are caused by the premature fusion of one or more cranial sutures, with isolated nonsyndromic CRS accounting for most of the clinical manifestations. Such premature suture fusion impacts both skull and brain morphology and involves regions far beyond the immediate area of fusion. The combined use of different neuroimaging tools allows for an accurate depiction of the most prominent clinical-radiological features in nonsyndromic CRS but can also contribute to a deeper investigation of more subtle alterations in the underlying nervous tissue organization that may impact normal brain development. This review paper aims to provide a comprehensive framework for a better understanding of the present and future potential applications of neuroimaging techniques for evaluating nonsyndromic CRS, highlighting strategies for optimizing their use in clinical practice and offering an overview of the most relevant technological advancements in terms of diagnostic performance, radiation exposure, and cost-effectiveness.

Elastodontic Appliances for the Interception of Malocclusion in Children: A Systematic Narrative Hybrid Review

BACKGROUND

Interceptive orthodontic treatment aims to eliminate factors that prevent the harmonious development of the maxillary and mandibular arches during childhood, and elastodontic appliances (EAs) represent a group of devices with an increasingly important role. This systematic narrative hybrid review (HR) aims to provide an overview of the clinical indications for the use of EAs according to the available evidence and to identify potential research areas for unexplored applications.

MATERIALS AND METHODS

To assess the available literature on the subject, selective database searches were performed between July 2023 and September 2023. With the assistance of a health sciences librarian, a search strategy that utilized terms related to elastodontic therapy was developed. Embase, Scopus, PubMed, and Web of Science were the databases used.

RESULTS

The current literature addressing the usability of EAs is scarce and mostly limited to case reports and case series. After 2168 citations were found through the searches, 13 studies were ultimately included. In this regard, information about the clinical use and effectiveness of EAs are reported in a narrative form, defining specific domains of the application that are clinically oriented, including sagittal and transversal discrepancies, atypical swallowing, teeth malposition, two-phase orthodontics and a lack of teeth retention.

CONCLUSIONS

Within the intrinsic quality limitation of the available literature, it seems that EAs may represent a promising treatment alternative for managing mild-to-moderate malocclusion in children as an adjuvant therapy to the interruption of spoiled habits.

A comprehensive anatomical network analysis of human brain topology

A network approach to the macroscopic anatomy of the human brain can be used to model physical interactions among regions in order to study their topological properties, as well as the topological properties of the overall system. Here, a comprehensive model of human brain topology is presented, based on traditional macroanatomical divisions of the whole brain, which includes its subcortical regions. The aim was to localise anatomical elements that are essential for the geometric balance of the brain, as to identify underlying phenotypic patterns of spatial arrangement and understand how these patterns may influence brain morphology in ontogeny and phylogeny. The model revealed that the parahippocampal gyrus, the anterior lobe of the cerebellum and the ventral portion of the midbrain are subjected to major topological constraints that are likely to limit or channel their morphological evolution. The present model suggests that the brain can be divided into a superior and an inferior morphological block, linked with extrinsic topological constraints imposed by the surrounding braincase. This information should be considered duly both in ontogenetic and phylogenetic studies of primate neuroanatomy.

Machine Learning in Metopic Craniosynostosis: Does Phenotypic Severity Predict Long-Term Esthetic Outcome?

BACKGROUND

There have been few longitudinal studies assessing the effect of preoperative phenotypic severity on long-term esthetic outcomes in metopic craniosynostosis. This study evaluates the relationship between metopic severity and long-term esthetic outcomes using interfrontal angle (IFA) and CranioRate, a novel metopic synostosis severity measure.

METHODS

Patients with metopic craniosynostosis who underwent bifrontal orbital advancement and remodeling between 2012 and 2017 were reviewed. Preoperative computed tomography head scans were analyzed for IFA and CranioRate, a machine learning algorithm which generates quantitative severity ratings including metopic severity score (MSS) and cranial morphology deviation (CMD). Long-term esthetic outcomes were assessed by craniofacial surgeons using blinded 3-rater esthetic grading of clinical photos. Raters assessed Whitaker score and the presence of temporal hollowing, lateral orbital retrusion, frontal bone irregularities and/or "any visible irregularities."

RESULTS

Preoperative scans were performed at a mean age of 7.7±3.4 months, with average MSS of 6/10, CMD of 200/300, and IFA of 116.8±13.8 degrees. Patients underwent bifrontal orbital advancement and remodeling at mean 9.9±3.1 months. The average time from operation to esthetic assessment was 5.4±1.0 years. Pearson correlation revealed a significant negative correlation between MSS and age at computed tomography ( r =-0.451, P =0.004) and IFA ( r =-0.371, P =0.034) and between IFA and age at surgery ( r =-0.383, P =0.018). In multinomial logistic regression, preoperative MSS was the only independent predictor of visible irregularities (odds ratio=2.18, B =0.780, P =0.024) and preoperative IFA alone significantly predicted Whitaker score, with more acute IFA predicting worse Whitaker score (odds ratio=0.928, B =-0.074, P =0.928).

CONCLUSIONS

More severe preoperative phenotypes of metopic craniosynostosis were associated with worse esthetic dysmorphology. Objective measures of preoperative metopic severity predicted long-term esthetic outcomes.

A network approach to the topological organization of the Brodmann map

Brain morphology is the result of functional factors associated with cortical areas, but it is also influenced by structural aspects due to physical and spatial constraints. Despite the noticeable advances in brain mapping, Brodmann's map is still used in many research fields that rely on macroscopic cortical features for practical or theoretical issues. Here, the topological relationships among the Brodmann areas were modelled according to the principles of network analysis, in order to provide a synthetic view of their spatial properties following a criterion of contiguity. The model evidences the importance of the parieto-temporal region in terms of biological burden and topological complexity. The retrosplenial region is particularly influenced by spatial constraints, and the cingulate cortex occupies a position that bridges the anterior and posterior topological blocks. Such spatial framework should be taken into account when dealing with brain morphology in both ontogeny and phylogeny. This article is protected by copyright. All rights reserved.

Cranial Anatomical Integration and Disparity Among Bones Discriminate Between Primates and Non-primate Mammals

The primate skull hosts a unique combination of anatomical features among mammals, such as a short face, wide orbits, and big braincase. Together with a trend to fuse bones in late development, these features define the anatomical organization of the skull of primates—which bones articulate to each other and the pattern this creates. Here, I quantified the anatomical organization of the skull of 17 primates and 15 non-primate mammals using anatomical network analysis to assess how the skulls of primates have diverged from those of other mammals, and whether their anatomical differences coevolved with brain size. Results show that primates have a greater anatomical integration of their skulls and a greater disparity among bones than other non-primate mammals. Brain size seems to contribute in part to this difference, but its true effect could not be conclusively proven. This supports the hypothesis that primates have a distinct anatomical organization of the skull, but whether this is related to their larger brains remains an open question.

Anatomical comparison across heads, fore- and hindlimbs in mammals using network models

Animal body parts evolve with variable degrees of integration that nonetheless yield functional adult phenotypes: but, how? The analysis of modularity with Anatomical Network Analysis (AnNA) is used to quantitatively determine phenotypic modules based on the physical connection among anatomical elements, an approach that is valuable to understand developmental and evolutionary constraints. We created anatomical network models of the head, forelimb, and hindlimb of two taxa considered to represent a 'generalized' eutherian (placental: mouse) and metatherian (marsupial: opossum) anatomical configuration and compared them with our species, which has a derived eutherian configuration. In these models, nodes represent anatomical units and links represent their physical connection. Here, we aimed to identify: (1) the commonalities and differences in modularity between species, (2) whether modules present a potential phylogenetic character, and (3) whether modules preferentially reflect either developmental or functional aspects of anatomy, or a mix of both. We predicted differences between networks of metatherian and eutherian mammals that would best be explained by functional constraints, versus by constraints of development and/or phylogeny. The topology of contacts between bones, muscles, and bones + muscles showed that, among all three species, skeletal networks were more similar than musculoskeletal networks. There was no clear indication that humans and mice are more alike when compared to the opossum overall, even though their musculoskeletal and skeletal networks of fore- and hindlimbs are slightly more similar. Differences were greatest among musculoskeletal networks of heads and next of forelimbs, which showed more variation than hindlimbs, supporting previous anatomical studies indicating that in general the configuration of the hindlimbs changes less across evolutionary history. Most observations regarding the anatomical networks seem to be best explained by function, but an exception is the adult opossum ear ossicles. These ear bones might form an independent module because the incus and malleus are involved in forming a functional primary jaw that enables the neonate to attach to the teat, where this newborn will complete its development. Additionally, the human data show a specialized digit 1 module (thumb/big toe) in both limb types, likely the result of functional and evolutionary pressures, as our ape ancestors had highly movable big toes and thumbs.

A retrospective computed tomography analysis of maxillary fractures and the clinical outcomes of their unreduced parts

BACKGROUND

Some parts of a maxillary fracture-for example, the medial and posterior walls-may remain unreduced because they are unapproachable or hard to deal with. This study aimed to investigate the self-healing process of unreduced maxillary membranous parts of fractures through a longitudinal computed tomography (CT) analysis of cases of unilateral facial bone injuries involving the maxillary sinus walls.

METHODS

Thirty-two patients who had undergone unilateral facial bone reduction surgery involving the maxillary sinus walls without reduction of the medial and posterior walls were analyzed in this retrospective chart review. Preoperative, immediate postoperative, and 3-month postoperative CT scans were analyzed. The maxillary sinus volume was calculated and improvements in bone continuity and alignment were evaluated.

RESULTS

The volume of the traumatized maxillary sinuses increased after surgery, and expanded significantly by 3 months postoperatively (p< 0.05). The significant preoperative volume difference between the normal and traumatized sides (p= 0.024) resolved after surgery (p> 0.05), and this resolution was maintained at 3 months postoperatively (p > 0.05). The unreduced parts of the maxillary bone showed improved alignment and continuity (in 75.0% and 90.6% of cases, respectively), and improvements in bone alignment and bone continuity were found to be correlated using the Pearson chi-square test (p= 0.002).

CONCLUSION

Maxillary wall remodeling through self-healing occurred concomitantly with an increase in sinus volume and simultaneous improvements in bone alignment and continuity. Midfacial surgeons should be aware of the natural course of unreduced fractured medial and posterior maxillary walls in complex maxillary fractures.

Orbital Fractures in Childhood

Pediatric orbital floor fractures exhibit distinctive features that distinguish them from orbital injuries seen in the adult population. This is mainly due to different anatomy and mechanical properties of the orbital bones in children. The management of pediatric orbital floor fractures requires consideration of these factors, including the age of the patient and therefore child's growth potential, using, if possible, a minimally invasive surgical approach. The aim of this paper is to report a case of a 1-year-old male child with a surgically treated blowout fracture of the orbital floor. To enable early diagnosis and treatment, accurate physical examination is mandatory, but a computed tomographic examination is important, especially in younger patients because of their inability to fully express their symptoms and poor compliance. We discuss the specific presentation and diagnostics of orbital floor fractures in early childhood and the related surgical planning and treatment.

Craniofacial skeletal response to encephalization: How do we know what we think we know?

Dramatic changes in cranial capacity have characterized human evolution. Important evolutionary hypotheses, such as the spatial packing hypothesis, assert that increases in relative brain size (encephalization) have caused alterations to the modern human skull, resulting in a suite of traits unique among extant primates, including a domed cranial vault, highly flexed cranial base, and retracted facial skeleton. Most prior studies have used fossil or comparative primate data to establish correlations between brain size and cranial form, but the mechanistic basis for how changes in brain size impact the overall shape of the skull resulting in these cranial traits remains obscure and has only rarely been investigated critically. We argue that understanding how changes in human skull morphology could have resulted from increased encephalization requires the direct testing of hypotheses relating to interaction of embryonic development of the bones of the skull and the brain. Fossil and comparative primate data have thoroughly described the patterns of association between brain size and skull morphology. Here we suggest complementing such existing datasets with experiments focused on mechanisms responsible for producing the observed patterns to more thoroughly understand the role of encephalization in shaping the modern human skull.

The biological basis of treating jaw discrepancies: An interplay of mechanical forces and skeletal configuration

Jaw discrepancies and malrelations affect a large proportion of the general population and their treatment is of utmost significance for individuals' health and quality of life. The aim of their therapy is the modification of aberrant jaw development mainly by targeting the growth potential of the mandibular condyle through its cartilage, and the architectural shape of alveolar bone through a suture type of structure, the periodontal ligament. This targeted treatment is achieved via external mechanical force application by using a wide variety of intraoral and extraoral appliances. Condylar cartilage and sutures exhibit a remarkable plasticity due to the mechano-responsiveness of the chondrocytes and the multipotent mesenchymal cells of the sutures. The tissues respond biologically and adapt to mechanical force application by a variety of signaling pathways and a final interplay between the proliferative activity and the differentiation status of the cells involved. These targeted therapeutic functional alterations within temporo-mandibular joint ultimately result in the enhancement or restriction of mandibular growth, while within the periodontal ligament lead to bone remodeling and change of its architectural structure. Depending on the form of the malrelation presented, the above treatment approaches, in conjunction or separately, lead to the total correction of jaw discrepancies and the achievement of facial harmony and function. Overall, the treatment of craniofacial and jaw anomalies can be seen as an interplay of mechanical forces and adaptations occurring within temporo-mandibular joint and alveolar bone. The aim of the present review is to present up-to-date knowledge on the mechano-biology behind jaw growth modification and alveolar bone remodeling. Furthermore, future molecular targeted therapeutic strategies are discussed aiming at the improvement of mechanically-driven chondrogenesis and osteogenesis.

Structure, function, and control of the human musculoskeletal network

The human body is a complex organism, the gross mechanical properties of which are enabled by an interconnected musculoskeletal network controlled by the nervous system. The nature of musculoskeletal interconnection facilitates stability, voluntary movement, and robustness to injury. However, a fundamental understanding of this network and its control by neural systems has remained elusive. Here we address this gap in knowledge by utilizing medical databases and mathematical modeling to reveal the organizational structure, predicted function, and neural control of the musculoskeletal system. We constructed a highly simplified whole-body musculoskeletal network in which single muscles connect to multiple bones via both origin and insertion points. We demonstrated that, using this simplified model, a muscle's role in this network could offer a theoretical prediction of the susceptibility of surrounding components to secondary injury. Finally, we illustrated that sets of muscles cluster into network communities that mimic the organization of control modules in primary motor cortex. This novel formalism for describing interactions between the muscular and skeletal systems serves as a foundation to develop and test therapeutic responses to injury, inspiring future advances in clinical treatments.

Developmental pathways inferred from modularity, morphological integration and fluctuating asymmetry patterns in the human face

Facial asymmetries are usually measured and interpreted as proxies to developmental noise. However, analyses focused on its developmental and genetic architecture are scarce. To advance on this topic, studies based on a comprehensive and simultaneous analysis of modularity, morphological integration and facial asymmetries including both phenotypic and genomic information are needed. Here we explore several modularity hypotheses on a sample of Latin American mestizos, in order to test if modularity and integration patterns differ across several genomic ancestry backgrounds. To do so, 4104 individuals were analyzed using 3D photogrammetry reconstructions and a set of 34 facial landmarks placed on each individual. We found a pattern of modularity and integration that is conserved across sub-samples differing in their genomic ancestry background. Specifically, a signal of modularity based on functional demands and organization of the face is regularly observed across the whole sample. Our results shed more light on previous evidence obtained from Genome Wide Association Studies performed on the same samples, indicating the action of different genomic regions contributing to the expression of the nose and mouth facial phenotypes. Our results also indicate that large samples including phenotypic and genomic metadata enable a better understanding of the developmental and genetic architecture of craniofacial phenotypes.

Bone Fusion in Normal and Pathological Development is Constrained by the Network Architecture of the Human Skull

Craniosynostosis, the premature fusion of cranial bones, affects the correct development of the skull producing morphological malformations in newborns. To assess the susceptibility of each craniofacial articulation to close prematurely, we used a network model of the skull to quantify the link reliability (an index based on stochastic block models and Bayesian inference) of each articulation. We show that, of the 93 human skull articulations at birth, the few articulations that are associated with non-syndromic craniosynostosis conditions have statistically significant lower reliability scores than the others. In a similar way, articulations that close during the normal postnatal development of the skull have also lower reliability scores than those articulations that persist through adult life. These results indicate a relationship between the architecture of the skull and the specific articulations that close during normal development as well as in pathological conditions. Our findings suggest that the topological arrangement of skull bones might act as a structural constraint, predisposing some articulations to closure, both in normal and pathological development, also affecting the long-term evolution of the skull.

Anatomical networks reveal the musculoskeletal modularity of the human head

Mosaic evolution is a key mechanism that promotes robustness and evolvability in living beings. For the human head, to have a modular organization would imply that each phenotypic module could grow and function semi-independently. Delimiting the boundaries of head modules, and even assessing their existence, is essential to understand human evolution. Here we provide the first study of the human head using anatomical network analysis (AnNA), offering the most complete overview of the modularity of the head to date. Our analysis integrates the many biological dependences that tie hard and soft tissues together, arising as a consequence of development, growth, stresses and loads, and motion. We created an anatomical network model of the human head, where nodes represent anatomical units and links represent their physical articulations. The analysis of the human head network uncovers the presence of 10 musculoskeletal modules, deep-rooted in these biological dependences, of developmental and evolutionary significance. In sum, this study uncovers new anatomical and functional modules of the human head using a novel quantitative method that enables a more comprehensive understanding of the evolutionary anatomy of our lineage, including the evolution of facial expression and facial asymmetry.