Margit Bacher

Digital Surface Photogrammetry for Anthropometric Analysis of the Cleft Infant Face

Objective To analyze the three-dimensional morphology of the cleft infant face with digital surface photogrammetry. Design Fifty plaster casts of unoperated infants with cleft lip and palate were imaged three-dimensionally with digital surface photogrammetry. Twenty-one standard craniofacial measurements were taken. The plaster casts were divided into 4 groups with unilateral, bilateral, complete, and incomplete clefts of the lip and palate. The measurements were compared with standard values for healthy infants. Results Significant differences (p < .0025) were found for the alar base width (33% to 55%), the alar base root width (59% to 103%), the width of the nose (7% to 25%), the length of the alar wing (18% to 25%), and the intercanthal (6% to 17%) and biocular (4% to 12%) width, depending on the cleft type. The vertical dimensions of the nose and the upper lip did not differ significantly from the controls. Conclusion This study describes preliminary data on the cleft infant facial deformity. The obtained results were mainly in agreement with data in the limited literature. Three-dimensional photogrammetry has proven to be reliable and can be applied more readily to potentially uncooperative patients.

External distraction of the maxilla in patients with craniofacial dysplasia.

Patients with severe maxillary hypoplasia secondary to craniofacial dysplasia present a challenge to the craniofacial surgeon. Maxillary distraction presents a promising tool to treat these patients more successfully. Fifteen patients aged 12 to 20 years with craniofacial dysplasia and maxillary retrusion were treated with two different techniques after complete Le Fort I osteotomy: one group underwent face mask protraction (2 patients), and the other group underwent rigid external distraction (13 patients). Cephalometric evaluation was performed before and after distraction. Rigid external distraction appeared to be superior to face mask protraction. Maxillary retrusion was fully corrected in this group. The path of maxillary positioning was well controlled by changing the traction force vector. Distraction osteogenesis has certainly improved treatment of these patients.

An Oral Appliance With Velar Extension for Treatment of Obstructive Sleep Apnea in Infants With Pierre Robin Sequence

Objective A new oral appliance to treat obstructive sleep apnea in infants with Pierre Robin sequence has recently been shown to be superior to a sham procedure. We now investigate safety and long-term effects of this appliance on obstructive sleep apnea in infants with Pierre Robin sequence. Design Case series with repetitive follow-up examinations. Setting Tertiary neonatal intensive care unit at the University Childrens Hospital Tuebingen, Germany. Patients Fifteen infants (11 girls and four boys; median age, 5 days) with Pierre Robin sequence and obstructive sleep apnea (i.e., mixed-obstructive-apnea index > 3). Intervention A custom-made intraoral appliance with velar extension was used continuously in situ from admission until 3 months after hospital discharge. Main Outcome Measure The mixed-obstructive-apnea index was determined prior to the intervention at admission, at discharge, and 3 months later using polygraphic sleep studies. The geometric mean of the mixed-obstructive-apnea index and its 95% confidence interval were calculated. Results Compared with admission (mean, 17.2; 95% confidence interval, 11.1–26.7), there was a significant decrease in the mixed-obstructive-apnea index to discharge (mean, 3.8; 95% confidence interval, 2.2–6.6) and 3 months later (mean, 1.2; 95% confidence interval, 0.7–2.2; p value < .001). No severe adverse events occurred. Conclusions This oral appliance was safe and appears to treat obstructive sleep apnea effectively in infants with Pierre Robin sequence.

Treatment of Upper Airway Obstruction and Feeding Problems in Robin-Like Phenotype

obin sequence (RS) was first delineated by Fairbairn in 1846 and Shukowsky in 1911; it was more formally investigated by the French stomatologist Pierre Robin in 1934, who later became the source of the eponym for this condition. Robin described it as consisting of a hypoplastic or retropositioned mandible and glossoptosis, resulting in respiratory distress, with or without a cleft palate. It fulfills criteria for a sequence, in which one or all anomalies found are secondary to another anomaly. The incidence varies between one in 8500 and one in 14 000 live births. The main functional problems associated with RS are upper airway obstruction (UAO) and failure to thrive (the latter resulting from feeding problems, UAO alone, or both problems). Feeding problems are often long-lasting, resulting in gastrostomy rates of 50% in large series. Interventions for RS should thus be assessed by their ability to improve polysomnography (PSG) results and weight gain. Although reported as used in infants with RS by 74% of US pediatric otolaryngology fellowship programs in 1994, only 39% believed PSG to be indicated for most patients with this condition, and just one in 5 performed serial PSG to test for treatment effectiveness. However, it is difficult to document the effect of treatments for RS on UAO without performing PSG, especially because anatomy does not correlate well with function. For this Medical Progress article, we searched PubMed for studies on the effectiveness of interventions suggested to improve UAO and weight gain in infants with RS (Table). It does not cover surgical techniques for which evidence in the literature is extremely scant or objective documentation of their effectiveness lacking.

Three-Dimensional Analysis of Cleft Palate Topology in Newborn Infants with Reference to the Cranial Skeleton

OBJECTIVE To describe a method of determining the three-dimensional topology of the palatal crest relative to a reproducible anthropomorphic coordinate system in newborn infants with unilateral cleft palate. For this purpose, physical models of the maxilla and face were analyzed by computer morphometry. DESIGN The study was limited to infants referred to the craniofacial center during the first 11 days after birth. SETTING The study was performed at a craniofacial center servicing a large geographic area. PARTICIPANTS The method was applied to 12 infants with unilateral cleft lip, alveolus, and palate (eight patients with left-side clefts and four with right-side clefts). MAIN OUTCOME MEASURES The three-dimensional topology of the palatal crest referenced to an anthropometric coordinate system was the primary outcome measure. The anthropometric reference system is defined by the tragus points and the midpoint of a line connecting the endocanthia. RESULTS The topology of the maxillary crests of the patients was characterized by considerable variability. The center of the premaxilla as defined by the attachment of the frenulum was frequently displaced by several millimeters from the midsagittal plane. The displacement was to the left in infants with right-side clefts and to the right in infants with left-side clefts. The premaxilla can be rotated by more than 30 degrees relative to the normal position. No significant retroposition of the minor segment as determined by the location of the tuber points was found. Several morphometric anomalies were found to be correlated linearly. CONCLUSIONS We propose that the morphologic deviations are in part caused by the neuromotor activity of the tongue and of the interrupted M. orbicularis oris. The data can serve as the starting point for a longitudinal study of craniofacial development in children with cleft palate and for studies on the efficacy of different therapeutic approaches.

Three-Dimensional Computer Morphometry of the Maxilla and Face in Infants with Pierre Robin Sequence—A Comparative Study

OBJECTIVE To analyze the morphology of the maxillary crest in infants with Pierre Robin sequence using an anthropometric coordinate system and to compare the data with those of healthy infants. SETTING The study was performed at a craniofacial center servicing a large geographic area. PARTICIPANTS The study involved eight infants aged 1-28 days (average, 7 days) with an established diagnosis of Pierre Robin sequence and six healthy infants aged 1-43 days (average, 22 days). MAIN OUTCOME MEASURES Physical models of the maxilla and face obtained by alginate replication were analyzed by computer morphometry yielding the three-dimensional topology of the maxillary crest. RESULTS The maxillary crest of children with Pierre Robin sequence shows an increased inclination relative to the transverse plane (30 +/- 3.9 degrees) as compared with that of healthy infants (20 +/- 2.9 degrees). The maxillary crest of the patients is shortened in the sagittal direction by comparison with healthy controls. CONCLUSIONS The increased inclination of the maxilla in infants with Pierre Robin sequence may aggravate the retroposition of the mandible and may thus be a pathogenetic factor contributing to the severe respiratory problems.

Facial Surface Changes After Cleft Alveolar Bone Grafting

PURPOSE The aim of this study was to assess the 3-dimensional facial surface changes after cleft alveolar bone grafting with digital surface photogrammetry. PATIENTS AND METHODS In a prospective study, 22 patients with cleft lip and palate underwent alveolar bone grafting. Before the procedure and 6 weeks postoperatively and before the continuation of orthodontic treatment, 3-dimensional images were taken with digital surface photogrammetry. Seven standard craniofacial landmarks on the nose and the upper lip were identified. Their spatial change because of bone grafting was assessed. Statistical analysis was performed with analysis of variance and t test. RESULTS A significant increase in anterior projection on the operative side (P < .05) was found for the labial insertion points of the alar base (subalare). No significant changes were detected for the position of the labial landmarks. CONCLUSION Our results show 3-dimensionally that there is a positive influence of the alveolar bone graft on the projection of the alar base on the cleft side.

Implementing a Superimposition and Measurement Model for 3D Sagittal Analysis of Therapy-induced Changes in Facial Soft Tissue: a Pilot Study

Aim:3D digital surface photogrammetry is an objective means of documenting the quantitative evaluation of facial morphology. However, there are no standardized superimposition and measurement systems for surveying soft tissue changes. The aim of this study was to present a superimposition and measurement model for three-dimensional analysis of therapy-induced sagittal changes in facial soft tissue and to ascertain its applicability based on the reproducibility of 3D landmark positions.Patients and Method:Twenty-nine children were examined (eight with cleft lip and palate, six with cleft palate, eight with Class III malocclusion and seven healthy controls, between 4.1 and 6.4 years). The mean time between examinations was 8.2 months for the patients and 8 months for the control group. Data was acquired with the DSP 400©imaging system. A mathematical model with seven superimposition points was developed. Two 3D images, one at the beginning and the other at the end of the examination, were generated. Both images were superimposed ten times. Ten landmarks for evaluating the soft tissue changes were geometrically defined on the superimposition image, put in place ten times, and measured. The landmarks’ reproducibility was calculated via statistical intraoperator analysis. Measurement error was identified using the root mean square error (RMSE).Results:The superimposition points were easy to locate and the landmarks well definable. All midface landmarks proved to be highly reproducible with an RMSE under 0.50 mm. The lower face landmarks demonstrated good reproducibility with an RMSE under 1 mm. The midface landmarks’ precision fell below the range of accuracy, while the lower face landmarks’ precision fell within the optoelectronic scanner device’s range of accuracy (0.50–1 mm).Conclusions:As an accurate, non-invasive, millisecond-fast, non-ionizing and ad infinitum repeatable procedure, 3D digital surface photogrammetry is very well suited for clinical and scientific application in orthodontics. We developed a reliable superimposition and measurement model with 3D digital surface photogrammetry. This new capturing and measurement system provides a simple means of determining 3D changes in facial soft tissue. Our landmarks proved to be highly reproducible for the midface while revealing good reproducibility for the lower face.ZusammenfassungZiel:Die digitale 3D-Oberflächenphotogrammetrie stellt ein objektives Verfahren dar, um die Gesichtsmorphologie quantitativ zu erfassen. Standardisierte Überlagerungs- und Auswertungsmodelle zur Vermessung von Weichteilveränderungen fehlen jedoch. Ziel dieser Studie war es, ein Überlagerungs- und Auswertungsmodell zur dreidimensionalen Analyse von therapiebedingten sagittalen Gesichtsweichteilveränderungen zu entwickeln und dessen Anwendbarkeit anhand der Reproduzierbarkeit der 3D-Landmarkenpositionierung zu überprüfen.Patienten und Methodik:Es wurden 29 Kinder, acht mit LKGSpalten, sechs mit Gaumenspalten, acht mit Klasse-III-Anomalien und sieben gesunden Kontrollen, zwischen 4,1 und 6,4 Jahren untersucht. Das Untersuchungsintervall betrug 8,2 Monate für die Patienten und 8 Monate für die Kontrolle. Die Datenakquisition erfolgte mit dem DSP-400©-System. Es wurde eine mathematische Konstruktion mit sieben Überlagerungspunkten entwickelt. Zwei 3D-Bilder, zum Untersuchungsbeginn und Untersuchungsende, wurden generiert und zehnfach überlagert. Auf dem Überlagerungssummenbild wurden zehn Messpunkte zur Erfassung der Weichgewebeveränderungen geometrisch bestimmt, zehnfach platziert und vermessen. Die Reproduzierbarkeit der Messpunkte wurde mit einer statistischen Intraoperatoranalyse überprüft. Der Messfehler wurde mit dem „Root Mean Square Error“ (RMSE) berechnet.Ergebnisse:Die Überlagerungspunkte ließen sich gut auffinden und die Messpunkte im Anschluss gut definieren. Alle Mittelgesichtspunkte zeigten eine hohe Reproduzierbarkeit mit einem RMSE kleiner als 0,50 mm. Die Untergesichtspunkte waren mit einem RMSE kleiner als 1 mm gut reproduzierbar. Die ermittelte Präzision der Mittelgesichtspunkte lag somit unterhalb und die der Untergesichtspunkte innerhalb der Genauigkeit des optoelektronischen Scanners (0,50–1 mm).Schlussfolgerungen:Als genaues, nichtinvasives, millisekundenschnelles, strahlenfreies und ad infinitum wiederholbares Verfahren ist die digitale 3D-Oberflächenphotogrammetrie sehr gut für den klinischen und wissenschaftlichen Einsatz in der Kieferorthopädie geeignet. Ein zuverlässiges Überlagerungs- und Auswertungssystem konnte mit der angewandten digitalen 3D-Oberflächenphotogrammetrie eingeführt werden. Es handelt sich um eine einfache Methode, faziale Weichteilveränderungen zu ermitteln. Die Messpunkte zeigten eine hohe (Mittelgesichtsbereich) bis gute (Untergesichtsbereich) Reproduzierbarkeit.

3D Soft Tissue Changes in Facial Morphology in Patients with Cleft Lip and Palate and Class III Mal occlusion under Therapy with Rapid Maxillary Expansion and Delaire Facemask

Aim:Rapid Maxillary Expansion (RME) and Delaire facemask are a well-established treatment method for patients with cleft lip and palate and Class III malocclusion. Several roentgenocephalometric studies on skeletal effects of this therapy are known. However, there are no systematic studies on soft tissue changes. The aim of this study was to analyze three-dimensionally the soft tissue changes in facial morphology of children with cleft lip and palate and Class III malocclusion under therapy with RME and Delaire facemask.Patients and Method:A prospective longitudinal clinical trial was undertaken. 29 children between 4.1 and 6.4 years were divided into four groups: eight patients with unilateral cleft lip and palate (group 1), six patients with isolated cleft palate (group 2), eight patients with Class III malocclusion (group 3). The mean treatment period with RME and Delaire mask was 8.2 months. Seven untreated children with no need of orthodontic treatment were chosen as the control (group 4). Two 3D images, one at the beginning and one at the end of the study, were generated with the DSP 400© imaging system. Both images were superimposed ten times and measured ten times.Results:We detected significant forward rotation and forward displacement of the soft tissue in the lower midface with the dentoalveolar areas in all patient groups. No significant asymmetric forward displacement of the soft tissue in the maxilla could be verified in the lower or upper midface, not even in the unilateral cleft lip and palate patients. Among the groups, the Class III malocclusion patients showed greater maxillary soft tissue changes.Conclusion:The RME and the Delaire facemask demonstrated the greatest effectiveness in the lower midface soft tissue in terms of forward displacement and forward rotation in the cleft lip and palate patients, particularly in the Class III patients. The 3D data allowed us to discriminatively interpret the effects of the orthopedic mask on the entire maxillary complex and maxillary alveolar process. In the unilateral cleft lip and palate patients, there was descriptively both symmetric and asymmetric advancement of the midface soft tissue.ZusammenfassungZiel:Die Gaumennahterweiterung (GNE) und Delaire-Maske stellen ein etabliertes Therapieverfahren bei Patienten mit Lippen- Kiefer-Gaumen-(LKG-)Spalten und Klasse-III-Anomalien dar. Viele röntgenkephalometrische Studien zum skelettalen Effekt dieser Therapie liegen vor. Systematische Untersuchungen zu Weichgewebeveränderungen fehlen jedoch. Ziel dieser Studie war es, die Weich gewebeveränderungen der Gesichtsmorphologie von Kindern mit Spaltbildungen und Klasse-III-Anomalien unter Therapie mit GNE und Delaire-Maske dreidimensional aufzuzeigen.Patienten und Methodik:Es wurde eine klinische prospektive Longitudinaluntersuchung mit 29 in vier Gruppen eingeteilten Kindern zwischen 4,1 und 6,4 Jahren durchgeführt. Acht Patienten mit einseitiger LKG-Spalte (Gruppe 1), sechs mit isolierter Gaumenspalte (Gruppe 2) und acht mit Klasse-III-Anomalie (Gruppe 3) wurden im Durchschnitt 8,2 Monate mit GNE und Delaire-Maske behandelt und untersucht. Sieben unbehandelte Kinder ohne kieferorthopädischen Behandlungsbedarf dienten als Kontrolle (Gruppe 4). Zwei 3D-Abbildungen, eine zum Untersuchungsbeginn und eine zum Untersuchungsende, wurden mit dem DSP-400©-System generiert, zehnfach überlagert und zehnfach vermessen.Ergebnisse:In allen Gruppen konnte eine signifikante Vorschwenkung und Vorverlagerung des Weichgewebes im unteren Mittelgesicht mit den dento-alveolären Bereichen nachgewiesen werden. Keine signifikante asymmetrische Vorverlagerung der Maxilla, weder im unteren noch im oberen Mittelgesicht, konnte beobachtet werden – auch nicht bei den einseitigen LKG-Spalten. Zwischen den Gruppen zeigten die Klasse-III-Patienten die größeren maxillären Weichgewebeveränderungen.Schlussfolgerungen:Die GNE und die Delaire-Maske zeigten bei den Spaltpatienten und vor allem bei den Klasse-III-Patienten eine deutliche Beeinflussbarkeit auf das Weichgewebe im Sinne einer Vorverlagerung und einer Vorschwenkung im unteren Mittelgesicht. Die Wirkungen der orthopädischen Maske auf den gesamten Maxillakomplex sowie auf den maxillären Alveolarfortsatz ließen sich anhand der 3D-Daten unterschiedlich interpretieren. Bei einseitigen LKG-Spalten kam es im Mittelgesicht deskriptiv sowohl zu symmetrischer als auch asymmetrischer Vorverlagerung des Weichgewebes.

Longitudinal cephalometric analysis after maxillary distraction osteogenesis.

Abstract:The aim of this study was to analyze the long-term dentoskeletal changes in patients who received distraction osteogenesis of the maxilla. Seventeen patients aged 12 to 31 years underwent rigid external distraction osteogenesis for treatment of maxillary hypoplasia. Cephalograms were evaluated retrospectively regarding linear and angular measurements. Follow-up times ranged from 1 to 5 years. In two patients, there was no consolidation of the Le Fort I segment to the midface. After the 0- to 12-month period, the maxilla had a stable position in all patients. Nevertheless, there was further decrease of SNA and ANB and an increase of the facial concavity thereafter. Ongoing growth of the facial skeleton must be considered when distraction osteogenesis is chosen for the advancement of the maxilla in adolescents.