Piriform Margin Research Articles

Morphological Observation of the Alar Region between the Piriform Aperture and the Alar Soft Tissue for Facial Approximation (Reconstruction)

Prediction methods for regions not lined by facial bones are important elements of forensic anthropology, including forensic facial approximation. The alar region can be predicted by measuring the distances from the piriform margin and multiples of the piriform width. However, studies investigating this region are limited, and some only focus on one side of the alar region. Hence, we aimed to measure the bony points/landmarks to predict the alar region.Post-mortem computed tomography images of the samples from 180 Japanese individuals were obtained and analyzed. The images were processed using Osirix (Pixmeo). The coordinates recorded from all samples were calculated, and the values obtained were stratified by sex, laterality, age, body mass index, and cephalic index. The distances between the alar and the five piriform points were measured. The mean, standard deviation, and confidence interval of all samples were calculated, and the sex-related differences were determined. We evaluated the correlation between alares and other boney landmarks and points. Our findings were compared with those of previous studies. We observed significant sex differences (p < 0.01) and asymmetry (p < 0.01) in laterality in this region; hence, asymmetry was assessed based on these results. Compared with the results of previous studies, the obtained measurements were larger than those of a previous Asian study, suggesting that laterality may influence the accuracy of prediction methods for regions not lined by hard tissues.

Computed Tomography-Assisted Auricular Cartilage Graft for Depression of the Alar Base in Secondary Unilateral Cleft Lip Repair: A Preliminary Report.

To evaluate the feasibility, effectiveness, and safety of computed tomography-assisted auricular cartilage grafting for treating alar base depression secondary to unilateral cleft lip. For patients with obvious depression of the alar base, the difference in heights of the alar base and the piriform margin between the cleft side and the noncleft side were measured with computed tomography. If both were >3.0 mm, the cartilage was harvested postauricularly and subdivided into 2 to 4 pieces. A multiple layer graft was inserted under the depressed alar base. The procedure was performed from 2006 to 2013, and the follow-up period was 3 to 15 months. Chinese patients with alar base depression secondary to unilateral cleft lip were selected. Suture and cartilage graft techniques. Differences in bilateral alar base heights and piriform apertures. There was no wound dehiscence, exposure of bone, or donor site morbidity. The difference in heights in the bilateral alar bases and piriform apertures decreased. There were no obvious scars in any of the cases. This technique has several advantages including ease of operation, minimal trauma, satisfactory outcomes, and useful references for operation provided by computed tomography. It is a superior alternative for reconstruction of secondary alar depression.

Piriform Margin Augmentation as a Treatment for Persistent Nasal Valve Dysfunction: A Cadaveric Investigation and Report of Initial Clinical Results

Piriform Margin Augmentation as a Treatment for Persistent Nasal Valve Dysfunction: A Cadaveric Investigation and Report of Initial Clinical Results

Anthropometric Analysis of the Maxillary Bone and the Alar Base in Unilateral Cleft Lip with Secondary Nasal Deformity: Classification of a Piriform Margin Bony Depression

This study was conducted to measure the soft tissue of the alar base and the piriform aperture area of the maxillary bone of unilateral cleft lips with secondary nasal deformities when secondary operation are necessary to classify the alar base depression and to provide a clinical reference for the second surgery. Twenty-six patients with unilateral cleft lip with secondary nasal deformity were treated at the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medial University. Nose data were attained preoperatively and postoperatively. Correlations were made between the soft tissue and the bony depression and patient satisfaction with the nasi basis. Classifications were then made based on these data. When the distance discrepancy of the bilateral piriform aperture depression was less than 4.5 mm, we obtained a fine appearance for the nose by repairing only the soft tissues. When it was more than 5 mm, we had to combine repair of the soft tissue with a bone graft or the restitution of the alveolar cleft. When the distance was between 4.5 mm and 5 mm, the surgeon considered both the wishes of the patient and the clinic's standard procedure. For patients with cleft lips and palates, the bony depression was not the only factor that resulted in postoperative alar depression. Anthropometry of the nose prior to surgery was important for choosing the methods that would yield satisfactory results.

Leprogenic odontodysplasia: new evidence from the St. Jørgen’s medieval leprosarium cemetery (Odense, Denmark)

Leprogenic odontodysplasia (LO), also known as dens leprosus, consists of anomalous root development of the permanent upper incisors. This dental anomaly was first reported by Danielsen in 1968 among Danish juvenile skeletons from medieval leprosaria cemeteries. As yet, no clinical cases have been documented and the etiological and epidemiological significance of the condition are poorly understood. The aim of this study is to discuss a case of LO found amongst the skeletons from the St. Jorgen's leprosarium cemetery (13th-16th/17th centuries), housed in the ADBOU (Anthropological Database of Odense University), Southern Denmark University. A juvenile individual presents a dis- articulated maxillary right central incisor possessing a short root that shows a groove caused by marked constriction beginning approximately 1.5 mm above the neck. From this groove, the diameter decreas- es considerably until the apex. Atrophy of the anterior alveolar maxillary process, extending laterally from the central incisors to the canines, is also apparent. This individual exhibits additional rhinomax- illary lesions (e.g. absorption of the piriform margin including the anterior nasal spine) and foot chang- es (including phalangeal acro-osteolysis) compatible with a diagnosis of lepromatous leprosy. This case contributes to the debate about the significance of this rare condition, particularly in terms of its presence in Scandinavian skeletons from medieval leprosaria cemeteries. Possible interpretations are discussed, including the pathognomonic value of the specific lesion and whether it indicates early childhood onset of leprosy during the Middle Ages. The understanding of LO epidemiology and its relationship with leprosy will benefit from future clinical and skeletal studies.

Retrospective assessment of the dismasking flap procedure as a craniofacial approach

In 1997 the authors presented the case of a 3-year-old girl who underwent complete resection of a huge tumor via a new technique using a dismasking flap. Since that report, 14 patients have undergone surgery using this technique. There have been few reports on long-term follow-up after a craniofacial surgical approach and reconstruction of a huge tissue defect. The authors report details of this procedure based on these cases, including long-term follow-up in the original case. The dismasking flap is a cranioorbitofacial degloving method that uses a circumpalpebral approach with or without piriform margin incisions and presents a wide surgical field under direct vision. Fourteen patients have undergone surgery using the dismasking flap technique. These patients had multiple craniofacial bone fractures (3 cases) and malignant or premalignant craniofacial tumors (11 cases). Patients ranged in age from 3 to 62 years old. The longest follow-up period was 15 years. The results of these cases are reported regarding changes in the facial bones and soft tissues with growth, the various pathologies involved, and complications. Complications using this approach were lagophthalmos with ectropion of the lower eyelid, disturbance of the superior orbital nerve, disturbance of the inferior orbital nerve, maxillary hypoplasia, and blepharoptosis. In all affected patients these complications were almost always temporary. In 2 of the 14 cases, a repair operation for lagophthalmos was necessary, while others showed spontaneous improvement approximately 6 months to a year after the procedure. In the case with the longest follow-up duration, the patient's nose is asymmetrical, especially the alar portion, due to hypoplasia of the grafted bone and/or the fixation with titanium miniplates. This flap is very useful for en bloc resection of huge skull base tumors, multiple craniofacial bone fractures, and as a lateral approach to a deep portion of the middle cranial base. Careful attention is necessary, however, because one may encounter unexpected complications if one does not ensure adequate protection of the perioperative flap. Meticulous postoperative management is also essential.

Surgical Rehabilitation of Nasoalveolar Complex in Patients With Alveolar Clefts

The objective of this study was to review the outcome of surgical rehabilitation of nasoalveolar complex in patients with alveolar clefts. Twenty-seven patients (13 female, 14 male) with 4 bilateral and 23 unilateral alveolar clefts who were treated in our clinic during the period between 2002 and 2009 were included in the study. All the patients had oronasal fistulas, and all of them were closed successfully except one. Recurrence of the oronasal fistula was seen in 1 patient. Alar base was supported by onlay cortical bone in most of the patients. Eleven of the canines at the cleft site erupted after the operation in to the grafted area. Seventy-six percent (n = 16) of the 21 patients could be assigned to the successful groups 1 and 2, whereas 24% (n = 5) were assigned to the unfavorable group. There was not any insufficient result. Bone graft placed along the piriform margin and alar wings during alveolar bone grafting improves the results of nasal correction. Late grafting should be performed at least to support the alar base for nasal symmetry.

Dynamic Analysis of the Effects of Upper Lip Pressure on the Asymmetry of the Facial Skeleton in Patients with Unilateral Complete Cleft Lip and Palate

Our purpose was to assess quantitatively the effect of increased upper-lip pressure on asymmetry of the facial bones in patients with unilateral complete lip-alveolar-palatal clefts. We collected computed tomographic images from 16 patients with unilateral complete lip-alveolar-palatal clefts and classified them into two groups based on absence/presence of alveolar bone grafting. We categorized eight patients (9.6 +/- 2.0 years old) who had not been treated with alveolar bone grafting as the ABG(-) group and the other eight patients (9.3 +/- 1.6 years old) who had received alveolar bone grafting as the ABG(+) group. After producing a computer-aided design model for each patient, we applied a uniform load on the anterior aspects of the maxilla, alveolus, and teeth of the model to simulate the upper-lip pressure. Then we calculated the degree of distortion each model presented using the finite element method. We compared the distortion pattern between the ABG(-) and ABG(+) groups. In the ABG(-) patients, asymmetry of distortion between the cleft and noncleft sides was present in wide areas involving the orbit, nasal bone, piriform margin, and anterior wall of the maxillary sinus. In the ABG(+) patients, asymmetry of distortion was limited to rather small areas. In unilateral complete lip-alveolar-palatal clefts patients, the upper-lip pressure works to dislocate the cleft-side segment to a more posterior position than the noncleft-side segment. This finding implies that the increased lip pressure exacerbates facial asymmetry of these patients. The exacerbating effect on facial asymmetry is alleviated by alveolar bone grafting.

Evaluation of Cleft Lip Bony Depression of Piriform Margin and Nasal Deformity with Cone Beam Computed Tomography: “Retruded-like” Appearance and Anteroposterior Position of the Alar Base

As the nasal platform, the piriform margin is considered the most important nasal structure. An insufficient bony structure has been suggested to be the major factor in secondary nasal deformities such as the "depressed alar base." It is unclear, however, how the piriform margin is depressed or how bony depression influences nasal shape. Using cone beam computed tomography, the anteroposterior positions of the cleft-side piriform margin and alar base were compared with those of the noncleft side in 52 postoperative unilateral cleft lip patients with no alveolar bone graft. Patients were divided based on cleft type into either the unilateral cleft lip, alveolus, and palate group or the unilateral cleft lip and alveolus group. In all cases, the cleft-side piriform margin was depressed. The anteroposterior position of the alar base was related to the piriform depression in both groups. However, in contrast with bony depression, the cleft-side alar base was located more anteriorly than the non-cleft-side alar base in 35 of 52 patients. The authors' study suggests that bony depression does not necessarily lead to postoperative alar depression. The postoperative cleft lip alar position can be maintained independently of the collapsed lesser segment of the maxilla. In addition, in many cleft lip newborns the cleft alar crease is hypoplastic, and the paranasal triangle is easily elevated by operative manipulation because of the muscular dysfunction. This shallowness leads to a "retruded" appearance. For improvement, preservation of the paranasal triangle and alar crease plasty are important.

V-Y advancement flap and composite graft for alar-groove reconstruction

A one-stage procedure combining a V-Y advancement flap with a composite graft for the reconstruction of alar-lobule and alar-groove defects is described. After tumour resection, a V-Y flap is advanced and retained at the level of the piriform margin to fill the dead space. To provide vascular support to the composite graft and to recreate the alar groove the advancing edge of the flap is de-epithelialised. In the same stage the composite graft is harvested and placed into the alar defect. A series of 12 patients underwent this procedure, with good results.

Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate.

The purpose of this study was to analyze the geometry of the primary cleft lip nasal deformity using three-dimensional computerized tomography in a group of 3-month-old infants with complete unilateral cleft lip and palate before surgical intervention. Coordinates and axes were reconfigured after the three-dimensional image was oriented into neutral position (Frankfurt horizontal, true anteroposterior, and vertical midline). Display and measurement of skin surface and osseous tissues were achieved by adjusting the computed tomographic thresholds. S-N, N-ANS, S-N-O, and S-N-ANS were measured from true lateral views. Biorbital (LO-LO), interorbital (MO-MO), intercanthal (en-en), and nasal (al-al) widths were measured from the anteroposterior view. The bony alveolar cleft width was measured from the inferior view. The study group was divided into two groups on the basis of skeletal alveolar cleft width: six patients with clefts narrower than 10 mm and six patients with clefts wider than 10 mm. Only the S-N-ANS angle differed between the two groups, i.e., it was greater in the group with the wider clefts (p < 0.05). Coordinates of six landmarks at the base of the nose [sellion (se), subnasale (sn), cleft-side and noncleft-side subalare (sbal-cl and sbal-ncl), and the most posterior point on the lateral piriform margins (PPA-CL and PPA-NCL)] were obtained for analysis of the nasal deformity. On average, the subnasale point was anterior to sellion and deviated to the noncleft side; the cleft-side sbal point was more medial, posterior, and inferior than the noncleft-side sbal point; and the PPA point on the cleft-side piriform margin was more lateral, posterior, and inferior than the PPA point on the noncleft side. These discrepancies were not universally observed. However, in all patients, four findings were observed without exception (p < 0.01): (1) subnasale (sn) was deviated to the noncleft side (mean distance from midline, 5.0 mm; range, 2 to 9.5 mm), (2) the cleft-side alar base (sbal-cl) was more posterior than the noncleft-side alar base (sbal-ncl) (mean difference, 3.6 mm; range, 1 to 5.5 mm), (3) the noncleft-side alar base (sbal-ncl) was further from the midline than the cleft-side alar base (sbal-cl) (mean difference in lateral distances of sbal-ncl and sbal-cl from the midline, 2.8 mm; range, 0.5 to 7 mm), and (4) the cleft-side piriform margin (PPA-CL) was more posterior than the noncleft side piriform margin (PPA-NCL) (mean difference, 2.1 mm; range, 0.5 to 4 mm). In conclusion, the nasal deformity in unilateral cleft lip and palate that has not been operated on is characterized by these four features and increased S-N-ANS angle with increased alveolar cleft width.

Primary repair of the unilateral cleft lip nose in the Oriental: a 20-year follow-up.

The unilateral cleft lip nasal deformity is corrected as a primary procedure with the lip repair. The abnormal attachment of the alar base is first released by an incision along the superior buccal sulcus and piriform margin. There is no intercartilaginous incision. Basically, we use the Brown-McDowell technique with the addition of an alar rim incision. Undermining of the ala between the two incisions is carefully and adequately done, splitting it into two layers. The first is a skin and the second, a chondrocutaneous (vestibular skin) layer, which is handled as a single unit, thus enhancing its vascularity. This second layer is a bipedicle flap with a broad medial pedicle and a narrow lateral pedicle at the alar base. When the alar base is rolled into its normal position, the chondrocutaneous unit hinging on its two pedicles counterrotates, correcting the subluxation of the ala, a major component of the cleft lip nasal deformity. We depend on the normal position of the alar base, the postoperative scar tissue, and the inherently thick nostril wall in the Oriental to keep the alar dome up. No transfixion sutures are used. Ten consecutive patients are shown 20 years after surgery. All had one operation only. None showed any disturbance of nasal growth.

The importance of the musculus nasalis and the use of the cleft margin flap in the repair of complete unilateral cleft lip

The deformities of the lip and nose in cleft lip patients are intimately inter-related and their repair should not be independent procedures. The reconstruction should be dynamic, taking into account the different functions of the groups of the perioral musculature. For the lip repair, attenuation of the musculus nasalis of the sound side and the formation of the levator sling are believed to be important. Nasal repair consists of upward transpositioning of the origin of the musculus nasalis and of plicating the nasal fascia, followed by the transfer of the bi-lobed cleft margin flap to the piriform margin.