Cleft Formation Research Articles

Surgical treatment of low lumbar osteoporotic vertebral collapse: a single-institution experience.

Low lumbar osteoporotic vertebral collapse (OVC) has not been well documented compared with OVC of the thoracolumbar spine. The differences between low lumbar and thoracolumbar lesions should be studied to provide better treatment. The aim of this study was to clarify the clinical and imaging features as well as outcomes of low lumbar OVC and to discuss the appropriate surgical treatment. Thirty patients (10 men; 20 women; mean age 79.3 ± 4.7 years [range 70-88 years]) with low lumbar OVC affecting levels below L-3 underwent surgical treatment. The clinical symptoms, morphological features of affected vertebra, sagittal spinopelvic alignment, neurological status before and after surgery, and surgical procedures were reviewed at a mean follow-up period of 2.4 years. The main clinical symptom was radicular leg pain. Most patients had old compression fractures at the thoracolumbar level. The affected vertebra was flat-type and concave or H-shaped type, not wedge type as often found in thoracolumbar OVC. There were mismatches between pelvic incidence and lumbar lordosis on plain radiographs. On CT and MR images, foraminal stenosis was seen in 18 patients (60%) and canal stenosis in 24 patients (80%). Decompression with short fusion using a posterior approach was performed. Augmentations of vertebroplasty, posterolateral fusion, and posterior lumbar interbody fusion were performed based on the presence/absence of local kyphosis of lumbar spine, cleft formation, and/or intervertebral instability. Although the neurological and visual analog scale scores improved postoperatively, 8 patients (26.7%) developed postoperative complications mainly related to instrumentation failure. In patients with postoperative complications, lumbar spine bone mineral density was significantly low, but the spinopelvic alignment showed no correlation when compared with those without complications. The main types of low lumbar OVC were flat-type and concave type, which resulted in neurological symptoms by retropulsed bony fragments generating foraminal stenosis and/or canal stenosis. For patients with low lumbar OVC, decompression of the foraminal and canal stenosis with short fusion surgery via posterior approach can improve neurological symptoms. Since these patients are elderly with poor bone quality and other complications, treatments for both OVC and osteoporosis should be provided to achieve good clinical outcome.

Hand/foot splitting and the ‘re-evolution’ of mesopodial skeletal elements during the evolution and radiation of chameleons

BackgroundOne of the most distinctive traits found within Chamaeleonidae is their split/cleft autopodia and the simplified and divergent morphology of the mesopodial skeleton. These anatomical characteristics have facilitated the adaptive radiation of chameleons to arboreal niches. To better understand the homology of chameleon carpal and tarsal elements, the process of syndactyly, cleft formation, and how modification of the mesopodial skeleton has played a role in the evolution and diversification of chameleons, we have studied the Veiled Chameleon (Chamaeleo calyptratus). We analysed limb patterning and morphogenesis through in situ hybridization, in vitro whole embryo culture and pharmacological perturbation, scoring for apoptosis, clefting, and skeletogenesis. Furthermore, we framed our data within a phylogenetic context by performing comparative skeletal analyses in 8 of the 12 currently recognized genera of extant chameleons.ResultsOur study uncovered a previously underappreciated degree of mesopodial skeletal diversity in chameleons. Phylogenetically derived chameleons exhibit a ‘typical’ outgroup complement of mesopodial elements (with the exception of centralia), with twice the number of currently recognized carpal and tarsal elements considered for this clade. In contrast to avians and rodents, mesenchymal clefting in chameleons commences in spite of the maintenance of a robust apical ectodermal ridge (AER). Furthermore, Bmp signaling appears to be important for cleft initiation but not for maintenance of apoptosis. Interdigital cell death therefore may be an ancestral characteristic of the autopodium, however syndactyly is an evolutionary novelty. In addition, we find that the pisiform segments from the ulnare and that chameleons lack an astragalus-calcaneum complex typical of amniotes and have evolved an ankle architecture convergent with amphibians in phylogenetically higher chameleons.ConclusionOur data underscores the importance of comparative and phylogenetic approaches when studying development. Body size may have played a role in the characteristic mesopodial skeletal architecture of chameleons by constraining deployment of the skeletogenic program in the smaller and earliest diverged and basal taxa. Our study challenges the ‘re-evolution’ of osteological features by showing that ‘re-evolving’ a ‘lost’ feature de novo (contrary to Dollo’s Law) may instead be due to so called ‘missing structures’ being present but underdeveloped and/or fused to other adjacent elements (cryptic features) whose independence may be re-established under changes in adaptive selective pressure.Electronic supplementary materialThe online version of this article (doi:10.1186/s12862-015-0464-4) contains supplementary material, which is available to authorized users.

Three-dimensional analysis of maxillary development in patients with unilateral cleft lip and palate during the first six years of life.

The purpose of this work was to analyse early upper-jaw development in patients with unilateral cleft lip and palate (UCLP) treated using two different concepts and to compare shape and size developments between these two groups and a group of noncleft patients. A total of 204 maxillary casts available for this study from 50 UCLP patients were analyzed for upper-jaw development based on three-dimensional measurements performed with a Reflex Microscope from birth up to 71 months of age. Thirty-five of these 50 patients were part of an early treatment group (two-stage cleft closure with single-stage palatoplasty at an age of 10-14 months) and 15 were part of a late treatment group (two-stage cleft closure with palatoplasty at an age of 4-7years). The control group included 39 casts of 17 noncleft patients. Analysis of shape and size between the patients in the three groups yielded statistically significant differences between the cleft and the noncleft patients. In both treatment groups, we made observations typically associated with cleft formation like lateralization, asymmetry of the greater and lesser cleft segments, and pronounced vertical deviations of the segments. Viewed in all dimensions, however, the patients in the early treatment group approached the control group more closely, although a statistically significant difference was still observed. Our results suggest that the timing of hard-palate closure is not a decisive factor for upper-jaw development. Intrinsic factors (initial cleft width, presence of tooth buds) and the surgeon's skills appear to have a much more defining role.

Peptide-modified Substrate for Modulating Gland Tissue Growth and Morphology In Vitro

In vitro fabricated biological tissue would be a valuable tool to screen newly synthesized drugs or understand the tissue development process. Several studies have attempted to fabricate biological tissue in vitro. However, controlling the growth and morphology of the fabricated tissue remains a challenge. Therefore, new techniques are required to modulate tissue growth. RGD (arginine-glycine-aspartic acid), which is an integrin-binding domain of fibronectin, has been found to enhance cell adhesion and survival; it has been used to modify substrates for in vitro cell culture studies or used as tissue engineering scaffolds. In addition, this study shows novel functions of the RGD peptide, which enhances tissue growth and modulates tissue morphology in vitro. When an isolated submandibular gland (SMG) was cultured on an RGD-modified alginate hydrogel sheet, SMG growth including bud expansion and cleft formation was dramatically enhanced. Furthermore, we prepared small RGD-modified alginate beads and placed them on the growing SMG tissue. These RGD-modified beads successfully induced cleft formation at the bead position, guiding the desired SMG morphology. Thus, this RGD-modified material might be a promising tool to modulate tissue growth and morphology in vitro for biological tissue fabrication.

Intervertebral bridging ossifications increase the risk of intravertebral cleft formation following a vertebral compression fracture.

To determine whether the presence of intervertebral bridging ossifications is associated with intravertebral cleft (IVC) formation following a vertebral compression fracture (VCF). Patients with a VCF who received conservative treatment for a minimum of 3months were recruited over a 3-year period. Baseline radiographs obtained within a month of onset were compared between 50 patients who developed an IVC at 3-month follow-up (IVC group) and 100 patients without an IVC (control group). Intervertebral bridging ossification was defined as complete bridging of the intervertebral space by ossification. The presence of bridging ossification was assessed at each intervertebral level from T9/10 to L5/S. In addition to the absolute levels of bridging ossifications, the level relative to a fresh VCF was recorded. The incidence of bridging ossification at levels T9/10 and T10/11 was significantly higher in the IVC group than in the control group. IVC group patients showed a significantly higher incidence of bridging ossification at the second proximal intervertebral segment than those in the control group. IVC group patients also had a significantly greater sagittal wedge angle and a greater local kyphosis angle than control group patients. A fresh VCF with bridging ossification at the second proximal intervertebral level is associated with increased risk of IVC formation. Careful observation and strict conservative treatment are recommended in such cases.

Melatonin inhibits embryonic salivary gland branching morphogenesis by regulating both epithelial cell adhesion and morphology.

Many organs, including salivary glands, lung, and kidney, are formed by epithelial branching during embryonic development. Branching morphogenesis occurs via either local outgrowths or the formation of clefts that subdivide epithelia into buds. This process is promoted by various factors, but the mechanism of branching morphogenesis is not fully understood. Here we have defined melatonin as a potential negative regulator or “brake” of branching morphogenesis, shown that the levels of it and its receptors decline when branching morphogenesis begins, and identified the process that it regulates. Melatonin has various physiological functions, including circadian rhythm regulation, free-radical scavenging, and gonadal development. Furthermore, melatonin is present in saliva and may have an important physiological role in the oral cavity. In this study, we found that the melatonin receptor is highly expressed on the acinar epithelium of the embryonic submandibular gland. We also found that exogenous melatonin reduces salivary gland size and inhibits branching morphogenesis. We suggest that this inhibition does not depend on changes in either proliferation or apoptosis, but rather relates to changes in epithelial cell adhesion and morphology. In summary, we have demonstrated a novel function of melatonin in organ formation during embryonic development.

Percutaneous coronary interventions in the diabetic patient: where do we stand?

Clinical observations made during the past 20 years have suggested that patients with diabetes mellitus (DM) have suboptimal outcomes after percutaneous coronary interventions (PCIs).1–4 During the same time period, mechanistic studies have provided insights into the cardiovascular risk of DM. In this report, we attempt to synthesize observations made in the experimental laboratory with those made in the clinical setting to identify how diabetic traits may compromise the success of PCI (Figure 1). Figure 1. Diabetic traits potentially compromising the success of percutaneous coronary intervention. The hallmarks of DM are hyperglycemia, insulin resistance or an absolute lack of endogenous insulin, and hyperinsulinemia. These metabolic derangements may lead to premature atherosclerosis, cardiomyocyte dysfunction, and renal failure through several mechanisms. ### Diabetic Arteriopathy In an early stage of atherogenesis, the presence of cholesterol crystals may induce the formation of small hydroxyapatite mineral clefts, which are also called microcalcifications, in the intima or media.5 In DM, medial calcification develops independently of hypercholesterolemia and may cause sheet-like calcific deposits that reduce vascular compliance.6 In the presence of hyperglycemia, medial calcification may be mediated by a glycosylation process, in which N-acetylglucosamine (O-GlcNAc) binds to serine and threonine residues of vascular proteins.7 In a drug-induced mouse model of type 1 DM, Heath et al6 found a strong increase in vascular O-GlcNAcylation after the onset of increased blood glucose levels, along with a significant increase in aortic calcium content and vascular stiffness. The connection between O-GlcNAcylation and the development of a mineralized matrix was confirmed in an experimental model of vascular smooth muscle cells cultured in osteogenic differentiation media along with an inhibitor of N-acetylglucosaminidase.6 The formation of vulnerable atherosclerotic lesions may be related to hyperglycemia8 or insulin resistance.9 Kuroda et al8 observed that daily glucose fluctuations, measured as the …

PAPC mediates self/non-self-distinction during Snail1-dependent tissue separation.

Cleft-like boundaries represent a type of cell sorting boundary characterized by the presence of a physical gap between tissues. We studied the cleft-like ectoderm-mesoderm boundary in Xenopus laevis and zebrafish gastrulae. We identified the transcription factor Snail1 as being essential for tissue separation, showed that its expression in the mesoderm depends on noncanonical Wnt signaling, and demonstrated that it enables paraxial protocadherin (PAPC) to promote tissue separation through two novel functions. First, PAPC attenuates planar cell polarity signaling at the ectoderm-mesoderm boundary to lower cell adhesion and facilitate cleft formation. Second, PAPC controls formation of a distinct type of adhesive contact between mesoderm and ectoderm cells that shows properties of a cleft-like boundary at the single-cell level. It consists of short stretches of adherens junction-like contacts inserted between intermediate-sized contacts and large intercellular gaps. These roles of PAPC constitute a self/non-self-recognition mechanism that determines the site of boundary formation at the interface between PAPC-expressing and -nonexpressing cells.

Age of cleft monazites in the eastern Tauern Window: constraints on crystallization conditions of hydrothermal monazite

Monazite-bearing Alpine clefts located in the Sonnblick region of the eastern Tauern Window, Austria, are oriented perpendicular to the foliation and lineation. Ion probe (SIMS) Th–Pb and U–Pb dating of four cleft monazites yields crystallization ages of different growth domains and aggregate regions ranging from 18.99 ± 0.51 to 15.00 ± 0.51 Ma. The crystallization ages obtained are overlapping or slightly younger than zircon fission track ages but older than zircon (U–Th)/He cooling ages from the same area. This constrains cleft monazite crystallization in this area to ~300–200 °C. LA-ICP-MS data of dated hydrothermal monazites indicate that in graphite-bearing, reduced host lithologies, cleft monazite is poor in As and has higher La/Yb values and U concentrations, whereas in oxidised host rocks opposite trends are observed. Monazites show negative Eu anomalies and variable La/Yb values ranging from 520 to 6050. The positive correlation between Ca and Sr concentration indicates dissolution of plagioclase or carbonates as the source of these elements. The data show that early exhumation and cleft formation in the Tauern is related to metamorphic dome formation caused by the collision of the Adriatic with the European plate and that monazite crystallization in the clefts occurred later. Our data also demonstrate that hydrothermal monazite ages offer great potential in helping to constrain the chronology of exhumation in collisional orogens.

Early postnatal ablation of the microRNA-processing enzyme, Drosha, causes chondrocyte death and impairs the structural integrity of the articular cartilage

In growth plate chondrocytes, loss of Dicer, a microRNA (miRNA)-processing enzyme, causes defects in proliferation and differentiation, leading to a lethal skeletal dysplasia. However roles of miRNAs in articular chondrocytes have not been defined invivo. To investigate the role of miRNAs in articular chondrocytes and to explore the possibility of generating a novel mouse osteoarthritis (OA) model caused by intrinsic cellular dysfunction, we ablated Drosha, another essential enzyme for miRNA biogenesis, exclusively in articular chondrocytes of postnatal mice. First, to confirm that the essential role of miRNAs in skeletal development, we ablated the miRNA biogenesis pathway by deleting Drosha or DGCR8 in growth plate chondrocytes. Next, to investigate the role of miRNAs in articular cartilage, we deleted Drosha using Prg4-CreER(T) transgenic mice expressing a tamoxifen-activated Cre recombinase (CreER(T)) exclusively in articular chondrocytes. Tamoxifen was injected at postnatal days, 7, 14, 21, and 28 to ablate Drosha. Deletion of Drosha or DGCR8 in growth plate chondrocytes caused a lethal skeletal defect similar to that of Dicer deletion, confirming the essential role of miRNAs in normal skeletogenesis. Early postnatal Drosha deletion in articular chondrocytes significantly increased cell death and decreased Safranin-O staining. Mild OA-like changes, including surface erosion and cleft formation, were found in male mice at 6 months of age; however such changes in females were not observed even at 9 months of age. Early postnatal Drosha deficiency induces articular chondrocyte death and can cause a mild OA-like pathology.

Basaloid follicular hamartoma on the upper eyelid.

Basaloid follicular hamartoma on the upper eyelid.

CBS c.844ins68 Polymorphism Frequencies in Control Populations: Implications on Nonsyndromic Cleft Lip with or without Cleft Palate

Nonsyndromic cleft lip with or without cleft palate (NSCLP) is a common birth defect with substantial clinical and social impact. Folate deficiency is one of the factors that have been associated with increased risk for NSCLP. Polymorphisms in folate and homocysteine pathway genes may act as susceptibility factors. The objective of this study was to evaluate prevalence estimates of cystathionine beta-synthase (CBS) insertion of 68-bp (c.844ins68) polymorphisms and their correlation with NSCLP. A total of 236 unrelated individuals from seven Indian populations and an additional 355 cases with NSCLP and 357 controls without NSCLP were included in this study. We investigated the CBS c.844ins68 polymorphism in all samples. Genotyping was performed with polymerase chain reaction and electrophoresis. The data were statistically analyzed using the chi-square test. The CBS c.844ins68 allele is present in six of the seven populations analyzed, and allele frequencies range from 1.5% in Balija to 9.1% in Sugali populations. The CBS c.844ins68 polymorphism showed a significant protective effect on NSCLP at both genotype (WW versus WI: odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.31 to 0.95, P = .149) and allele levels (W versus I: OR = 0.56, 95% CI = 0.32 to 0.96, P = .033). The current study observed significant differences in the frequency of the CBS 844ins68 allele across populations. There is a significant association between CBS c.844ins68 polymorphism and cleft lip and palate in the Indian population. Additional studies are warranted to identify the functional variants in the genes controlling homocysteine as etiological contributors to the formation of oral clefts.

Prognostic stratification of ulcerated melanoma: not only the extent matters.

For patients with melanoma, ulceration is an important prognostic marker and interestingly also a predictive marker for the response of adjuvant interferon. A consensual definition and accurate assessment of ulceration are therefore crucial for proper staging and clinical management. We evaluated the prognostic impact of the extent and type of ulceration and the epidermal involvement theoretically preceding it (consumption of epidermis and cleft formation) or seen subsequent to the inflammation (reepithelialization and reactive epidermal hyperplasia), aiming for better prognostic stratification of ulcerated lesions. From H&E-stained sections, the status (presence vs absence), extent (percentage of the total tumor length), and type (infiltrative vs attenuative) of ulceration and epidermal involvement were evaluated from 385 patients with cutaneous melanoma. The presence of ulceration (hazard ratio [HR], 1.83), an attenuative type of ulceration (HR, 3.02), and excessive ulceration (HR, 3.57) were independent predictors of poor melanoma-specific survival. Further subdivision of minimal/moderate ulceration showed independent prognostic value only for lesions with epidermal involvement of the surrounding epidermis (HR, 1.78). The extent and type of ulceration and involvement of the surrounding epidermis provided more accurate prognostic information than the mere absence or presence and may be useful markers allowing better stratification of ulcerated lesions.

Eutecticum Morphology in Al-Si Alloys

The structure of casting silumins (Al-Si alloys) contains a big share of eutecticum (40-75%) which, as mentioned afore, enhance fluidity and decrease tendency towards formation of clefts and microporosity. Due to this fact the properties of α - phase on one hand as well as quantity, morphology, size, and distribution of eutectic silicium on the other hand are the most significant factors influencing mechanical properties of the casting.

LIM kinase regulation of cytoskeletal dynamics is required for salivary gland branching morphogenesis.

Coordinated actin microfilament and microtubule dynamics is required for salivary gland development, although the mechanisms by which they contribute to branching morphogenesis are not defined. Because LIM kinase (LIMK) regulates both actin and microtubule organization, we investigated the role of LIMK signaling in mouse embryonic submandibular salivary glands using ex vivo organ cultures. Both LIMK 1 and 2 were necessary for branching morphogenesis and functioned to promote epithelial early- and late-stage cleft progression through regulation of both microfilaments and microtubules. LIMK-dependent regulation of these cytoskeletal systems was required to control focal adhesion protein-dependent fibronectin assembly and integrin β1 activation, involving the LIMK effectors cofilin and TPPP/p25, for assembly of the actin- and tubulin-based cytoskeletal systems, respectively. We demonstrate that LIMK regulates the early stages of cleft formation--cleft initiation, stabilization, and progression--via establishment of actin stability. Further, we reveal a novel role for the microtubule assembly factor p25 in regulating stabilization and elongation of late-stage progressing clefts. This study demonstrates the existence of multiple actin- and microtubule-dependent stabilization steps that are controlled by LIMK and are required in cleft progression during branching morphogenesis.

Metabolic characterization of all-trans-retinoic acid (ATRA)-induced craniofacial development of murine embryos using in vivo proton magnetic resonance spectroscopy.

AimTo characterize the abnormal metabolic profile of all-trans-retinoic acid (ATRA)–induced craniofacial development in mouse embryos using proton magnetic resonance spectroscopy (1H-MRS).MethodsTimed-pregnant mice were treated by oral gavage on the morning of embryonic gestation day 11 (E11) with all-trans-retinoic acid (ATRA). Dosing solutions were adjusted by maternal body weight to provide 30, 70, or 100 mg/kg RA. The control group was given an equivalent volume of the carrier alone. Using an Agilent 7.0 T MR system and a combination of surface coil coils, a 3 mm×3 mm×3 mm 1H-MRS voxel was selected along the embryonic craniofacial tissue. 1H-MRS was performed with a single-voxel method using PRESS sequence and analyzed using LCModel software. Hematoxylin and eosin was used to detect and confirm cleft palate.Result 1H-MRS revealed elevated choline levels in embryonic craniofacial tissue in the RA70 and RA100 groups compared to controls (P<0.05). Increased choline levels were also found in the RA70 and RA100 groups compared with the RA30 group (P<0.01). High intra-myocellular lipids at 1.30 ppm (IMCL13) in the RA100 group compared to the RA30 group were found (P<0.01). There were no significant changes in taurine, intra-myocellular lipids at 2.10 ppm (IMCL21), and extra-myocellular lipids at 2.30 ppm (EMCL23). Cleft palate formation was observed in all fetuses carried by mice administered 70 and 100 mg/kg RA.ConclusionsThis novel study suggests that the elevated choline and lipid levels found by 1H-MRS may represent early biomarkers of craniofacial defects. Further studies will determine performance of this test and pathogenetic mechanisms of craniofacial malformation.

Non-steroidal anti inflammatory drugs, glucocorticoids and disease modifying anti-rheumatic drugs for the management of rheumatoid arthritis before and during pregnancy

To review the recent literature on the safety of nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and traditional disease-modifying antirheumatic drugs before and during pregnancy. Recent data suggest that the risk of cleft palate formation after in-utero glucocorticoid exposure is lower than previously reported. Two studies of inadvertent leflunomide exposure during early pregnancy suggest that this medication may be less teratogenic than previously thought. Although NSAIDs are well tolerated for use during the first two trimesters of pregnancy, they should be avoided during a conception cycle so as not to impede implantation. After gestational week 30, these medications should be discontinued as they may cause premature closure of the ductus arteriosus. The nonfluorinated glucocorticoids, prednisone and prednisolone, can be used throughout pregnancy, although use during the first trimester may increase the risk of cleft palate formation. Protracted glucocorticoids exposure during pregnancy can cause maternal preterm premature rupture of the membranes, gestational hypertension and gestational diabetes. Methotrexate and leflunomide are teratogenic and should be avoided during pregnancy. The immunosuppressive agents, azathioprine, 6-mercaptopurine and cyclosporine A, are compatible with pregnancy.

Floral structure and development in Rafflesiaceae with emphasis on their exceptional gynoecia

The holoparasitic plant family Rafflesiaceae include the world's largest flowers. Despite their iconic status, relatively little is known about the morphology and development of their flowers. A recent study clarified the organization of the outer (sterile) floral organs, surprisingly revealing that their distinctive floral chambers arose via different developmental pathways in the two major genera of the family. Here, we expand that research to investigate the structure and development of the reproductive organs of Rafflesiaceae. Serial sectioning, scanning electron microscopy, and x-ray tomography of floral buds were employed to reconstruct the structure and development of all three Rafflesiaceae genera. Unlike most angiosperms, which form their shoot apex from the primary morphological surface, the shoot apex of Rafflesiaceae instead forms secondarily via internal cell separation (schizogeny) along the distal boundary of the host-parasite interface. Similarly, the radially directed ovarial clefts of the gynoecium forms via schizogeny within solid tissue, and no carpels are initiated from the floral apex. The development of the shoot apex and gynoecium of Rafflesiaceae are highly unusual. Although secondary formation of the morphological surface from the shoot apex has been documented in other plant groups, secondary derivation of the inner gynoecium surface is otherwise unknown. Both features are likely synapomorphies of Rafflesiaceae. The secondary derivation of the shoot apex may protect the developing floral shoot as it emerges from within dense host tissue. The secondary formation of the ovarial clefts may generate the extensive placental area necessary to produce hundreds of thousands of ovules.

Towards A Multicultural Approach in Occidental Health Care: The Example of Orofacial Clefts

Latest studies concerning the psychological impact of orofacial cleft showed that, with the improvements in surgery and with adequate multidisciplinary support, clefts were no more associated with major psychological problems. However, the growth of humanitarian craniofacial care, as well as the increase of populations’ migration, raises new concerns about cultural influences in the perception and satisfaction with surgical interventions, and treatment success, suggesting that medical acts alone are not the only answer to such malformation. Moreover, at a time of world migrations and mixed ethnicities, physicians and surgeons are exposed in their practice to a multiplicity of cultures that understands and conceptualizes “health” and “illness” differently. These differences in the perception of illness and care could lead to a gap of understanding between physicians and patients, which could impact patients’ adherence to treatment, healing processes and further utilization of health care systems. Therefore, it is now crucial to assess and implement models of health care integrating cultural aspects. Orofacial cleft is a frequent craniofacial anomaly, with an incidence of 2 per 1000 newborns in occidental countries [1]. Cleft formation occurs between the 4th and the 12th week of gestation [2], but may vary according to cleft types (cleft lip and/or palate and/or maxillary, uni- or bilateral), and is usually detected around the fifth month of gestation, during the morphologic ultrasound, or at childbirth.

The management of palatally displaced maxillary canines: Considerations and challenges

This article opens with a recognition that ectopic maxillary canines may lead to frank impactions requiring a coordinated and multidisciplinary approach to their surgical/orthodontic management and the potential benefit of managing canine ectopia, particularly palatally displaced canines, more conservatively in their pre-eruptive ectopic positions in an effort to avoid impaction. The prevalence of palatally displaced canines (PDC) in various populations and corroborating as well as competing or conflicting opinions of etiology are briefly reviewed. Some of the traditional as well as relatively newer strategies and associated investigations of managing pre-eruptive palatally displaced maxillary canines are discussed, and the imaging techniques utilized to identify and locate ectopic maxillary canines are also discussed. Early detection of ectopic canines must include at the very least panoramic and/or periapical radiographs as part of any mixed dentition orthodontic examination and assessment. The sometimes unpredictable continued path of the ectopic maxillary canine poses clinical and ethical issues to the clinician when developing treatment strategies as part of any overall orthodontic treatment plan for young patients presenting with maxillary canine ectopia. The need for more thoughtful and carefully designed randomized clinical trials with a greater emphasis on subject sample scrutiny is strongly recommended to add much needed clarity to the clinical management of ectopic maxillary canines.