A Three-Dimensional Computed Tomographic Analysis of the Cervical Spine in Unoperated Infants with Cleft Lip and Palate

Facial Surface Anthropometric Features and Measurements With an Emphasis on Rhinoplasty

BACKGROUND

Facial features and measurements are utilized to analyze patients' faces for various reasons, including surgical planning, scientific communications, patient-surgeon communications, and post-surgery evaluations.

OBJECTIVES

There are numerous descriptions regarding these features and measurements scattered throughout the literature, and the authors did not encounter a current compilation of these parameters in the medical literature.

METHODS

A narrative literature review of the published medical literature for facial measurements used for facial analysis in rhinoplasty was conducted through the electronic databases MEDLINE/PubMed and Google Scholar, along with a citation search.

RESULTS

A total of 61 facial features were identified: 45 points (25 bilateral, 20 unilateral), 5 lines (3 bilateral, 2 unilateral), 8 planes, and 3 areas.A total of 122 measurements were identified: 48 distances (6 bilateral, 42 unilateral), 57 angles (13 bilateral, 44 unilateral), and 17 ratios. Supplemental figures were created to depict all features and measurements utilizing a frontal, lateral, or basal view of the face.

CONCLUSIONS

This paper provides the most comprehensive and current compilation of facial measurements to date. The authors believe this compilation will guide further developments (methodologies and software tools) for analyzing nasal structures and assessing the objective outcomes of facial surgeries, in particular rhinoplasty. Moreover, it will improve communication as a reference for facial measurements of facial surface anthropometry, in particular rhinoplasty.

Three-Dimensional Assessment of Cervical Vertebrae Anomalies in Patients With Cleft Lip and Palate

OBJECTIVE

To evaluate the occurrence of cervical vertebrae anomalies (CVA) in patients with unilateral (UCLP) and bilateral cleft lip and palate (BCLP) using cone beam computed tomography (CBCT) examinations.

DESIGN

Retrospective assessment of CBCT images. Descriptive statistics were calculated. Fisher exact test or χ² test was performed to evaluate the differences among each CVA between sex and type of cleft.

SETTING

School of Dentistry.

PARTICIPANTS

One hundred fifty-one patients with cleft lip and palate (103 UCLP/48 BCLP).

INTERVENTIONS

No relevant intervention.

MAIN OUTCOME MEASURES

Cone beam computed tomography images were assessed for the presence or absence of 12 most commonly observed CVA: spina bifida, dehiscence, cleft of the posterior arch, cleft of the anterior arch, fusion between cervical vertebrae, block fusion, occipitalization, narrowing of the intervertebral space, posterior ponticle, os odontoideum, ossiculum terminale, and subdental cartilaginous remnants.

RESULTS

The presence of subdental cartilaginous remnants was the most frequently observed alteration-found in 81.45% of the sample-and it was the only CVA with statistically significant frequencies in the individuals with BCLP. Considering only the other CVA, 22.51% presented 1 and 5.29% presented 2 or more CVA.

CONCLUSIONS

Patients with cleft lip and palate may present an overall high incidence of CVAs. However, when comparing the distribution of the CVAs among sex and types of cleft, the only significant difference noted was a higher incidence of subdental cartilaginous remnants among patients with BCLP.

Exploring copy number variants in deceased fetuses and neonates with abnormal vertebral patterns and cervical ribs

Background

Cervical patterning abnormalities are rare in the general population, but one variant, cervical ribs, is particularly common in deceased fetuses and neonates. The discrepancy between the incidence in the general population and early mortality is likely due to indirect selection against cervical ribs. The cause for the co‐occurrence of cervical ribs and adverse outcome remains unidentified. Copy number variations resulting in gain or loss of specific genes involved in development and patterning could play a causative role.

Methods

Radiographs of 374 deceased fetuses and infants, including terminations of pregnancies, stillbirths and neonatal deaths, were assessed. Copy number profiles of 265 patients were determined using single nucleotide polymorphism array.

Results

274/374 patients (73.3%) had an abnormal vertebral pattern, which was associated with congenital abnormalities. Cervical ribs were present in 188/374 (50.3%) and were more common in stillbirths (69/128 [53.9%]) and terminations of pregnancies (101/188 [53.7%]), compared to live births (18/58, 31.0%). Large (likely) deleterious copy number variants and aneuploidies were prevalent in these patients. None of the rare copy number variants were recurrent or overlapped with candidate genes for vertebral patterning.

Conclusions

The large variety of copy number variants in deceased fetuses and neonates with similar abnormalities of the vertebral pattern probably reflects the etiological heterogeneity of vertebral patterning abnormalities. This genetic heterogeneity corresponds with the hypothesis that cervical ribs can be regarded as a sign of disruption of critical, highly interactive stages of embryogenesis. The vertebral pattern can probably provide valuable information regarding fetal and neonatal outcome.

Cervical vertebrae anomalies and cleft lip and palate: a systematic review and meta-analysis

OBJECTIVES

This study investigated the association of congenital cervical vertebrae anomalies (CVA) with the prevalence of cleft lip and palate (CLP) specifying the most frequent associations.

METHODS

A meta-analysis was based on the Preferred Reporting Items of Systematic reviews and Meta-Analyses guideline. A search of the PubMed, Embase, Web of Science, Science Direct, Scopus and Lilacs database was performed until March 2018. Clinical studies that evaluated CVA in individuals with CLP (experimental group) and without CLP (control group) was included. For the statistical analysis, the software Comprehensive Meta-Analysis (Biostat; Englewood, NJ) was used, with a p-value < 0.05 considered significant.

RESULTS

A total of 10 articles were included, for a total of 2566 individuals with CLP and 2301 individuals without CLP. The meta-analysis indicated statistically significant differences and the group of individuals with CLP had an increased number of CVA when compared to the group of individuals without CLP (p < 0.05; 95% confidence interval, 2.41-6.11; heterogeneity: Q-value 32.8, I2 72.6%).

CONCLUSIONS

This study indicated that CVA are associated with the presence of CLP. Among the patients with CVA the most frequent anomalies were the deficiency of the posterior arch, followed by the fusion of cervical vertebrae. Individuals with cleft palate and those with unilateral cleft lip and palateCLP had an increased prevalence of CVA.

Morphologic Anomalies of Upper Cervical Vertebrae in Swedish Children Born with Nonsyndromic Cleft Lip and/or Palate Compared to Swedish Children without Cleft

OBJECTIVE

To examine and compare the prevalence of morphologic anomalies of the upper cervical vertebrae in Swedish children with nonsyndromic cleft lip and/or palate to Swedish children without cleft.

DESIGN

Retrospective study on lateral cephalograms.

SETTING

Division of Orthodontics, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.

PATIENTS

The cleft group consisted of 325 children (150 girls and 175 boys) born with nonsyndromic cleft lip and/or palate (mean age: 11.1 years). The control group consisted of 325 children without cleft, matched for age and gender.

MAIN OUTCOME MEASURES

Lateral cephalograms exposing upper cervical vertebrae (C1-C3) were examined regarding morphologic anomalies such as posterior arch deficiencies, fusion of vertebrae, odontoid anomalies, and deviations of the vertebral artery canal.

RESULTS

The prevalence of children with morphologic anomalies of the upper cervical vertebrae was 24.3% (n = 79) in children with cleft and 12.6% (n = 41) in children without cleft. Posterior arch deficiency and vertebral fusion were significantly more frequent in children with cleft (P < .001). No statistically significant differences were found between the 2 groups regarding odontoid and vertebral artery canal anomalies.

CONCLUSIONS

Morphologic anomalies of the upper cervical vertebrae in Swedish children with nonsyndromic cleft lip and/or palate were significantly more frequent compared to similar anomalies in Swedish children without cleft.

Influence of skeletal class in the morphology of cervical vertebrae: A study using cone beam computed tomography

OBJECTIVES

To quantify the prevalence of cervical vertebrae anomalies and to analyze any association between them and skeletal malocclusions or head posture positions in the same study.

MATERIALS AND METHODS

Two hundred forty patients who were attending the Department of Orthodontics of the University of Valencia for orthodontic treatment were selected and divided into three groups: skeletal Class I (control group, 0° <ANB < 4°), Class II (ANB ≥ 4°), and Class III (ANB ≤ 0°) according to ANB Steiner angle. The morphology of the first five cervical vertebrae was analyzed with cone beam computed tomography to identify any anomalies. Intra- and interobserver error methods were calculated.

RESULTS

Dehiscence and fusion of one unit (both 23.3%) and partial cleft (11.7%) were the most frequent anomalies, while occipitalization was the least common (3.3%). Dehiscence anomaly was observed when the control group was compared with Classes II and III and partial cleft anomaly when Class I was compared with Class III. Furthermore, NSBa and ss-N-sm/ANB angles were associated with partial cleft anomaly, while NSL/NL angle and extended head posture were associated with fusion anomaly.

CONCLUSIONS

Fusion, dehiscence, and partial cleft were the most frequent cervical vertebrae anomalies. Dehiscence and partial cleft were found to present statistically significant differences between Class I and Classes II and III. Cervical vertebrae anomalies and head posture were associated with fusion.

Integration of comprehensive 3D microCT and signaling analysis reveals differential regulatory mechanisms of craniofacial bone development

Growth factor signaling regulates tissue-tissue interactions to control organogenesis and tissue homeostasis. Specifically, transforming growth factor beta (TGFβ) signaling plays a crucial role in the development of cranial neural crest (CNC) cell-derived bone, and loss of Tgfbr2 in CNC cells results in craniofacial skeletal malformations. Our recent studies indicate that non-canonical TGFβ signaling is activated whereas canonical TGFβ signaling is compromised in the absence of Tgfbr2 (in Tgfbr2(fl/fl);Wnt1-Cre mice). A haploinsufficiency of Tgfbr1 (aka Alk5) (Tgfbr2(fl/fl);Wnt1-Cre;Alk5(fl/+)) largely rescues craniofacial deformities in Tgfbr2 mutant mice by reducing ectopic non-canonical TGFβ signaling. However, the relative involvement of canonical and non-canonical TGFβ signaling in regulating specific craniofacial bone formation remains unclear. We compared the size and volume of CNC-derived craniofacial bones (frontal bone, premaxilla, maxilla, palatine bone, and mandible) from E18.5 control, Tgfbr2(fl/fl);Wnt1-Cre, and Tgfbr2(fl/fl);Wnt1-Cre;Alk5(fl/+)mice. By analyzing three dimensional (3D) micro-computed tomography (microCT) images, we found that different craniofacial bones were restored to different degrees in Tgfbr2(fl/fl);Wnt1-Cre;Alk5(fl/+) mice. Our study provides comprehensive information on anatomical landmarks and the size and volume of each craniofacial bone, as well as insights into the extent that canonical and non-canonical TGFβ signaling cascades contribute to the formation of each CNC-derived bone. Our data will serve as an important resource for developmental biologists who are interested in craniofacial morphogenesis.

Cervical vertebral column morphology and head posture in preorthodontic patients with anterior open bite

INTRODUCTION

Cervical vertebral column morphology and head posture were examined and related to craniofacial morphology in preorthodontic children and adolescents with anterior open bite.

METHODS

One hundred eleven patients (ages, 6-18 years) with an anterior open bite of more than 0 mm were divided into 2 groups of skeletal or dentoalveolar open bite. The skeletal open-bite group comprised 38 subjects (19 girls, 19 boys). The dentoalveolar open-bite group comprised 73 subjects (43 girls, 30 boys). Visual assessment of the cervical column and measurements of craniofacial morphology and head posture were made on profile radiographs.

RESULTS

Deviations in the cervical vertebral column morphology occurred in 23.7% of the subjects in the skeletal open-bite group and in 19.2% in the dentoalveolar open-bite group, but the difference was not significant. Head posture was significantly more extended in the skeletal open-bite group compared with the dentoalveolar open-bite group (craniovertical angle [Mx/VER], P <0.05; craniocervical angles [Mx/OPT, Mx/CVT], P <0.01. Only head posture was associated with craniofacial morphology: extended posture was associated with a large cranial base angle (P <0.01, P <0.001), large vertical craniofacial dimensions (P <0.05; P <0.01; P <0.001), and retrognathia of the jaws (P <0.001).

CONCLUSIONS

Cervical column morphology is described for the first time in children and adolescents with open bite. No significant differences in the cervical vertebral column's morphologic deviations were found between the skeletal and the dentoalveolar open-bite groups. Significant differences were found in head posture between the groups and with regard to associations with craniofacial dimensions. This might indicate a respiratory etiologic component in children with anterior open bite.

Cervical vertebral column morphology in patients with obstructive sleep apnoea assessed using lateral cephalograms and cone beam CT. A comparative study

OBJECTIVES

Few studies have described morphological deviations in obstructive sleep apnoea (OSA) patients on two-dimensional (2D) lateral cephalograms, and the reliability of 2D radiographs has been discussed. The objective is to describe the morphology of the cervical vertebral column on cone beam CT (CBCT) in adult patients with OSA and to compare 2D lateral cephalograms with three-dimensional (3D) CBCT images.

METHODS

For all 57 OSA patients, the cervical vertebral column morphology was evaluated on lateral cephalograms and CBCT images and compared according to fusion anomalies and posterior arch deficiency.

RESULTS

The CBCT assessment showed that 21.1% had fusion anomalies of the cervical column, i.e. fusion between two cervical vertebrae (10.5%), block fusions (8.8%) or occipitalization (1.8%). Posterior arch deficiency occurred in 14% as partial cleft of C1 and in 3.5% in combination with block fusions. The agreement between the occurrence of morphological deviations in the cervical vertebral column between lateral cephalograms and CBCT images showed good agreement (κ = 0.64).

CONCLUSIONS

Prevalence and pattern in the cervical column morphology have now been confirmed on CBCT. The occurrence of morphological deviations in the cervical vertebral column showed good agreement between lateral cephalograms and CBCT images. This indicates that 2D lateral cephalograms (already available after indication in connection with, e.g. treatment planning) are sufficient for identifying morphological deviations in the cervical vertebral column. For a more accurate diagnosis and location of the deviations, CBCT is required. New 3D methods will suggest a need for new detailed characterization and division of deviations in cervical vertebral column morphology.

The nasopharynx in infants with cleft lip and palate

OBJECTIVE

The purpose of this study was to use three-dimensional computed tomography data and computer imaging technology to assess the skeletal components of the naso-pharyngeal area in patients with cleft lip and palate and to quantify anatomical variations.

METHODS

CT scans were obtained from 29 patients of Malay origin with cleft lip and palate aged between 0 and 12 months and 12 noncleft patients in the same age group, using a GE Lightspeed Plus Scanner housed in Hospital Universiti Sains Malaysia. Measurements were obtained using the 'Persona' three-dimensional software package, developed at Australian Craniofacial Unit, Adelaide.

RESULTS

The results of the present study show that there is an increased nasopharyngeal space in cleft lip and palate that may lead to compression of the nasopharyngeal structures, including the Eustachian tube. Alterations of the medial pterygoid plate and the hamulus may lead to an alteration in the origin and orientation of the tensor veli palatini muscle leading to alteration in its function.

CONCLUSIONS

These anatomical variations may compromise the dilatory mechanism of the Eustachian tube, thus leading to recurrent middle ear infections in cleft children and subsequent loss of hearing.

Associations between the Cervical Vertebral Column and Craniofacial Morphology

Aim. To summarize recent studies on morphological deviations of the cervical vertebral column and associations with craniofacial morphology and head posture in nonsyndromic patients and in patients with obstructive sleep apnoea (OSA). Design. In these recent studies, visual assessment of the cervical vertebral column and cephalometric analysis of the craniofacial skeleton were performed on profile radiographs of subjects with neutral occlusion, patients with severe skeletal malocclusions and patients with OSA. Material from human triploid foetuses and mouse embryos was analysed histologically. Results. Recent studies have documented associations between fusion of the cervical vertebral column and craniofacial morphology, including head posture in patients with severe skeletal malocclusions. Histological studies on prenatal material supported these findings. Conclusion. It is suggested that fusion of the cervical vertebral column is associated with development and function of the craniofacial morphology. This finding is expected to have importance for diagnostics and elucidation of aetiology and thereby for optimal treatment.

[Cleft lip and palate: indications for radiological postnatal explorations]

AIM

We evaluated the utility of systematic neonatal radiological explorations in 20 instances of isolated cleft lip and palate in 20 cases.

METHODS

This study included 13 infants with prenatal ultrasound diagnosis. The type of cleft and possible associated anomalies were noted. A systematic chromosomal test was done. In 7 cases, the cleft lip was noted at birth. Postnatal outcome was obtained and a clinical examination and radiological explorations were carried out.

RESULTS

For the cases with prenatal diagnosis, the chromosomal test was normal in 11 cases and we noted associated anomalies in three cases. For the cases with neonatal diagnosis, the chromosomal test was normal in 6 cases and 1 infant had associated anomalies.

CONCLUSIONS

The biological and radiological explorations can be numerous. In our study, the systematic neonatal radiological explorations did not find more elements compared with neonatal clinical examinations. The high risk of having a chromosomal anomaly in children with cleft lip requires systematic prenatal chromosomal exploration.

Association between the development of the body axis and the craniofacial skeleton studied by immunohistochemical analyses using collagen II, Pax9, Pax1, and Noggin antibodies

STUDY DESIGN

Immunohistochemical analyses on the axial skeleton from wild type mice.

OBJECTIVE

In the clinic, we have previously observed cervical spine defects associated with deviations in the posterior part of the occipital bone and with morphologic and functional variations in the craniofacial skeleton. As examples, cervical spine fusions occurred frequently in patients with mandibular overjet and even more frequently and more caudally in the cervical spine in patients with sleep apnoea. The aims of the present study were to elucidate this association between the spine and the cranium by comparing gene expression domains of important developmental genes known to be involved in vertebral column formation with gene expression in the craniofacial region.

SUMMARY OF BACKGROUND DATA

This is the first study looking specifically on gene expression in the basilar part of the occipital bone that is formed around the cranial part of the notochord, thus connecting the spine and the craniofacial skeleton.

METHODS

The material consisted of 4 mouse embryos p.c. day 13.5, NMRI wild-type mice, from the same litter. The body axis, the cranial base, and the craniofacial area were studied by immunohistochemical analyses using Collagen II, Pax9, Pax1, and Noggin antibodies.

RESULTS

Pax1 expression was highly similar in the posterior part of the occipital bone and in the vertebral column, indicating that the basilar part of the occipital bone from a developmental standpoint can be considered the uppermost vertebra. Pax9 and Noggin expression domains were in accordance with those described previously.

CONCLUSION

The present study supports that the basilar part of the occipital bone may be regulated by similar developmental mechanisms as the vertebral column and may thus be regarded the uppermost vertebra. Thus, the clinically observed association between the cervical column and the craniofacial area has been proved by immunohistochemical methods.

Cervical vertebral body fusions in patients with skeletal deep bite

Cervical column morphology was examined in 41 adult patients with a skeletal deep bite, 23 females aged 22-42 years (mean 27.9) and 18 males aged 21-44 years (mean 30.8) and compared with the cervical column morphology in an adult control group consisting of 21 subjects, 15 females, aged 23-40 years (mean 29.2 years) and six males aged 25-44 years (mean 32.8 years) with neutral occlusion and normal craniofacial morphology. None of the patients or control subjects had received orthodontic treatment. For each individual, a visual assessment of the cervical column and measurements of the cranial base angle, vertical craniofacial dimensions, and morphology of the mandible were performed on a profile radiograph. In the deep bite group, 41.5 per cent had fusion of the cervical vertebrae and 9.8 per cent posterior arch deficiency. The fusion always occurred between C2 and C3. No statistically significant gender differences were found in the occurrence of morphological characteristics of the cervical column (females 43.5 per cent, males 38.9 per cent). Morphological deviations of the cervical column occurred significantly more often in the deep bite group compared with the control group (P < 0.05). Logistic regression analysis showed that the vertical jaw relationship (P < 0.05), overbite (P < 0.001), and upper incisor inclination (P < 0.01) were significantly correlated with fusion of the cervical vertebrae (R(2) = 0.40).