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The history of craniofacial surgery is one of many fundamental advances by monumental figures. Although craniosynostosis has been known to exist for multiple centuries, modern management has evolved over roughly the last century. An overview of early history, early scientific exploration, the advancement of surgical treatment of craniofacial deformities and the current state of craniosynostosis management is discussed. To fully appreciate the evolution of craniosynostosis surgery, one must understand the gradual advancements that have brought the specialty to this modern era.

Objective To determine the risk factors and their respective magnitudes for developing Obstructive Sleep Apnea (OSA) in Down syndrome (DS) patients. Design Retrospective cohort study. Patients The 2016 Kids’ Inpatient Database (KID) was queried to identify all patients diagnosed with DS. Main Outcome Measures The primary predictor variables were tonsillar hypertrophy (TH), adenoidal hypertrophy (AH), Hypertrophy of Tonsils & Adenoids (HTA), Laryngeal Stenosis (LS), Hypotonia, Glossoptosis, Congenital Laryngomalacia (CL), and Overweight & Obesity (OO). The primary outcome variable was OSA. Results The final sample consisted of 18,181 patients with a diagnosis of DS. Relative to patients aged 0-5, patients aged 6-10 (OR 3.5, P < 0.01), 11-5 (OR 3.4, P < 0.01), and 16 & above (OR 3.6, P < 0.01) were each independently associated with increased odds of OSA. Further, TH (OR 23.2, P < 0.01), AH (OR 20.3, P < 0.01), HTA (OR 64.2, P < 0.01), glossoptosis (OR 5.0, P < 0.01), CL (OR 4.3, P < 0.01), and OO (OR 3.7, P < 0.01) were all independent risk factors for OSA. Conclusions The presence of hypertrophied tonsils and adenoids together was the strongest risk factor for OSA. DS patients aged six and above were at risk for OSA development relative to younger patients. Patients with DS should be tested for OSA, which otherwise will deteriorate their existing comorbidities.

The purpose of this study was to determine the risk factors for epilepsy among patients with craniosynostosis.This is a retrospective cohort study that was completed with the Kids' Inpatient Database. All patients diagnosed with craniosynostosis between the years 2000 and 2012 were included. The primary predictor variables were obstructive sleep apnea (OSA), hydrocephalus, brain compression (BC), cerebral edema, papilledema, dolichocephaly, and plagiocephaly. The outcome variable was epilepsy. Logistic regression analysis was used to determine odds ratios (ORs) for the outcome (epilepsy).Our final sample had 4,709 patients with craniosynostosis, of whom 244 patients exhibited epilepsy (5.2%). The mean age of the patients was 1.43 years (range: 0-20). Relative to Asian patients, Black patients were 4 times more likely to have epilepsy (P .05). Relative to patients in fringe counties of metro areas with a population of at least 1 million, patients in metro areas of 50,000 to 249,999 population were almost 2 times more likely to have epilepsy (P .01). Hydrocephalus (OR, 6.6; P .001), BC (OR, 2.4; P .01), and OSA (OR, 3.0; P .001) were independent risk factors for epilepsy among our sample of patients with craniosynostosis.Hydrocephalus, OSA, and BC increase the risk of epilepsy in patients with craniosynostosis. Black patients with craniosynostosis are also at increased risk for epilepsy. With regard to location, patients in areas with a population of 50,000 to 250,000 were at increased risk for epilepsy.

The aim of this study was to evaluate the dynamic perfusion of the maxilla during various stages of a Le Fort I osteotomy using indocyanine green (ICG) dye angiography. This was a retrospective evaluation of patients who underwent a Le Fort I osteotomy. ICG was used to assess perfusion at specific time points during the procedure. Twenty-four patients underwent a Le Fort I osteotomy with dynamic perfusion ICG angiography. Statistically significant differences in perfusion were noted at all three locations assessed between preoperative (T0), post down-fracture (T1), and postoperative (T2) time points. When controlling for mean arterial pressure, statistically significant differences were noted at all three locations assessed between T0 and T1, and between T0 and T2. There were no statistically significant differences in patient age, heart rate, preservation or sacrifice of the descending palatine arteries, or conventional vs. segmental Le Fort I osteotomies across T0, T1, and T2. In conclusion, there was a statistically significant decrease in perfusion, as assessed by intraoperative dynamic angiography, to the anterior maxilla following maxillary down-fracture. Patient age, conventional vs. segmental Le Fort I osteotomy, changes in mean arterial pressure and/or heart rate, and preservation of the descending palatine vessels had no statistically significant effect on perfusion.

Mid-face augmentation via a Le Fort I osteotomy is a commonly performed operation. Advancement of the upper jaw and associated structures (nose, lower cheek areas) can certainly improve function as well as facial aesthetics and harmony. Often, in patients with severe mid-face deficiency, hypoplasia of the maxilla extends all the way up to the infraorbital rims. The receding infraorbital rim contributes to the negative vector of the globes. In patients with this level of mid-face hypoplasia, while advancing the maxilla at the Le Fort I level satisfies all of the requirements for orthognathic surgery, the deficient infraorbital rim remains unchanged and can actually accentuate the negative vector of the globes. This article explains our approach in augmentation of the deficient infraorbital rim using alloplastic silicone implants at the time of a Le Fort I osteotomy.

This chapter explores the effects of obstructive sleep apnea in the pediatric population. The prevalence of pediatric obstructive sleep apnea is 2–5% and is most commonly diagnosed in preschool-aged children, and the incidence increases in children diagnosed with craniofacial abnormalities. Several anatomic factors contribute to the pathophysiology, but the most common in children is adenoid and tonsillar hypertrophy. A thorough physical examination along with polysomnography remains the mainstay of diagnosis. Adenotonsillectomy improves the symptoms of OSA with a 79–85% success rate, but there are several other treatment modalities. The general census among the specialists that treat pediatric OSA is that it is an underdiagnosed condition that causes significant morbidity and reduction in the quality of life when left untreated.

Primary delayed onset craniosynostosis is a rarely reported phenomenon. The unique case of a 2-year-old boy who had computed tomography (CT) scans performed 20 months apart demonstrating the post-gestational development of sagittal suture craniosynostosis is presented. The otherwise healthy male initially presented to the emergency department at age 7 months with soft tissue swelling over his left parietal region secondary to a fall. A CT scan revealed a possible left parietal skull fracture without intracranial pathology and patent cranial sutures with a normocephalic calvarial configuration. Twenty months later, his paediatrician referred the boy to the craniofacial service for evaluation of progressive dolichocephaly. A new CT scan showed complete fusion of the sagittal suture with resultant biparietal narrowing, frontal bossing, and occipital prominence. The patient subsequently underwent uncomplicated frontoparietal craniotomy with calvarial vault reconstruction. Prior reports in the literature of cases of non-syndromic primary delayed onset craniosynostosis all lack 'pre-synostosis' CT imaging that proves post-birth patency of the cranial sutures. This case report documents CT demonstrating true primary delayed onset craniosynostosis.

Purpose Tracheotomy is one of the oldest surgical procedures known. There are multiple indications for tracheostomies. Operative complications have ranged between 5-40%. This manuscript describes our experience with 171 open tracheostomies at a major academic medical center. Methods A retrospective review of all patients’ records who underwent an open tracheostomy by the Division of OMS between July 1, 2007 to December 31, 2010 was performed. Specific information including indication for procedure, age of patient, type and size of tracheostomy tube, and any post-operative complications were compiled. Based on the data gathered, statistical analysis was performed to establish incidence of complications and its correlation to the specific indication for the tracheostomy. Trends and outcome assessments were then determined. Results Median age for tracheostomy in the group was 36 (17-89). Majority of tracheostomies were performed in conjunction with head and neck oncologic procedures (51%). Complication rate was 4.1% (7 patients out of 171). Conclusion Open tracheostomy is an extremely useful surgical procedure. If performed appropriately, it is associated with a low complication rate.

Purpose This study was undertaken to evaluate the efficacy of closed reduction of nasal fractures and determine the incidence of the need for post-traumatic septo-rhinoplasty in the management of residual nasal deformities. Patients and Methods Medical records of all patients with nasal fractures evaluated and treated by the Division of Oral and Maxillofacial Surgery at the University of Florida Health Science Center, Jacksonville, FL between January 2001 and October 2004 were retrospectively evaluated. Out of a total of 344 patients, 50 patients met the inclusion criteria. Forty-four patients (group A) underwent closed reduction of nasal bones and septum along with a septoplasty if needed within 2 weeks of initial injury. Six patients (group B) could not tolerate any surgical intervention because of multisystem injury or comorbidities. All 50 patients were then followed up in the Division of Oral and Maxillofacial Surgery to determine overall efficacy of the initial treatment modality, as well as the need for secondary post-traumatic septo-rhinoplasty. Group A was then further subdivided into groups A1 and A2. Group A1 consisted of patients who underwent a closed reduction of their nasal complex fracture without a residual deformity or the need for a secondary post-traumatic septo-rhinoplasty. Group A2 consisted of patients who underwent a closed reduction of their nasal complex fracture and developed a secondary nasal deformity significant enough to require a septo-rhinoplasty. Results The follow-up period ranged from 1 week to 12 months. Nine patients in group A were lost to follow-up. Patients in group A1 (31 patients) were pleased with their results and did not require a secondary surgery. Four patients developed a post-traumatic nasal deformity requiring a post-traumatic septo-rhinoplasty (group A2). All patients in group B required post-traumatic septo-rhinoplasty. Conclusion Closed reduction of nasal fractures appears to be an effective method of treatment as long as careful attention is paid to the key regions in the nasal complex, including the septum at the initial time of treatment. Ideal results are obtained when surgery is performed within 2 weeks of initial injury. Factors such as timing of surgery, the status of the nasal septum, delay in treatment, and other associated injuries may influence the overall result.

Purpose This study was undertaken to compare total operating room cost, total operating time, and potential complications in frontal sinus obliteration using 2 different techniques. Patients and methods Hospital records of all patients with frontal sinus fractures treated by the Division of Maxillofacial Surgery at the University of Florida, Jacksonville between October 1998 and December 2003 were reviewed. Twelve patients required frontal sinus obliteration based on the severity and location of injury. All cases were caused by traumatic etiology. Patients were divided into group A or B. Six patients (group A) were treated using autogenous abdominal fat for obliteration purposes, while the other 6 patients (group B) underwent frontal sinus obliteration using a hydroxyapatite cement. Total operating cost, total operating time, and any complications were recorded and analyzed for each group and then statistically evaluated using a t test. Results Follow-up ranged from 2 weeks to 6 months. Patients in group A had a lower total operating cost compared with group B. This cost difference was statistically significant. Total operating time was slightly greater in group A versus group B, although this was not statistically significant. Conclusion Frontal sinus obliteration using autogenous abdominal fat appears to be more cost effective compared with hydroxyapatite cement. The slight difference in total operating time was not statistically significant and this factor alone should not be a deterrent from performing this surgical procedure.

Traumatic carotid-cavernous fistulae are rare yet potentially lethal vascular anomalies in the skull base seen after craniomaxillofacial trauma. This aberrant vascular communication has been extensively evaluated and classified, with a number of treatment modalities available to clinicians. The ultimate and definitive treatment of carotid-cavernous fistulae falls beyond the scope of craniomaxillofacial surgery. Nevertheless, clinicians treating patients with craniofacial injuries should have a complete understanding of this pathological entity, because urgent intervention may improve patient outcome.

As the new millennium approaches, it seems appropriate to look back at where we have been and where we are going with the care of patients with facial deformities. None of us can deny that although changes have been made, many current treatment modalities are no more than modifications of old techniques. We are, however, poised to make dramatic improvements in the management of facial abnormalities as we enter the new century and millennium. Biotechnology, genetic manipulation, and new surgical technology will become pervasive, and perhaps we will move from “modification” of the old into a completely new era of therapeutic approaches to the care of dentofacial deformities. “Opportunities multiply as they are seized” (from Sun Tzu), and the time of opportunity is approaching. This review will attempt to look at the state of the art in cleft care and in oral and maxillofacial surgery: where we have been and where we are going. It will be clear that there is overlap between specialties and that these overlaps will become greater as new regimens in the care of facial deformities come to the forefront.

c H o c i n m C f t c a p r w m i he inability of the growing child to breath adeuately may have profound effects on their future evelopment. There is little controversy surrounding he need for early intervention to establish adequate entilation in children with airway obstruction that nterferes with sleep and normal oxygenation. The ontroversy lies in the method of establishing the irway. The “gold standard” for alleviating airway obtruction, including those in neonates and infants, has een the tracheostomy. However, even though the rocedure may be lifesaving, it has been associated ith complications and developmental impacts. Edards et al reported that even with advances in oordinated pediatric and neonatal care, children ith tracheostomies remain in the hospital much onger than other children. Another study reported a 5% complication rate and 1 death related to the racheostomy procedure in a series of 17 children. ven in an article supportive of pediatric tracheostoies, the authors reported a tracheostomy-related ortality rate of 0.5% and a complication rate of 19% n the first week following the procedure. They also eported a late complication rate of 58%, all of which ad an impact on clinical outcomes. The mortality ate was consistent with the study by Carr et al, who eviewed the charts of 142 children and found a racheostomy-related mortality rate of 0.7%. There are long-term issues with tracheostomies as ell. Griese et al theorized that there might be hronic airway inflammation in pediatric patients ith tracheostomies secondary to easier access by

Objectives This study tested various protocols for bone decontamination after bacterial contact to determine if these treatments altered bone structure. Study design Femurs from five Sprague-Dawley rats were sectioned and separated into eight groups. These were contaminated in a broth containing Pseudomonas aeroginosa and Staphylococcus aureus . Subsequently, the groups were treated with eight different decontamination regimens. A Scheffe's Grouping test was used to statistically compare the bacterial counts after each treatment protocol. Results Treatment with 4% chlorhexidine gluconate and 4% alcohol, Neosporin, cefazolin, and saline solution had little effect on bacterial growth. However, povidone-iodine, autoclaving, and ethyl alcohol with ethanol did significantly decrease the bacterial colony counts from the bone specimens. The autoclave and ethyl alcohol/ethanol induced changes in bony histologic examination. Conclusions Results suggested that povidone-iodine decontaminates bone specimens without altering histologic conditions. Determination of successful grafting of bone treated with this protocol is required before its recommendation for clinical use.

To date, surgical management of ameloblastoma has been a controversial subject. Numerous excellent reviews have addressed this topic) -7 The debate stems from confusion in the literature regarding histologic type of the tumor and from lack of standardization of definitions for "conservat ive" and " radica l" surgical approaches. The objective of this article is to clarify this confusion and to assist surgeons to develop a rational approach to the surgical management of ameloblastoma through assessment and evaluation of the literature.

Purpose To compare military with civilian gunshot wounds (GSWs) in the maxillofacial region in order to establish differences in presentation, morbidity, and surgical management. Materials and Methods A cross-sectional study design was used. The University of Florida at Jacksonville oral and maxillofacial surgery operating room census and hospital trauma registry were both reviewed to identify maxillofacial GSW cases from 2005 through 2011. Military GSW data (2005 through 2011) were obtained from the US Department of Defense (DOD). The predictor variables were civilian versus military GSW events. The outcome variables of interest included the region of the face involved, race, gender, death during admission, hospital length of stay, and number of days in the intensive care unit (ICU). Descriptive statistics were computed. Results The sample was divided into military maxillofacial GSWs (n = 412) and civilian maxillofacial GSWs (n = 287 treated of 2,478 presented). A significant difference was measured between study groups regarding the region of the face involved (P = .0451), gender (P ≤ .0001), and race (P ≤ .0001). No significant relationship was measured regarding deaths during admission (P = .6510) for either study group. No standard deviation values for hospital length of stay or number of ICU days were provided by the DOD. The mean hospital length of stay for the military group was within the 95% confidence interval of the civilian group findings (6.0-7.6). The mean number of ICU days for the military group was not within the civilian group's 95% confidence interval (1.9-2.9). Conclusions These data showed important differences in anatomic location, gender, and race distribution of maxillofacial GSWs between military and civilian populations. Limited analysis of hospital length of stay and number of ICU days might indicate no meaningful difference in hospital length of stay, although there was a statistical difference in the number of ICU days between the 2 populations. Future research comparing surgical strategies in these 2 environments could assist maxillofacial surgeons in providing optimal care to their patients.

Purpose: Bioresorbable implant systems have been used for the rigid fixation of cranial and facial bones. A relatively recent advancement has been the fixation of these implants using an ultrasonic device. Published reports with such a device in pediatric craniofacial surgery have been limited. We report our experience with ultrasound-aided fixation of bioresorbable implants in the craniofacial surgery of children. Methods: We retrospectively examined the clinical information, complications and outcome following the use of a commercially available ultrasound-aided bioresorbable implant system (SonicWeld Rx™, KLS Martin, Jacksonville, Fla., USA) during craniofacial surgery by University of Florida College of Medicine Jacksonville surgeons. Follow-up was obtained via clinical examination or telephone interview. Results: Over a period of 3 years, 37 pediatric patients (age range: 2 months to 16 years) had placement of these implants for immediate bony fixation during craniofacial procedures. Pathology consisted mainly of craniosynostosis (n = 19), and trauma (n = 16). Twenty-eight had combined craniofacial procedures; 9 patients had facial procedures. Reoperation was performed for: wound infection (n = 1), plate extrusion (n = 1). Delayed subcutaneous plate-related swelling was seen in 5 patients (4 were infants) and had a benign clinical course. Good cosmetic outcomes were seen in all patients. Conclusions: The use of a bioresorbable implant system with ultrasound-aided pin fixation in pediatric craniofacial surgery achieves rapid fixation with minimal morbidity and good cosmetic outcome. This system is easy to use and provides reliable stability in the setting of pediatric trauma and craniosynostosis.

Thin section and freeze-fracture transmission electron microscopy were used to examine and identify the cytoplasmic and membrane structures in a cell line derived from a melanotic neuroectodermal tumor of infancy (MNTI). The cultured cells had a uniform appearance after 70 population doublings characterized by long dendritic processes and evidence of melanin production. The cytoplasm contained numerous melanosomes in various stages of development, vesiculated rough endoplasmic reticulum, microfilaments and uncoated as well as coated vesicles. The membrane specializations included caveoli, coated pits, gap junctions, microfilaments, desmosome-like structures and lamellipodia. The ultrastructural appearance of the cultured MNTI cells was similar to features previously seen in electron micrographs of MNTI tumor specimens. However, correlated freeze-fracture and thin section micrographs permitted further identification of structures previously described. The MNTI cell line represents one of the cell types of the tumor and provides an opportunity for further study of the pathogenesis of this rare tumor.

Introduction: Minimally invasive endoscopic techniques for the treatment of sagittal craniosynostosis have been shown to achieve excellent long-term outcomes. The objective assessment of calvarial reconfiguration centers on serial measurement of cephalic index. Limited objective information is present in the literature about changes in the cephalic index over the course of postoperative helmet therapy. Our primary objective in this retrospective case series is to quantify this change in cephalic index, with secondary objectives intending to show that the rate of cephalic normalization decreases further from surgery irrespective of other variables. Methods: We analyzed data from 7 cases of primary sagittal craniosynostosis treated with endoscopic wide vertex craniectomy and biparietal wedge osteotomies performed at our institution between 2012-2013 in infants aged 3-6 months. Each patient’s cephalic index was quantified using preand postoperative STAR scanning over the course of up to one year. We compared changes in cephalic index one week after surgery to the rate of change further from the operation using ttest analysis. Results: Although patient compliance with STAR Scan was not consistent, (range of 36 STAR Scans per patient) the immediate postoperative difference from surgery to first (1 week) STAR Scan was significant. In comparison to the total change, 33% of cephalic index normalization occurred during this one week period versus the rest of the year (average change of 0.0436). In fact, 4 months after surgery little to no change in cephalic index occurred. At the conclusion of the study, all patients noted normalization of cephalic index (range of 0.76-0.81). Conclusions: The majority of improvement in cephalic index occurs most rapidly after initial surgical intervention, consistent with observations at other institutions. This change is noticeably visible on the operating room table, and quantifiable at initial STAR scan. Change occurs throughout helmet therapy, but at a slower rate of change further from surgical inter

Limited mouth opening in the neonatal patient is primarily caused by either soft tissue or hard tissue pathologic features. Differentiation between the two can usually be elicited by physical examination with the patient under anesthesia. Limited opening from soft tissue pathologic features can be increased with stretching. In contrast, osseous pathologic features will produce an anatomic stop. Syndromic cases with hard tissue pathologic features are primarily due to coronoid hyperplasia. Our aims are to help clinicians evaluate and identify mandibular hypomobility in the pediatric patient resulting from coronoid hyperplasia and to promote early treatment to improve long-term oral function. We present the case of a 2-month-old male who was born premature at 30 weeks by emergency cesarean section. Examination revealed multiple anomalies, including significant trismus with a maximal opening of 4 mm. A computed tomography scan revealed significant bilateral coronoid hyperplasia. At the age of 90 days, the patient underwent bilateral coronoidectomies with endoscopic guidance under general anesthesia. After resection, the patient was able to open his mouth to 25 mm. This opening was maintained with postoperative physiotherapy. Clinical problems can arise from the potential sequelae of neonatal trismus. Acutely, these problems can range from feeding difficulty and potential malnutrition to aspiration and emergent airway compromise. Long-term consequences include growth restrictions because of malnutrition, speech delay, muscle contracture and atrophy, facial asymmetry, and the risk of infection owing to poor oral hygiene. Information is limited about neonatal treatment of condylar hyperplasia in the published data. Treatment tends to be delayed owing to a late diagnosis and referral, and patients are prone to developing relapse. Postoperative physical therapy will help to prevent relapse and allows for maintenance of the improved jaw range of motion.

Purpose This study was designed to assess the use of the endoscopic transmaxillary approach to correcting orbital blowout fractures (OBFs) with placement of alloplastic implants. Materials and Methods This was a prospective study of patients treated in the Division of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville over a 6-month period, July to December 2005. Ten patients (7 males, 3 females, age range 19 to 47 years [average age 37.3 years]) met the inclusion criteria for the study and consented to undergo surgical repair. The injury was most commonly secondary to assault (6 cases); the remainder were secondary to motor vehicle collisions. The time from injury to correction ranged from 3 to 36 days (average, 10.9 days). A computed tomography scan with axial and coronal views was obtained in each patient at the time of presentation. All patients who met the inclusion criteria for the study underwent an endoscopic-assisted transmaxillary repair of their OBF with placement of a Medpor implant (Porex Surgical Products, Newnan, GA). Results Of the 10 patients, 9 presented with diplopia preoperatively and 4 had associated entrapment on upward gaze. One patient did not have entrapment or diplopia but had a fracture larger than 2 cm2. All patients underwent successful OBF repair with placement of a Medpore implant through the endoscopic transmaxillary approach, and all experienced resolution of preoperative diplopia and/or entrapment. None of the patients developed enophthalmos at a mean follow-up of 12.7 weeks. Conclusions The endoscopic transmaxillary approach to correcting OBF is an excellent alternative to the transconjunctival approach. This approach carries a very low morbidity and may be used in circumstances in which conventional approaches are not feasible.

This study evaluated the influence of recombinant human bone morphogenetic protein 2 (rhBMP-2) on the development and eruption of the secondary dentition. Primary premolar tooth extraction sockets in 12 16-week-old felines were implanted with either rhBMP-2, in collagen sponge or with buffer/absorbable collagen sponge (ACS). Unoperated jaw quadrants served as controls. Experimental conditions were randomized between jaw quadrants in all animals. Two animals receiving rhBMP-2/ACS and buffer/ACS in two quadrants per implant were sacrificed at 4 weeks postsurgery. Ten animals receiving rhBMP-2/ACS (two quadrants), buffer/ACS implants (one quadrant), and one quadrant serving as an unoperated control were evaluated at 12 weeks postsurgery. Clinical assessments included healing, eruption patterns, and crown development. Radiographic assessments included tooth development, eruption patterns, and bone formation. Histological observations were also made from the 4-week animals. The secondary dentition remained unerupted at 4 weeks postsurgery. Histological analysis showed normal alveolar bone coronal to the erupting teeth in rhBMP-2/ACS-implanted quadrants. At 12 weeks postsurgery, all teeth were erupted without differences between quadrants. Clinically, the crowns of all teeth were normal. Radiographs suggested that teeth in rhBMP-2/ACS- and buffer/ACS-implanted jaw quadrants exhibited similar tooth development and eruption patterns as the normal control. The evidence from this study suggests that surgical implantation of rh-BMP-2/ACS in the pathway of the developing and erupting secondary dentition does not interfere with the normal development and eruption patterns of the teeth.

Abnormal breathing during sleep may frequently occur in early childhood, but it is usually unnoticed because of unperceived medical or physiologic seque1a.l Infants and children with neuromuscular disease exhibit a higher incidence of obstructive sleep apnea secondary to hypotonicity of the pharyngeal musculature that allows collapse of the airway.z~3 In addition, the potential for airway obstruction is further increased by supine positioning, neck flexion, and increased secretions during sleep.* Initial management of obstructive sleep apnea in children has traditionally included pharmacologic treatment, the use of nasopharyngeal airway devices, oxygen supplementation, and positive airway pressure.*,* When these fail, surgical procedures such as tonsillectomy, adenoidectomy, uvulopalatopharyngyoplasty, or tracheostomy may be required to correct or bypass the abnormal anatomic features contributing to obstruction of the airway. Recent literature has suggested that facial skeletal advancement using distraction osteogenesis might be beneficial in those

Purpose This study determined the incidence of maxillofacial involvement in patients diagnosed with arthrogryposis multiplex congenita (AMC), Patients and Methods Twenty-three patients were evaluated by the pediatric physical medicine and rehabilitation, orthopedic surgery, and pediatric oral and maxillofacial surgery departments. Any patient in whom the diagnosis of AMC was in doubt was excluded from the study. All patients with limited mandibular function underwent computed tomography (CT) examination of their temporomandibular joints (TMJ). The results of physical therapy were followed. Results Five of the 23 patients diagnosed with AMC were found to have maxillofacial involvement, eg, presence of cleft palate, Robin-like sequence, high-arched palate, open-bite deformity, facial muscle weakness, esophageal dysfunction, and limited mandibular opening. No TMJ abnormalities were found by CT scan. Physical therapy was used for treatment of the limited opening, but relapse occurred quicky after therapy was discontinued. Conclusion The incidence of maxillofacial findings is similar to that of most other reports. Treatment involves surgical correction of abnormal anatomy when possible (ie, cleft repair), symptomatic management (ie, esophageal dysfunction), and physical therapy.

Trismus is a common problem presenting to the dental practitioner. It is usually of a benign nature; however a number of types can have serious implications. This review outlines the aetiology and diagnosis of clinically evident jaw trismus.

Adenoid cystic carcinoma constitutes 2% to 6% of all salivary gland tumors, and approximately 20% of those are considered malignant. The accessory salivary glands are affected more often than the major salivary glands. A review of the literature revealed only two reported cases in the retromolar pad area

Visual examination of the intensity of Procion dye in hamster femurs revealed that dye incorporation decreased during hibernation. Little or no dye was observed after hibernation lasting longer than 50 days. It seems that hibernation may be associated with increased bone resorption and a loss of bone matrix.

Secondary dentin and cementum were studied histologically in 17 known-age (2–8 years) specimens of Myotis lucifugus and M. velifer and in 30 adult specimens of unknown age representing Pteronotus parnellii, Leptonycteris nivalis, Artibeus jamaicensis, Sturnira ludovici , and Desmodus rotundus . Incremental lines in secondary dentin and cementum were highly variable (both between and within individuals) and did not correspond exactly to age although there generally was a loose correlation between number of lines and age. Difficulties in using such histologically recognizable characteristics to determine age are discussed and previous studies of age determination in bats are reviewed. Incremental lines in secondary dentin were associated with changes in direction and shape of dentinal tubules. Chemical and structural alterations in collagenous matrix and ground substance also were implicated in the formation of incremental lines. Incremental changes in cement were related to stress, consequent dental drift, and eruption.

The effects of cold-stress and hibernation on bone dynamics in the femurs of hamsters were investigated using histometric analyses. Control animals were maintained at 27 degrees C for 90 days; experimental animals were kept at 5 degrees C and hibernated for 7, 15, 21, 50, or 90 days. Histometric analyses of cross sections indicated that bone diameter and cortical thickness at the femoral midshaft increased after 83 days of extreme cold and 7 days of hibernation but decreased significantly after 69 days of cold stress and 21 days of hibernation. Osteoporosis was evident although the number of osteons per unit area of bone increased during hibernation. An initial decrease in the number of non-Haversian longitudinal vessels per unit area of bone was seen in experimental animals which was apparently related to a corresponding reduction in cortical thickness. Lacunar area increased in these animals, suggesting that osteocytic osteolysis may be a significant mechanism for calcium regulation during hibernation.

Popliteal pterygium syndrome (PPS) is a rare congenital disorder consisting of limb, genital, and orofacial malformations. Approximately fifty cases have been described, and the extremely variable nature of this syndrome has been shown. Two new cases of PPS are reported in this article. Surgical management and airway control are also described.