Prediction of orthognathic surgery need in children with unilateral cleft lip palate : Dental arch relationships and 5-year-olds' index

Objective To evaluate whether dental arch relationships at 6 years of age can categorize treatment outcome and predict later need for orthognathic surgery in children with unilateral cleft lip and palate (UCLP). Setting and sample population A retrospective longitudinal single-centre study. The study sample comprised 70 consecutive non-syndromic children (47 boys) with complete UCLP operated on by pushback techniques during 1981-1989 and followed until early adulthood in the same cleft centre. Materials and methods Dental casts and maxillomandibular relationships were assessed before orthodontic treatment and secondary alveolar bone grafting at mean age 6.1 years (range 5.6-6.8) using the 5-year-olds' index and lateral cephalograms. The need for orthognathic surgery was retrieved from patient files. Student's t test, Pearson's correlation, and Kappa statistics were used in statistical analyses. Results Orthognathic surgery frequency was 41% (29/70). Those needing orthognathic surgery comprised all 3 patients with an index score of 5 (very poor), 14 of 17 (82%) scoring 4 (poor), 10 of 26 (38%) scoring 3 (fair), and 2 of 19 (11%) scoring 2 (good). Of the five patients with index score 1 (excellent), none needed osteotomies. The mean index score was 2.9. The score was significantly better in those without orthognathic surgery (2.4 versus 3.6). A significant negative correlation existed between the 5-year-olds' index and cephalometric angles ANB and anb. Conclusion The use of 5-year-olds' index may help to predict treatment outcome and the clinical need for orthognathic surgery especially in patients with the lowest and highest index scores.Peer reviewe

Vartijaimusolmuketutkimus diagnostisena työkaluna rintasyövän hoidossa

The purpose of this study was to evaluate the use of sentinel node biopsy (SNB) in the axillary nodal staging in breast cancer. A special interest was in sentinel node (SN) visualization, intraoperative detection of SN metastases, the feasibility of SNB in patients with pure tubular carcinoma (PTC) and in those with ductal carcinoma in situ (DCIS) in core needle biopsy (CNB) and additionally in the detection of axillary recurrences after tumour negative SNB. Patients and methods. 1580 clinically stage T1-T2 node-negative breast cancer patients, who underwent lymphoscintigraphy (LS), SNB and breast surgery between June 2000 - 2004 at the Breast Surgery Unit. The CNB samples were obtained from women, who participated the biennial, population based mammography screening at the Mammography Screening Centre of Helsinki 2001 - 2004.In the follow- up, a cohort of 205 patients who avoided AC due to negative SNB findings were evaluated using ultrasonography one and three years after breast surgery. Results. The visualization rate of axillary SNs was not enhanced by adjusting radioisotope doses according to BMI. The sensitivity of the intraoperative diagnosis of SN metastases of invasive lobular carcinoma (ILC) was higher, 87%, with rapid, intraoperative immunohistochemistry (IHC) group compared to 66% without it. The prevalence of tumour positive SN findings was 27% in the 33 patients with breast tumours diagnosed as PTC. The median histological tumour size was similar in patients with or without axillary metastases. After the histopathological review, six out of 27 patients with true PTC had axillary metastases, with no significant change in the risk factors for axillary metastases. Of the 67 patients with DCIS in the preoperative percutaneous biopsy specimen , 30% had invasion in the surgical specimen. The strongest predictive factor for invasion was the visibility of the lesion in ultrasound. In the three year follow-up, axillary recurrence was found in only two (0.5%) of the total of 383 ultrasound examinations performed during the study, and only one of the 369 examinations revealed cancer. None of the ultrasound examinations were false positive, and no study participant was subjected to unnecessary surgery due to ultrasound monitoring. Conclusions. Adjusting the dose of the radioactive tracer according to patient BMI does not increase the visualization rate of SNs. The intraoperative diagnosis of SN metastases is enhanced by rapid IHC particularly in patients with ILC. SNB seems to be a feasible method for axillary staging of pure tubular carcinoma in patients with a low prevalence of axillary metatastases. SNB also appears to be a sensible method in patients undergoing mastectomy due to DCIS in CNB. It also seems useful in patients with lesions visible in breast US. During follow-up, routine monitoring of the ipsilateral axilla using US is not worthwhile among breast cancer patients who avoided AC due to negative SN findings.Rintasyövän hoidossa ympäröivien imusolmukkeiden tila on merkittävin potilaan ennusteeseen vaikuttava tekijä. Leikkaushoidon osana toteutettu kainaloimusolmukkeiden poisto, nk. kainaloevakuaatio on merkittävästi parantanut rintasyöpäpotilaiden ennustetta tarjoten tietoa liitännäishoitojen suunnittelua varten ja poistaen syövän etäpesäkkeet (metastaaasit). Kainaloevakuatioon liittyy kuitenkin huomattavaa, etenkin yläraajaan kohdistuvaa sairastavuutta. Nykyään suurin osa uusista rintasyövistä onnistutaan diagnosoimaan jo taudin alkuvaiheessa ja siten näistä vain alle puolella on kainalometastaasit. Täten on pyritty löytämään vähemmän invalidisoivia ja samalla tarkkoja kainalostatuksen tutkimusmenetelmiä. Vartijaimusolmuke on ensimmäinen kasvaimesta imunestettä keräävä solmuke, niitä voi olla yksi tai useampia. Myös syöpäsolujen on havaittu leviävän ensimmäiseksi juuri näihin imusolmukkeisiin. Siten kyseisten imusolmukkeiden löytäminen, poistaminen ja tutkiminen tuo tietoa kainaloevakuaation ja liitännäishoitojen tarpeesta. Vartijasolmukkeiden ollessa terveitä ei muissakaan kyseisen imusolmukealueen solmukkeissa oleteta olevan ko. syövän metastaaseja. Vartijasolmukebiopsian on todettu tarjoavan varsin tarkan kuvan rintasyövän levinneisyydestä kainaloimusolmukkeisiin. Vartijasolmukebiopsiaa pidetään käypänä hoitona varhaisvaiheen rintasyövässä. Väitöskirjatutkimuksessa selvitettiin vartijaimusolmukebiopsian käyttökelpoisuutta erilaisten rintasyöpäpotilaiden diagnostiikassa ja hoidossa. Toisena tavoitteena oli vartijasolmukebiopsiassa käytettävien menetelmien kehittäminen. Löydöksinä oli, ettei annetun isotooppimerkkiaineen annoksen säätäminen potilaan painokertoimen (BMI) mukaan lisännyt vartijasolmukkeiden kuvautumista leikkausta edeltävässä kuvantamisessa. Toisaalta todettiin leikkauksen aikaisen immunohistokemiallisen tutkimuksen parantavan merkitsevästi toiseksi yleisimmän rintasyöpätyypin, lobulaarisen syövän metastaasien havaitsemista jo leikkauksen aikana ja mahdollisesti muissakin syövissä pienimpien, nk. mikrometastaasien toteamisen paranemisessa. Tutkimus osoitti myös aiemmista julkaisuista poiketen harvinaisemman, tubulaarisen syövän omaavan kohtuullisen merkittävän metastasointitaipumuksen. Mikäli poistetut vartijasolmukkeet ovat terveitä, kainaloresidivoinnin riski on todettiin erittäin pieneksi eikä ultraäänitutkimuksella saada seurannassa merkittävää lisähyötyä. Tutkimuksen tulokset osoittavat myös, että vartijasolmukebiopsia kannatta suorittaa paikallisen, in situ – kasvain potilaille, joilta taudin vuoksi poistetaan rinta sekä myös tietyissä tapauksissa, joissa suoritetaan rinnan osapoisto

The use of patient-specific implants in orthognathic surgery : A series of 32 maxillary osteotomy patients

The use of virtual surgery, patient-specific saw and drill guides, and custom-made osteosynthesis plates is rapidly spreading from deformity surgery to orthognathic surgery. Most of the commercially available systems are using computer-aided design/computer-aided manufacture (CAD/CAM) wafers to produce patient-specific saw guides. However, most plate systems provided are still the conventional "in stock" mini plates that can be individually designed by pre-bending according to the stereolithographic model of the patient. Custom made three-dimensional (3D) printed implants have earlier been demonstrated to be an ideal solution in deformity surgery and in reconstruction of complex posttraumatic cases. In this study, we report the novel use of patient-specific saw and drill guides combined with patient-specific 3D titanium alloy implants as a fixation system in maxillary movement after Le Fort I and bimaxillary osteotomies (n = 32). The implants were individually designed for each patient to follow anatomical structures and to provide exact positioning and stability of the repositioned maxilla. (C) 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.Peer reviewe

The use of patient-specific implants in orthognathic surgery : A series of 30 mandible sagittal split osteotomy patients

Purpose: Virtual surgery combined with patient-specific saw and drill guides and osteosynthesis materials are rapidly spreading from reconstructive surgery to orthognathic surgery. Most commercial partners are already providing computer-aided design and computer-aided manufacture (CAD/CAM) wafers and patient-specific saw guides. Clear benefits have been demonstrated for custom-made drill guides combined with individually designed three-dimensional (3D) printed patient-specific implants (PSI) as a reposition and fixation system in Le Fort I osteotomy. Materials and methods: We treated 30 patients who underwent bilateral sagittal split osteotomy (BSSO) due to class II dento-skeletal deformities with the additional use of drill guides combined with PSI as a fixation and positioning system. Results: The PSIs fitted bilaterally with total precision in 11 of the 30 patients. In 17 patients, the PSIs were used with some modifications. In 2 of 30 patients, the PSIs could not be used as a fixation due to misfit. Conclusion: Due to unpredictable fitting, the use of PSIs with drill guides alone in BSSO without wafers cannot be recommended. Further studies are needed to evaluate the interfering parts, which seem to be related to condylar positioning and bony interferences at the osteotomy sites. (C) 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.Peer reviewe

Additional squamosal suture synostosis and segmented intracranial volume in patients with non-syndromic sagittal synostosis

PurposeTo evaluate the incidence of squamosal suture synostosis (SQS) in children with non-syndromic sagittal synostosis and to evaluate whether the additional SQS affects the intracranial volume (ICV).MethodsThirty-four consecutive patients (23 boys) who had been operated by cranial vault remodelling because of sagittal synostosis were compared retrospectively from 3D-CT imaging data sets obtained from volumetric CT. The mean age of the patients at preoperative CT imaging was 0.48 (range 0.13-1.3) years. Mann-Whitney U test was used in the statistical analyses.ResultsSagittal synostosis was combined with SQS in four children (11.7%) but the additional SQS did not affect the ICV. SQS was unilateral in all children, two were located on the right and two on the left side. The length of the SQS varied between 4 and 27mm. The children with SQS had a shorter sagittal suture synostosis length ratio (length of synostosis/total sagittal suture lengthx100) than those without SQS.ConclusionsThe incidence of SQS in non-syndromic sagittal synostosis was 11.7% but SQS did not affect the ICV.Peer reviewe

Dental Age, Agenesis, and Morphology in Patients With Operated Single-Suture Craniosynostoses

Peer reviewe

Atypical Craniosynostosis with Torticollis and Neurological Symptoms: A Rhombencephalosynapsis Sequence

Purpose. We describe a case of 3-year-old girl with rhombencephalosynapsis, a rare cerebellar anomaly. Patient. A 3-year-old girl was admitted to our hospital due to congenital torticollis and asymmetry of face, skull and trunk. Craniosynostosis was suspected due to abnormal head shape. 3D-CT revealed closure of the sagittal suture without scaphocephalic skull. Due to atypical craniosynostosis with neurological symptoms, brain-MRI was performed revealing rhombencephalosynapsis. Results. Our patient presented with atypical craniosynostosis and balance problems, not typical for scaphocephaly. Operative treatment for craniosynotosis was not carried out because the cause of the problems was the cerebellum instead of the brain. Conclusions. Therefore, we conclude that patients with atypical craniosynostosis should be examined with brain-MRI to exclude the intracranial malformations, which 3D-CT does not reveal. Without brain-MRI, decision (not) to perform surgery could have been different

Sähkösavukkeet ja haavan paraneminen

Vertaisarvioitu. English abstract.Nikotiini on verisuonia voimakkaasti supistava aine. Sen tiedetään haittaavan haavan paranemista ¬verisuonikouristuksen ja vähentyneen hapensaannin kautta. Tutkimusnäyttö viittaa siihen, että nikotiinia sisältävän sähkösavukkeen käyttö heikentää haavan ¬paranemista ja kudoskielekkeiden verenkiertoa. Sähkösavukkeiden käyttäjät eivät miellä itseään tupakoijiksi, joten on tärkeää kysyä sähkösavukkeista ¬erikseen. Jo nykyisen tutkimustiedon perusteella ennen elektiivistä kirurgiaa sähkösavukkeiden käyttäjiä tulisi ¬opastaa lopettamaan samalla lailla kuin tupakoijiakin.Peer reviewe

Early experience of wafer-free Le Fort I osteotomy with patient-specific implants in cleft lip and palate patients

Summary Purpose The use of virtual surgical planning and patient-specific saw and drill guides combined with customized osteosynthesis is becoming a gold standard in orthognathic surgery. The aim of this study is to report preliminary results of the use of virtual surgical planning and wafer-free PSI technique in cleft patients. Materials and methods Patient-specific saw and drill guides combined with milled patient-specific 3D titanium alloy implants were used in reposition and fixation in Le Fort I osteotomy of 12 cleft patients. Surgical information was retrieved from hospital records. Pre- and postoperative lateral cephalograms were analyzed. Results In ten of 12 cases, the implants fitted as planned to predesigned drill holes and bone contours with high precision. In one patient, the mobilization of the maxilla was too demanding for virtually planned advancement and the implants could not be used. In another patient PSI fitting was impaired due to an insufficient mobilization of maxilla and tension on PSI fixation with screws. After the surgery the mean advancement of the anterior maxilla (point A) of all patients was 5.8 mm horizontally (range 2.7–10.1) and -3.1 mm vertically (range -9.2–3.4). Skeletal relationships of the maxilla and mandible could be corrected successfully in all patients except for the one whose PSI could not be used. Conclusions Virtual surgical planning combined with PSI is a possible useful clinical adjunct for correction of maxillary hypoplasia in cleft patients. Large maxillary advancements and scarring may be cause problems for desired advancement and for the use of implants.Peer reviewe

Pierre Robin Sequence : Incidence of Speech-Correcting Surgeries and Fistula Formation

Objective: Children with Pierre Robin sequence (PRS) and cleft palate have a high rate of velopharyngeal insufficiency (VPI) following primary palatoplasty. Our purpose was to determine the long-term incidence of speech-correcting surgeries (SCSs) and fistula rates in PRS after primary palatoplasty and the influence of possible causal factors. Design: A retrospective single-center, observational chart review study. Participants: After exclusion, the study cohort comprised 78 nonsyndromic PRS children (48 females) born between 1990 and 2009 and treated at the Cleft Palate and Craniofacial Center of Helsinki University Hospital, Finland. Causal factors included gender, surgeon, age at primary palatoplasty, surgical technique, airway obstruction in infancy, and cleft severity. We analyzed the outcome at age 8 years and at data retrieval, with a median follow-up of 14 years (range: 8-27 years). Results: Thirty-four (43.6%) children received SCS by age 8 years, and of the 19 (24.4%) postoperative fistulas, 6 (7.7%) underwent closure. At data retrieval, 37 (47.4%) children had undergone SCS and 8 (10.3%) had a fistula closure. Median age at SCS was 6 years. The results showed no significant association for gender, surgeon, age at primary palatoplasty, surgical technique, cleft severity, or airway obstruction in infancy regarding incidence of SCS, fistulas, or repaired fistulas. Conclusion: Pierre Robin sequence in children is associated with a high incidence of SCS and fistula formation, which necessitates accurate clinical follow-up and observation of speech development. The development of VPI in PRS is complex and most likely involving multiple factors.Peer reviewe