Antje Kirbschus

Presurgical nasoalveolar molding in patients with unilateral clefts of lip, alveolus and palate. Case study and review of the literature

INTRODUCTION The case of a newborn female patient with unilateral cleft lip, alveolus and palate is presented with a markedly sunken nasal wing at the cleft side. This finding may lead to a very unsatisfactory aesthetic result after primary cheiloplasty and nasoplasty. PATIENT AND METHOD Five months prior to surgery, the patient was treated with a palatal plate and additionally with a nasoalveolar conformer for 4 months thereof. The device consisted of an acrylic pelotte (attached to the maxillary plate with a wire) which lifted the nasal dome and was activated regularly. Under this presurgical treatment, the cleft edges moved closer to each other by 1.8 mm at the alveolar ridge and by 4.5 mm in the palatal area. The nasal wing was lifted by 5 mm. This was enabling elevation of the nasal wing during primary surgery in the case described. Questions are raised as to the remaining effects on nasal symmetry until completion of growth and, on the other hand, as to the chances to reduce postsurgical alar relapse by continued nasal molding beyond primary surgery. CONCLUSION Presurgical nasal molding seems to improve aesthetics of the nose in patients with unilateral clefts of lip, alveolus and palate and distinctly flattend nasal wings.

Prenatal diagnostics of cleft deformities and its significance for parent and infant care.

INTRODUCTION This study aimed to demonstrate clefts of the secondary palate in embryos found to have cleft lip in order to evaluate the validity of prenatal ultrasound examination and, thus, to assess the significance of this diagnostic method for coordination and care of parents and infant. PATIENTS AND METHODS Over a period of 2.5 years, 7 fetuses with cleft deformities were examined sonographically during the 20th and 25th gestational week. The results were compared to postnatal clinical diagnosis. This study was made by two experienced examiners using 2D ultrasound devices (Acuson 128 XP-10/ C7; Toshiba Aplio XV). Postnatal clinical diagnosis was made by an orthodontist. RESULTS Three of the ultrasound-based diagnoses coincided with the postnatal result. In three of the examined cases the extent of the cleft was underestimated, whereas a greater extent suspected in one patient could not be confirmed clinically. CONCLUSION The results of the present study support the propositions of current literature: Diagnosis of a cleft of the lip and the alveolar process could correctly be made by an experienced ultrasound diagnostician. However, problems arise with clefts of the secondary palate.

Examiner differences in the assessment of different malocclusions.

Background:In the current discussion about ensuring treatment quality and reducing costs in the health sector, indication systems with which to determine the need for a treatment and the success of therapy are increasingly being used in orthodontics. These indication systems require the objective evaluation of malocclusions. Our objective was to determine the examiner reliability in the assessment of various malocclusions.Materials and Methods:In 180 adults (64 male, 116 female, aged 20–49) from the population-based Study of Health in Pomerania (SHIP), malocclusions were recorded clinically and on models by calibrated examiners. An experienced orthodontist conducted the clinical examination. Another orthodontically-experienced examiner analyzed the models. To compare the model examiners, two examiners with varying degrees of orthodontic experience evaluated 60 of the 180 models as well (29 male, 31 female). One of the model examiners repeated the assessment of 60 models at a later time (intra-individual comparison).Results and Conclusions:Reliability amongst the examiners depended on which malocclusions were judged: crowding and contact point displacement showed little agreement, while cross bite, edge-to-edge bite, deep bite and enlarged overjet revealed greater agreement.Comparison between the clinical examination and model analysis (kappa median 0.57) revealed the greatest differences between the examiners. Comparison of the three model examiners also showed differences. The contrast to the orthodontically least experienced examiner was greater (kappa median 0.61 and 0.62) than the divergence between the two orthodontically more experienced examiners (kappa median 0.70). The intra-individual examiner comparison revealed the smallest differences (kappa median 0.82).ZusammenfassungHintergrund:In der aktuellen Diskussion um Qualitätssicherung und Kostensenkung im Gesundheitswesen werden in der Kieferorthopädie zunehmend Indikationssysteme angewendet, die den Behandlungsbedarf bzw. den Behandlungserfolg erfassen sollen. Diese Indikationssysteme setzen eine objektive Bewertung der ihnen zugrunde liegenden Dysgnathiesymptome voraus. In der vorliegenden Untersuchung soll erörtert werden, wie gut die Befunde mehrerer Untersucher bei der Erhebung unterschiedlicher Dysgnathiesymptome übereinstimmen.Material und Methodik:Bei 180 erwachsenen Probanden (64 männlich, 116 weiblich, im Alter von 20–49 Jahren) der Studie „Study of Health in Pomerania∘(SHIP) wurden von kalibrierten Untersuchern kieferorthopädische Dysgnathiesymptome klinisch und am Modell erhoben. Die klinische Untersuchung erfolgte durch eine erfahrene Kieferorthopädin, die Modellanalyse ebenfalls durch eine kieferorthopädisch erfahrene Untersucherin. Für einen reinen Modelluntersuchervergleich werteten zwei kieferorthopädisch unterschiedlich erfahrene Untersucher 60 der 180 Modelle (29 männlich, 31 weiblich) zusätzlich aus. Die Hauptmodelluntersucherin wiederholte ihre eigene Auswertung an 60 Modellen zeitversetzt (intraindividueller Vergleich).Ergebnisse und Schlussfolgerungen:Die Untersucherunterschiede hingen vom zu beurteilenden Dysgnathiesymptom ab. Engstand/Kontaktpunktabweichung zeigten geringe Übereinstimmungen in allen Untersuchungsgruppen, während für Kreuzbiss, Kopfbiss, Tiefbiss und die vergrößerte sagittale Frontzahnstufe höhere Übereinstimmungen ermittelt wurden.Im Vergleich der klinischen Untersuchung mit der Modellauswertung (Kappa-Median 0,57) zeigten sich die größten Untersucherunterschiede. Auch beim Vergleich der drei Modelluntersucher untereinander waren Unterschiede feststellbar, wobei der Vergleich mit dem kieferorthopädisch unerfahrenen Untersucher größere Unterschiede aufwies (Kappa-Median 0,61 und 0,62) als der Vergleich der kieferorthopädisch erfahrenen Untersucher untereinander (Kappa-Median 0,70). Die geringsten Untersucherunterschiede fanden sich im intraindividuellen Vergleich (Kappa-Median 0,82).

Comparison of craniofacial morphology in patients with unilateral cleft lip, alveolus and palate with and without secondary osteoplasty

PROBLEM What kind of skeletal differences do exist between juvenile patients with unilateral cleft lip, alveolus and palate treated with or without secondary osteoplasty, and between cleft patients and non-cleft patients? PATIENTS AND METHODS Thirty-nine patients with unilateral cleft lip, alveolus and palate at a mean age of 15.8 years who were surgically treated with (n = 18) and without (n 21) secondary osteoplasty were compared with a control group of non-cleft patients (mean age 15.1 years). The patients were analyzed using lateral cephalograms. Cephalometric analysis included common sagittal and vertical variables as well as measurements of anterior tooth position and soft-tissue profile. RESULTS Analysis of lateral cephalograms revealed no significant differences between the two groups of cleft patients. The differences in comparison with the control group mainly revealed maxillary retroposition, a vertically open configuration, a steep position of the upper and lower anterior teeth and a decreased Holdaway-angle (flat midface). CONCLUSION Secondary osteoplasty exhibited no significant influence on craniofacial growth in children with unilateral cleft lip and palate. Both groups of cleft patients are not markedly different regarding sagittal and vertical skeletal configurations.

Complete cleft lip and palate without bone grafting and its effect on craniofacial morphology in three planes

The aim of the study was to analyze the morphology of the viscerocranium in patients with unilatertal or bilateral cleft lip and palate (CLP) who had undergone no surgical intervention of the alveolous meaning that no bone grafting was conducted. In this cross-sectional study 47 patients with complete unilateral (UCLP) or bilateral clefts (BCLP) were examined, and compared to a group of 42 patients without facial clefts. Each group was subdivided into two age groups (ca. 8 and ca. 15 years) approximately before and after the pubertal growth maximum. All patients with CLP received a complete palate closure by means of velopharyngoplasty at age of three, without any alveolar ridge osteoplasty. The craniofacial morphology of all patients was analysed in three planes (sagittal, coronal, horizontal) with help of model analysis and cephalometric analysis. The craniofacial morphology of all groups of CLP patients differed from that of the control groups. On average, more markedly impaired growth was observed in the older age group. Moderate retrognathic maxilla and slight mandible, a coronal skeletal excess, and a remarkable retrusion of the upper and lower anterior teeth were characteristic. Horizontal restriction of width could only be identified in the region of maxillary canines. CLP patients who had no bone grafting showed that the craniofacial developmental impairment was reasonably slight compared to patients without CLP, although it became more pronounced in the older age groups.

Influence of examiner differences on KIG-classification when assessing malocclusions.

Objective:Indication systems such as the German KIG system (Kieferorthopädische Indikationsgruppen = Orthodontic Indication Groups) presuppose the objective assessment of underlying malocclusions. In this survey, we aimed to investigate the degree of agreement among the findings of several examiners in the assessment of different malocclusions and their classification according to the KIG system.Subjects and Methods:Calibrated examiners assessed in the clinical evaluation and on plaster models orthodontic malocclusions in 180 adults (aged 20–49, 64 male, 116 female) from the population-based Study of Health in Pomerania (SHIP). Clinical examination was carried out by an experienced orthodontist, and the plaster models were also analysed by an examiner experienced in orthodontics. To compare inter- and intra-individual model examiners, we had two examiners with differing orthodontic experience carry out additional analyses of 60 of the 180 models (29 male, 31 female).Results:The examiner differences yielded various KIG classifications and hence different assessments (i. e., whether KIG case-costs should be borne by health insurance). The comparison “clinical examination versus model analysis” revealed differences regarding 16.7% of the study participants in the assessment of whether the expense would be borne by the statutory health insurance fund. At 5.0–8.3%, the number of participants whose assessments had differed was much smaller in the inter-individual comparison of model-examiners and was smallest (at 3.3–6.7%) when comparison was made between intra-individual assessments (by a sole examiner). With regard to overall malocclusion assessment, the greatest examiner differences were again revealed when comparing the clinical examination with the model analysis (median kappa 0.57). The model-examiner comparison revealed larger differences among examiners with less orthodontic experience (median kappa 0.61 and 0.62) than the comparison between examiners with orthodontic experience (median kappa 0.70).Conclusions:There can occasionally be considerable examiner differences in the classification of participants according to orthodontic indication groups and hence varying assessments of whether such persons are KIG cases or not. Various means of data collection (clinical evaluation—plaster models) in the assessment of malocclusions by multiple examiners and by those with little orthodontic experience may negatively influence agreement among examiners.ZusammenfassungZiel:Indikationssysteme wie die „Kieferorthopädischen Indikationsgruppen“ (KIG) setzen eine objektive Bewertung der ihnen zugrunde liegenden Dysgnathiesymptome voraus. In der vorliegenden Untersuchung sollte erörtert werden, wie gut die Befunde mehrerer Untersucher bei der Erhebung unterschiedlicher Dysgnathiesymptome und die Einstufung in die „KIG“ übereinstimmen.Probanden und Methodik:Bei 180 erwachsenen Probanden (64 männlich, 116 weiblich, im Alter von 20–49 Jahren) aus der populationsbasierten Study of Health in Pomerania (SHIP) wurden von kalibrierten Untersuchern kieferorthopädische Dysgnathiesymptome klinisch und am Modell erhoben. Die klinische Untersuchung erfolgte durch eine erfahrene Kieferorthopädin, die Modellanalyse ebenfalls durch eine kieferorthopädisch erfahrene Untersucherin. Für einen inter- und intraindividuellen Modelluntersuchervergleich werteten zwei kieferorthopädisch unterschiedlich erfahrene Untersucher 60 der 180 Modelle (29 männlich, 31 weiblich) zusätzlich aus.Ergebnisse:Bei der Einteilung in das KIG-System führten die Untersucherunterschiede zu unterschiedlichen Einstufungen (KIG-Fall/Kostenübernahme—ja oder nein). Der Vergleich „klinische Untersuchung/Modellanalyse“ zeigte für 16,7% der Probanden eine unterschiedliche Einstufung für die Kostenübernahme. Die Gruppe der unterschiedlich beurteilten Probanden fiel bei dem Vergleich der Modelluntersucher untereinander mit 5,0–8,3% deutlich geringer und bei ein und demselben Untersucher mit 3,3–6,7% am geringsten aus. Bei der Erhebung der Dysgnathiesymptome insgesamt zeigten sich im Vergleich der klinischen Untersuchung mit der Modellauswertung wiederum die größten Untersucherunterschiede (Kappa-Median 0,57). Im Modelluntersuchervergleich traten bei dem kieferorthopädisch unerfahrenen Untersucher größere Unterschiede (Kappa-Median 0,61 und 0,62) auf als beim Vergleich der kieferorthopädisch erfahrenen Untersucher untereinander (Kappa-Median 0,70).Schlussfolgerungen:Es gibt teilweise erhebliche Untersucherunterschiede bei der Einstufung von Probanden in die Kieferorthopädischen Indikationsgruppen und damit unterschiedliche Einteilungen dieser in KIG-Fälle oder Non-KIG-Fälle. Unterschiedliche Erhebungsmethoden (Klinik/Modell) bei der Befundung von Dysgnathiesymptomen durch mehrere Untersucher sowie kieferorthopädisch unerfahrene Untersucher können einen ungünstigen Einfluss auf die Untersucherübereinstimmung haben.

The Influence of Craniofacial Growth in a Case of Transverse Facial Cleft

This report presents the case of a female patient bearing a right-side transverse facial cleft. She has received interdisciplinary treatment since birth. At regular intervals, dental casts were made, and profile and full-face photographs, lateral and postero-anterior cephalograms were taken during the course of orthodontic treatment and maxillofacial surgery. We evaluated her diagnostic records with the intent of documenting the effects of growth and therapy on the skeletal structures of the facial cranium and on occlusion, and to show the influence on facial esthetics.Her facial morphology and occlusion were manifest at birth and in the primary dentition. The maxilla and mandible deviated from the midsagittal plane toward the cleft side, with the mandible considerably more affected, revealing a markedly posterior position. The lateral skeletal deviation of both jaws increased slightly during growth, yet the midline deviation of the dental arches and malocclusion clearly worsened. The increasing deviation was not obvious in full-face photographs. Especially in the primary and mixed dentition, the mandible shifted to the anterior, which was visible in both the lateral cephalograms and profile photographs.On the whole, however, no noteworthy alteration in the character of the craniofacial morphology occurred by the time growth was complete, despite functional jaw-orthopedic and maxillofacial surgical treatment consisting of two distraction osteogenesis procedures.ZusammenfassungDargestellt wird der Fall einer Patientin mit rechtsseitiger querer Gesichtsspalte, die sich seit Geburt in interdisziplinärer Behandlung befindet. In regelmäßigen Zeitabständen wurden im Rahmen der kieferorthopädisch-kieferchirurgischen Therapie Profil- und Enface-Fotos, Situationsmodelle, Fernröntgenseiten- und Schädel-PA-Aufnahmen erstellt. Die Auswertung der diagnostischen Unterlagen erfolgte einerseits unter dem Aspekt, die Auswirkungen von Wachstum und Therapie auf die skelettalen Strukturen des Viszerokraniums sowie auf die Okklusion zu erfassen und andererseits den Einfluss auf die Gesichtsästhetik darzustellen.Der Charakter der Gesichtsmorphologie und der Okklusion war mit der Geburt bzw. im Milchgebiss manifest. Ober- und Unterkiefer waren von der Gesichtsmitte zur Spaltseite hin abgewichen, der Unterkiefer wesentlich deutlicher als der Oberkiefer, wobei der Unterkiefer zusätzlich eine ausgeprägte Rücklage aufwies. Die skelettale Seitabweichung beider Kiefer verstärkte sich leicht im Laufe des Wachstums, die Mittellinienabweichung der Zahnbögen und die Malokklusion hingegen deutlich. In den Enface-Fotos wurde die zunehmende Abweichung nicht deutlich. Der Unterkiefer hat sich besonders im Milch- und frühen Wechselgebiss anterior verlagert, was sich im Fernröntgenseitenbild sowie im Profilfoto zeigte.Insgesamt trat jedoch bis zum Wachstumsabschluss trotz funktionskieferorthopädischer und kieferchirurgischer Therapie in Form von zwei Distraktionsosteogenesen keine nennenswerte Veränderung des Charakters der Gesichtsschädelmorphologie ein.