Craniofacial Malformations Research Articles

An Adverse Outcome Pathway Approach Linking Retinoid Signaling Disruption to Teratogenicity and Population-Level Outcomes

Recent research efforts in endocrine disruption have focused on evaluating non-EATS (estrogen, androgen, thyroid, and steroidogenesis) pathways. Retinoid signaling disruption is noteworthy because of its teratogenic effects and environmental relevance. However, current environmental risk assessments are limited in their ability to evaluate impacts on individuals and populations. This study characterizes an Adverse Outcome Pathway (AOP) network linking retinoid signaling disruption to teratogenicity and survival in zebrafish. We identified Retinoic Acid Receptor (RAR) overactivation as the molecular initiating event leading to key events including craniofacial (CFM) and tail (TM) malformations, posterior swim bladder (SB) non-inflation, impaired swimming performance, and reduced feeding, ultimately resulting in decreased survival. Our study (1) determines critical sensitivity windows for CFM, posterior SB non-inflation, and TM, (2) provides quantitative measurements for CFM and TM, and (3) defines impacts on higher biological levels including food ingestion, swimming, and survival. Results show that all-trans retinoic acid (ATRA) induces strong teratogenic effects with sensitivity windows between 4-48 hours post fertilization (hpf) for CFM, TM, and posterior SB non-inflation. TM is the most sensitive indicator, with EC50 of 0.2 - 0.26 µg/L across exposure windows 4-48, 4-72, 4-96, and 4-120 hpf. Besides inducing known malformations, ATRA impaired posterior SB inflation with EC50 of 1 - 1.21 µg/L across the same exposure windows. ATRA exposure (1 µg/L) resulted in 50% food ingestion inhibition at 7 days post fertilization (dpf) and 10% survival at 14 dpf. This study provides a regulatory-relevant framework linking developmental effects to population outcomes, highlighting ecological risks and needs for improved risk assessments.

A Novel’s Evidence of MSG-Induced Craniofacial Defects in Chick Embryo Models

Monosodium glutamate (MSG), commonly used as an additive food enhancer, has been reported to have teratogenic effects on the embryo during development. The present study aimed to investigate the effect of MSG-induced teratogenicity, focusing on craniofacial formation in the chick embryo model. One hundred eighty fertilized eggs were divided into control and MSG groups. The chemicals were administered, and the results were investigated in 3-day-old embryos (ED-3), ED-6, and ED-10. The morphology and histology of craniofacial structures were studied using a stereomicroscope and light microscopy. The neural crest cells (NCCs) were investigated by the immunostaining technique. The results showed that a dose of 3 mg of MSG induced anterior neuropore opening and eye malformation in ED-3, and this was clearly demonstrated in ED-6. MSG also caused craniofacial bone malformation and delayed calcification in ED-10. Moreover, MSG induced apoptosis of NCCs and reduced the proliferation of NCCs in the craniofacial structures. These findings are the 1st report to demonstrate the teratogenicity of high doses of MSG-induced craniofacial defects in chick embryos during organogenesis. HIGHLIGHTS Monosodium glutamate exposure causes craniofacial defects in chick embryos. The functions of the neural crest cells were abrogated due to monosodium glutamate-induced teratogenesis, which led to birth defects. The experimental protocols benefit teratogenicity studies, and the results can be applied to future studies to elucidate the causes of birth defects during organogenesis. GRAPHICAL ABSTRACT

Diagnostic and treatment possibilities in the management of positional plagiocephaly.

Positional plagiocephaly, characterized by an asymmetric skull shape, is the most common craniofacial malformation in infancy. Associated risk factors include apreference for the supine position, first and assisted delivery, multiple pregnancy, prematurity, and congenital muscular torticollis. The diagnosis is established by clinical and anthropometric examinations. In the case of moderate or severe deformity, three-dimensional optical scanning enables adetailed depiction of the deformity and provides asafe and noninvasive tool for follow-up. Treatment mainly includes repositioning of the infant, while orthotic therapy is considered in cases of severe deformity. Cranial orthotic therapy is most effective when started between 4and 7months of age. The total duration of orthotic treatment ranges from 2to 6months. Although the clinical course of positional plagiocephaly is generally benign and the prognosis favorable, its increasing prevalence has prompted the development of novel diagnostic and therapeutic strategies over the past decade.

TGF-β signaling in the cranial neural crest affects late-stage mandibular bone resorption and length.

Malocclusions are common craniofacial malformations that cause quality of life and health problems if left untreated. Unfortunately, the current treatment for severe skeletal malocclusion is invasive surgery. Developing improved therapeutic options requires a deeper understanding of the cellular mechanisms responsible for determining jaw bone length. We have recently shown that neural crest mesenchyme (NCM) can alter jaw length by controlling the recruitment and function of mesoderm-derived osteoclasts. Transforming growth factor beta (TGF-β) signaling is critical to craniofacial development by directing bone resorption and formation, and heterozygous mutations in the TGF-β type I receptor (TGFBR1) are associated with micrognathia in humans. To identify the role of TGF-β signaling in NCM in controlling osteoclasts during mandibular development, the mandibles of mouse embryos deficient in the gene encoding Tgfbr1, specifically in NCM, were analyzed. Our laboratory and others have demonstrated that Tgfbr1 fl/fl ;Wnt1-Cre mice display significantly shorter mandibles with no condylar, coronoid, or angular processes. We hypothesize that TGF-β signaling in NCM can also direct late bone remodeling and further regulate late embryonic jaw bone length. Interestingly, analysis of mandibular bone based on micro-computed tomography and Masson's trichrome revealed no significant difference in bone quality between the Tgfbr1 fl/fl ;Wnt1-Cre mice and controls, as measured by the bone perimeter/bone area, trabecular rod-like diameter, number and separation, and gene expression of collagen type 1 alpha 1 (Col1α1) and matrix metalloproteinase 13 (Mmp13). Although there was not a difference in localization of bone resorption within the mandible indicated by tartrate-resistant acid phosphatase (TRAP) staining, Tgfbr1 fl/fl ;Wnt1-Cre mice had approximately three-fold less osteoclast number and perimeter than controls. Gene expression of receptor activator of nuclear factor kappa-β (Rank) and Mmp9, markers of osteoclasts and their activity, also showed a three-fold decrease in Tgfbr1 fl/fl ;Wnt1-Cre mandibles. Evaluation of osteoblast-to-osteoclast signaling revealed no significant difference between Tgfbr1 fl/fl ;Wnt1-Cre mandibles and controls, leaving the specific mechanism unresolved. Finally, pharmacological inhibition of Tgfbr1 signaling during the initiation of bone mineralization and resorption significantly shortened jaw length in embryos. We conclude that TGF-β signaling in NCM decreases mesoderm-derived osteoclast number, that TGF-β signaling in NCM impacts jaw length late in development, and that this osteoblast-to-osteoclast communication may be occurring through an undescribed mechanism.

Pituitary gland duplication syndrome - An international imaging analysis.

Duplication of the pituitary gland is a rare developmental anomaly. Multiple associated craniofacial malformations have previously been reported with the largest series to date consisting of five patients. In this multi-institutional series of ten patients, we present a detailed review of the imaging features and discuss a possible overarching pathogenesis that would explain most of the detected malformations. Inclusion criteria for this retrospective imaging review were the presence of a pituitary stalk and gland duplication and the characteristic appearance of the hypothalamic ventral midline. In addition to the clinical presentation, we recorded the imaging findings of ten patients (9 female) through onsite and online reviews. Genetic analysis was available for six patients. The duplicated pituitary stalk and gland showed normal imaging appearances in all patients. Mammillary bodies were clearly identified lateral to the characteristic prominence of the hypothalamic ventral midline. Strands of tissue extending to the anterior dura ("limited ventral myeloschisis") were noted at the medulla oblongata in 10, and at the cervical spinal cord in 7 patients. The medulla oblongata showed a "butterfly" appearance on axial images in 9 patients. Ten patients had cervical segmentation anomalies ("zipper"-like), 9 anterior-posterior brainstem patterning defects (small pons, elongated medulla), and corpus callosum measurements were abnormal in all patients. Three patients each presented with diencephalic-mesencephalic junction abnormalities and 4 with an anterior mesencephalic "cap". An oropharyngeal teratoma was present in four patients. Genetics was normal in three of the six patients studied; the remainder were found to have mutations in EFNB1 and a gene variant of GIT1, two copies of 7. And 8. exon of SMN1 gene, and 2.126 megabase duplication at bands q11.1 and q11.2 of one chromosome 15, respectively. Duplication of the pituitary gland presents as well-defined craniofacial and cervical spine malformation phenotype. Axial mesoderm duplication generating an excess of Sonic Hedgehog may be the primary embryological driver leading to this condition. CFNS＝ Craniofrontonasal Syndrome; DPG＝ Duplication of the Pituitary Gland; SHH＝ Sonic Hedgehog.

CLPr_in_ML: Cleft Lip and Palate Reconstructed Features with Machine Learning

Background: Cleft lip and palate are two of the most common craniofacial congenital malformations in humans. It influences tens of millions of patients worldwide. The hazards of this disease are multifaceted, extending beyond the obvious facial malformation to encompass physiological functions, oral health, psychological well-being, and social aspects. Objective: The primary objective of our study is to demonstrate the importance of imaging in detecting cleft lip and palate. By observing the morphological and structural abnormalities involving the lip and palate through imaging methods, this study aims to establish imaging as the primary diagnostic approach for this disease. Methods: In this work, we proposed a novel model to analyze unilateral complete cleft lip and palate after velopharyngeal closure and non-left lip and palate patients from the Department of Stomatology of Xuzhou First People's Hospital, Conical Beam CT (CBCT) images in silicon. In order to demonstrate the generalization, the simulated dataset was constructed using the random disturbance factor, which is from the actual dataset. We extracted several raw features from CBCT images in detail. Then, we proposed a novel feature reconstruction method, including six types of reconstructed factors, to reconstruct the existing features. Then, the reconstructed features weretrained with machine learning algorithms. Finally, the testing and independent data model was utilized to analyze the performance of this work. Results: By comparing different operator features, the min operator, max operator, average operator, and all operators can achieve good performances in both the testing set and the independent set. result: none Conclusion: With the different operator features, the majority of classification models, including Gradient Boosting, Hist Gradient Boosting, Multilayer Perceptron, lightGBM, and broadened learning, classification algorithms can get the well-performances in the selected reconstructed feature operators.

Malformaciones congénitas asociadas alSíndrome Down en recién nacidos de un hospitalde referencia nacional: Experiencia de un registrode defectos congénitos

Objective: Down syndrome is the most common chromosomal abnormality in newborns and the first genetic cause of intellectual disability. The objective of this study was to describe associated birth defects with Down syndrome in newborns at the Edgardo Rebagliati MartinsHospital (HNERM). Materials and methods: A descriptive, retrospective and cross-sectionalstudy was conducted. The study population consisted of 191 births diagnosed with Downsyndrome, during the period 2013-2017 of the registry of the Latin American Collaborative Study of Congenital Malformations (ECLAMC) of the HNERM. Results: In the study period, a total of 191 newborns with suspected Down syndrome were reported, of which 180 wereconfirmed with karyotyping, out of a total of 34,326 live births. Free trisomy accounted for98.9%, while mosaicism and translocation trisomy occurred in 0.6% of newborns. The median maternal age was 39 years (range 20-46 years). Congenital heart disease was observed in 61.7%, gastrointestinal malformation 10%, craniofacial malformation 5%, genitourinary 3.9%, musculoskeletal malformation 1.7% and central nervous system malformation 1.7%. Conclusions: The birth prevalence rate of Down syndrome in the study period was 52.4 per 10,000 births. The most frequent malformations associated with Down syndrome are congenital heart disease and secondly malformations of the gastrointestinal tract. Other lessfrequently associated malformations are craniofacial, genitourinary, musculoskeletal and central nervous system malformations.

9194 Generation of a Human-Induced Pluripotent Stem Cell Line From a Patient With Hypopituitarism and a Novel Nonsense Variant in FOXA2

Abstract Disclosure: M.A. Camilletti: None. G.T. Chirino Felker: None. G. Amin: None. S. Castañeda: None. F. Zabalegui: None. C. Romano Florit: None. A. Waisman: None. M. Ciaccio: None. M.I. Di Palma: None. E. Vaiani: None. A. Belgorosky: None. S.G. Miriuka: None. L.N. Moro: None. M.I. Perez-Millan: None. Congenital Hypopituitarism (CH) is a genetically complex disease characterized by one or more pituitary hormone deficiencies. Forkhead Box A2 (FOXA2, 600288) is a pioneer transcription factor associated with development of multiple tissues in humans and mice. Heterozygous loss of function mutations in FOXA2 were recently shown to cause CH with hyperinsulinemic hypoglycemia, but little is known about the molecular mechanism of FOXA2 action during pituitary development. We identified a novel, heterozygous nonsense variant in FOXA2 (c.686C<A; p.S229X) in a patient diagnosed with GH deficiency at 1.7 years of age, with anterior lobe hypoplasia and absent pituitary stalk, asymptomatic hypoglycemia, and craniofacial malformations. To discover the mechanism of FOXA2 regulation of pituitary development we generated an induced pluripotent stem cell line (FOXA2mut-iPSC) from the patient’s polymorphonuclear blood cells (PBMCs) using an EF1a-hSTEMCCA-loxP vector containing the pluripotency genes OCT-4, SOX-2, c-MYC and KLF4. FOXA2mut-iPSC clone R1 had a normal karyotype and embryonic stem cell-like morphology. These cells express endogenous pluripotency-associated markers NANOG, SOX2, and OCT4, have alkaline phosphatase activity, and can differentiate into all three developmental layers, indicating that these cells are pluripotent. Short tandem repeat (STR) analysis confirmed that FOXA2mut-iPSC R1 clone profiles matched those of the donor PBMCs. Next, we compared pituitary differentiation of FOXA2mut-iPSC vs. control-iPSCs in vitro. Cells were cultured in a differentiation medium containing BMP4, the smoothened agonist SAG, and fibroblast growth factor (FGF), as described in Zimmer et al., 2016 (1). Gene expression analysis (by qRT-PCR) of samples collected on days 0, 4, 7, and 15 of the differentiation protocol showed an increased expression of genes associated with anterior pituitary development including OTX2, PITX1/2, and SIX1 in both cell lines (n=2). These preliminary data suggest that pituitary cell fate can be induced in the heterozygous FOXA2mut-iPSC clone. Ongoing studies will assess pituitary hormone-producing cell differentiation after longer periods of FOXA2mut-iPSC cell culture. In sum, patient iPSC differentiation is a promising tool for assessment of normal and variant FOXA2 function in human pituitary development, and for enlightening the mechanisms of FOXA2 action in human pituitary development. (1) Zimmer et al., Stem Cell Reports. 2016 Jun 14;6(6):858-872. Presentation: 6/1/2024

7151 Generation of a Human-Induced Pluripotent Stem Cell Line From a Patient With Hypopituitarism and a Novel Nonsense Variant in FOXA2

Abstract Disclosure: M.A. Camilletti: None. G.T. Chirino Felker: None. G. Amin: None. S. Castañeda: None. F. Zabalegui: None. C. Romano Florit: None. A. Waisman: None. M. Ciaccio: None. M.I. Di Palma: None. E. Vaiani: None. A. Belgorosky: None. S.G. Miriuka: None. L.N. Moro: None. M.I. Perez-Millan: None. Congenital Hypopituitarism (CH) is a genetically complex disease characterized by one or more pituitary hormone deficiencies. Forkhead Box A2 (FOXA2, 600288) is a pioneer transcription factor associated with development of multiple tissues in humans and mice. Heterozygous loss of function mutations in FOXA2 were recently shown to cause CH with hyperinsulinemic hypoglycemia, but little is known about the molecular mechanism of FOXA2 action during pituitary development. We identified a novel, heterozygous nonsense variant in FOXA2 (c.686C<A; p.S229X) in a patient diagnosed with GH deficiency at 1.7 years of age, with anterior lobe hypoplasia and absent pituitary stalk, asymptomatic hypoglycemia, and craniofacial malformations. To discover the mechanism of FOXA2 regulation of pituitary development we generated an induced pluripotent stem cell line (FOXA2mut-iPSC) from the patient’s polymorphonuclear blood cells (PBMCs) using an EF1a-hSTEMCCA-loxP vector containing the pluripotency genes OCT-4, SOX-2, c-MYC and KLF4. FOXA2mut-iPSC clone R1 had a normal karyotype and embryonic stem cell-like morphology. These cells express endogenous pluripotency-associated markers NANOG, SOX2, and OCT4, have alkaline phosphatase activity, and can differentiate into all three developmental layers, indicating that these cells are pluripotent. Short tandem repeat (STR) analysis confirmed that FOXA2mut-iPSC R1 clone profiles matched those of the donor PBMCs. Next, we compared pituitary differentiation of FOXA2mut-iPSC vs. control-iPSCs in vitro. Cells were cultured in a differentiation medium containing BMP4, the smoothened agonist SAG, and fibroblast growth factor (FGF), as described in Zimmer et al., 2016 (1). Gene expression analysis (by qRT-PCR) of samples collected on days 0, 4, 7, and 15 of the differentiation protocol showed an increased expression of genes associated with anterior pituitary development including OTX2, PITX1/2, and SIX1 in both cell lines (n=2). These preliminary data suggest that pituitary cell fate can be induced in the heterozygous FOXA2mut-iPSC clone. Ongoing studies will assess pituitary hormone-producing cell differentiation after longer periods of FOXA2mut-iPSC cell culture. In sum, patient iPSC differentiation is a promising tool for assessment of normal and variant FOXA2 function in human pituitary development, and for enlightening the mechanisms of FOXA2 action in human pituitary development. (1) Zimmer et al., Stem Cell Reports. 2016 Jun 14;6(6):858-872. Presentation: 6/1/2024

Foxe1 mutant zebrafish show indications of a hypothyroid phenotype and increased sensitivity to ethanol for craniofacial malformations.

FOXE1 mutations in humans are associated with cleft palate and hypothyroidism. We previously developed a foxe1 mutant zebrafish demonstrating mineralization defects in larvae. In the present study, we investigate the thyroid status and skeletal phenotype of adult foxe1 mutants. Mutant fish have increased expression of tshβ in the pituitary, and of hepatic dio1 and dio2. In plasma, we found higher Mg levels. Together these findings are indicative of hypothyroidism. We further observed mineralization defects in scales due to enhanced osteoclast activity as measured by increased expression levels of tracp, ctsk, and rankl. Gene-environment interactions in the etiology of FOXE1-related craniofacial abnormalities remain elusive, which prompts the need for models to investigate genotype-phenotype associations. We here investigated whether ethanol exposure increases the risk of developing craniofacial malformations in foxe1 mutant larvae that we compared to wild types. We found in ethanol-exposed mutants an increased incidence of developmental malformations and marked changes in gene expression patterns of cartilage markers (sox9a), apoptotic markers (casp3b), retinoic acid metabolism (cyp26c1), and tissue hypoxia markers (hifaa, hifab). Taken together, this study shows that the foxe1 mutant zebrafish recapitulates phenotypes associated with FOXE1 mutations in human patients and a clear foxe1-ethanol interaction.

Efcab7 deletion sensitizes mice to the teratogenic effects of gastrulation-stage alcohol exposure

Alcohol exposure during the gastrulation stage of development can disrupt Sonic hedgehog (Shh) signaling and cause eye, craniofacial, and brain defects. One of the genes that regulates Shh signaling is Efcab7, which encodes a protein that facilitates the actions of Smoothened (Smo), a critical component of the Shh pathway. Previous work from our lab has demonstrated that Efcab7 is differentially expressed between two sub-strains of C57BL/6 mice that differ in their sensitivity to gastrulation-stage alcohol exposure. The more alcohol-sensitive C57BL/6 J mice express lower levels of Efcab7 during gastrulation than do the less alcohol-sensitive C57BL/6NHsd mice. The current study examined whether partial or full Efcab7 deletions render mice more sensitive to gastrulation-stage alcohol exposure and affect the sensitivity to other modulators of Shh signaling that cause craniofacial malformations. Efcab7+/- dams were mated with Efcab7+/- sires to produce Efcab7+/+, Efcab7+/-, and Efcab7-/- fetuses. On gestational day 7 (GD 7), they received either alcohol (two doses of 2.9 g/kg, i.p., given 4 hours apart), the Smo antagonist vismodegib (40 mg/kg, or vehicle, p.o.), the Smo agonist SAG (20 mg/kg) or the appropriate vehicles. GD 17 fetuses were collected and examined for ocular and craniofacial dysmorphology. As compared to Efcab7+/+ fetuses, Efcab7-/- fetuses exposed to alcohol or vismodegib treatment had more severe ocular and craniofacial malformations. In contrast, Efcab7-/- fetuses had less severe malformations induced by SAG. These results confirm that Efcab7 can modify responses to Shh agonists and antagonists and further identify Efcab7 as a gene important for the sensitivity to gastrulation-stage alcohol exposure.

Proboscis Lateralis of the Nose

Abstract Proboscis lateralis (PL) of the nose is a very uncommon craniofacial anomaly characterized by a rudimentary tubular nose-like structure seen a little away from the midline of the face. It may be associated with other anomalies such as heminasal aplasia, mental retardation, callosal agenesis, microphthalmia, heminasal hypoplasia, and atypical clefting syndrome. Patients with this congenital craniofacial malformation need proper evaluation with the help of a computed tomography scan to assess the growth of facial and skull bones. The esthetic aspects and psychological problems are often a concern for patient’s families. The cartilaginous part or bony support of the nose can be reconstructed following proper growth of the face. Here, we presented a male neonate of 15 days with PL of the nose. There was no evidence of cleft lip or cleft palate. Parents were counseled for staged repair at an early age to avoid anxiety and to allow proportionate growth of the nose and face.

Etiology of craniofacial and cardiac malformations in a mouse model of SF3B4-related syndromes

Pathogenic variants in SF3B4, a component of the U2 snRNP complex important for branchpoint sequence recognition and splicing, are responsible for the acrofacial disorders Nager and Rodriguez Syndrome, also known as SF3B4-related syndromes. Patients exhibit malformations in the head, face, limbs, vertebrae as well as the heart. To uncover the etiology of craniofacial malformations found in SF3B4-related syndromes, mutant mouse lines with homozygous deletion of Sf3b4 in neural crest cells (NCC) were generated. Like in human patients, these embryos had craniofacial and cardiac malformations with variable expressivity and penetrance. The severity and survival of Sf3b4 NCC mutants was modified by the level of Sf3b4 in neighboring non-NCC. RNA sequencing analysis of heads of embryos prior to morphological abnormalities revealed significant changes in expression of genes forming the NCC regulatory network, as well as an increase in exon skipping. Additionally, several key histone modifiers involved in craniofacial and cardiac development showed increased exon skipping. Increased exon skipping was also associated with use of a more proximal branch point, as well as an enrichment in thymidine bases in the 50 bp around the branch points. We propose that decrease in Sf3b4 causes changes in the expression and splicing of transcripts required for proper craniofacial and cardiac development, leading to abnormalities.

Fgf8 contributes to the pathogenesis of Nager syndrome

Nager syndrome (NS, OMIM 154400) is a rare disease characterized by craniofacial and limb malformations due to variants in the gene encoding splicing factor 3B subunit 4 (SF3B4). Although various noncanonical functions of SF3B4 unrelated to splicing have been previously described, limited studies elucidate molecular mechanisms underlying NS pathogenesis. Here we showed that sf3b4-deficient fish displayed craniofacial and segmentation defects associated with suppression of fgf8 levels, which perturbed FGF signaling and neural crest cell (NCC) expression. Our finding also pointed out that oxidative stress-induced apoptosis was prominently detected in sf3b4-deficient fish and may further exaggerate the bone remodeling process. Notably, injection of exogenous FGF8 significantly rescued the demonstrated defects in sf3b4-deficient fish, which further supported the participation of Fgf8 in NS pathogenesis. Overall, our study provides valuable insights into the molecular mechanism underlying developmental abnormalities observed in NS and suggests future therapeutic strategies to protect against the pathogenesis of NS and possibilities for preventing severe outcomes.

Clinical phenotype and genetic analysis of a rare case with 6p duplication and terminal deletion syndrome

To explore the genetic basis for a child with developmental delay and intellectual deficit (DD/ID). A child who was admitted to the Maternal and Child Health Care Hospital of Longhua District of Shenzhen City on June 3, 2023 due to DD/ID, craniofacial malformations, and recurrent infections of upper respiratory tract was selected as the study subject. G-banded chromosomal karyotyping was carried out for the child and her parents. Low-depth genome-wide copy number variation sequencing (CNV-seq) and chromosomal microarray analysis (CMA) were used to screen for genome-wide copy number variations (CNV), and fluorescence in situ hybridization (FISH) was used to verify the origin of candidate CNV. The child, an 8-year-old girl, had featured unexplained growth and intellectual development delay, multiple craniofacial malformations, and recurrent infections of the upper respiratory tract. She was found to have a karyotype of 46,XX,der(6)add(6)(q23), while both of her parents were normal. Both CNV-seq and CMA showed that the child has harbored a 21.38 Mb interstitial duplication at 6p25.3p22.3 and a 0.78 Mb terminal deletion at 6p25. FISH verified that both the duplication and deletion had occurred de novo. The abnormal phenotype of the child may be attributed to the 6p duplication and terminal deletion.

Mixed reality guided advancement osteotomies in congenital craniofacial malformations

We describe the use of mixed reality intra-operative guides, in patients with congenital craniofacial malformations. Our experience shows the potential MR has as an adjunct and possible replacement for conventional cutting guides and intra-operative navigation. SummaryThis paper describes our experience with mixed reality (MR) intra-operative guides, in patients with congenital craniofacial malformations.The first case was a patient with bilateral hemifacial microsomia. He underwent bilateral mandibular distraction osteogenesis. Pre-operative virtual planning determined the sites of osteotomy. Standard Tessellation Language (STL) files of mandibular 3D models with osteotomy sites were uploaded onto the HoloLens 2® MR glasses (Microsoft®, Washington, USA). The superimposed hologram denoted the osteotomy line. This was validated with a physical cutting guide.The second case was a patient with Crouzon’s syndrome. A modified Lefort 2 advancement was performed to correct his midfacial deficiency. Pre-operative virtual planning was performed to determine the sites of osteotomies. Superimposed hologram using the Hololens 2® denoted the osteotomy sites. These were validated with a conventional intra-operative navigation system.The advantages of using MR include its immediate availability for use; saving time and costs. MR allows surgeons to maintain continuous line-of-sight within the operative field. A robust registration system is required to anchor the hologram onto the patient’s skull, without variations in hologram position from different angles of gaze. MR has the potential to function as an adjunct and possible replacement for conventional cutting guides and intra-operative navigation.

In-House Virtual Planning and 3D Printed Surgical Guides for Reconstructive Rhinoplasty.

Performing rhinoplasty in patients with craniofacial malformations remains a challenge, even for experienced surgeons. Advances in 3D technology and its application in surgical planning and printing of cutting guides and splints have become important tools to improve aesthetic and functional results. To describe an in-house workflow for surgical planning and printing of cutting guides and splints for complex rhinoplasty cases. This article describes an in-house workflow for complex rhinoplasty, as used in the maxillofacial department of a children's hospital specialized in the treatment of cleft and craniofacial malformations. Customized surgical guides help the surgeon to harvest and mold potential septal and costochondral grafts more accurately, to reduce surgical time and to verify the dimensions of the sculpted nasal shape following surgical planning templates. Patient satisfaction degree according to Rhinoplasty Outcome Evaluation questionnaire was 18/24. The presented workflow represents a potential asset in obtaining more accurate and satisfactory results in complex rhinoplasties.

Lingual Tonsillectomy as Part of a DISE-Directed Multilevel Upper Airway Surgery to Treat Complex Pediatric OSA: A Safe and Appropriate Procedure.

To study the efficiency of lingual tonsillectomy (LT) as part of multilevel surgery in children with complex obstructive sleep apnea (OSA). To evaluate the safety and the outcomes of LT. Retrospective case series. Pediatric tertiary care academic center. We included all children operated for LT to treat complex OSA, from January 2018 to June 2022. All patients underwent a protocolized drug-induced sleep endoscopy (DISE) followed by a coblation LT, associated with the treatment of all other obstructive sites. Patient demographics, medical history, surgery, and outcomes were reviewed. The efficiency of LT was analyzed exclusively in patients with a preoperative and postoperative sleep study. One hundred twenty-three patients were included. Median age was 8 years (interquartile range, IQR [3-12]). Sixty-five (53%) patients had Down syndrome, 22 (18%) had a craniofacial malformation, and 8 (7%) were obese. LT was associated with adenoidectomy (n = 78, 63%), partial tonsillectomy (n = 70, 57%), inferior turbinoplasty/turbinectomy (n = 59, 48%), epiglottoplasty (n = 92, 75%), and/or expansion pharyngoplasty (n = 2, 2%). Eighty-nine patients underwent a sleep study before and after surgery. The median apnea-hypopnea index (AHI) decreased from 18 events/h (IQR [9-36]) before surgery to 3 events/h (IQR [1-5]) after surgery (P < .001) (patients with a postoperative AHI <1.5 events/h, n = 31, 35%, and an AHI <5 events/h, n = 32, 36%). Seventeen out of 30 (57%) patients could be weaned from continuous positive airway pressure after surgery. Two patients had a postoperative hemorrhage and 2 patients required a transient postoperative reintubation. In children with complex OSA, LT as part of a DISE-directed multilevel upper airway surgery, was a very efficient and safe procedure.

Osseous Outcomes of Cleft Alveolar Bone Grafting with Allograft and Platelet-Rich Fibrin: Preliminary Study with Radiological Outcome.

Cleft lip and palate are the most common craniofacial malformations worldwide. The alveolar cleft is treated with a bone graft, between 4 and 7 years of age in mixed dentition. This is an important step because it provides good quality jawbone and a better support of the lip and the alar cartilage on the side of the cleft. Bone autografting with iliac harvesting remains the most commonly used technique, but it is not without risks. Allograft techniques have therefore been described to reduce this morbidity (pain, infectious risk, hemorrhagic risk, fracture risk). The aim of this study was to evaluate, one year after allografting, the efficiency and consolidation of the bone allograft in the alveolar cleft. A retrospective study was conducted in the department of pediatric craniomaxillofacial surgery in the Woman-Mother-Child Hospital in Lyon, France. This series includes 22 patients or 25 alveolar cleft bone grafts, including 16 boys and 6 girls, with an average age of 6.1 years. Quantify the residual bone allograft by evaluating the ratio between the volume of the bone graft and the volume of the initial space on pre- and post-operative cone beam computed tomography. The residual bone allograft percentage at 1 year was 58.5% (± 22.3). Alveolar cleft bone graft with bone allograft is an alternative to iliac autografting to reduce donor site morbidity.

In house 3-D printed surgical guide for frontal sinus osteotomy in traumatology: A technical note

Frontal sinus surgery and particularly frontal sinus osteotomy represent historically a procedure demanding precision and careful planning. Achieving optimal results while minimizing complications requires meticulous preoperative planning and execution. Cutting guides are crucial tools in surgical procedures, particularly in complex osteotomies like could be those involving the frontal sinus. The aim of the study is to show the worflow for the in-house custom made cutting guide for secure and accurated frontal sinus approach. Given the simplicity, efficacy, rapidity, and safety of the procedure, the workflow for programming the cutting guide can be considered valid for all surgical procedures that contemplate performing an osteotomy on the anterior wall of the frontal sinus, such as trauma pathology, inflammatory naso-sinus pathology, benign or malignant neoplastic pathology, and craniofacial malformation pathology.