Sutural Research Articles

Osteoprotegerin deficiency results in disruption of posterofrontal suture closure in mice: implications in nonsyndromic craniosynostosis.

Little is known about the role of osteoclasts in cranial suture fusion. Osteoclasts are predominantly regulated by receptor activator of nuclear factor kappa B and receptor activator of nuclear factor kappa B ligand, both of which lead to osteoclast differentiation, activation, and survival; and osteoprotegerin, a soluble inhibitor of receptor activator of nuclear factor kappa B. The authors' work examines the role of osteoprotegerin in this process using knockout technology. Wild-type, osteoprotegerin-heterozygous, and osteoprotegerin-knockout mice were imaged by serial micro-computed tomography at 3, 5, 7, 9, and 16 weeks. Suture density measurements and craniometric analysis were performed at these same time points. Posterofrontal sutures were harvested from mice after the week-16 time point and analyzed by means of histochemistry. Micro-computed tomographic analysis of the posterofrontal suture revealed reduced suture fusion in osteoprotegerin-knockout mice compared with wild-type and heterozygous littermates. Osteoprotegerin deficiency resulted in a statistically significant decrease in suture bone density in knockout mice. There was no reduction in the density of non-suture-containing calvarial bone between wild-type and osteoprotegerin-knockout mice. Histochemistry of suture sections supported these micro-computed tomographic findings. Finally, osteoprotegerin-knockout mice had reduced anteroposterior skull distance at all time points and an increased interorbital distance at the week-16 time point. The authors' data suggest that perturbations in the expression of osteoprotegerin and subsequent changes in osteoclastogenesis lead to alterations in murine cranial and posterofrontal suture morphology.

Biomechanical Analysis of Scapholunate Ligament Repair Techniques

To evaluate the biomechanical properties of 3 scapholunate repair techniques. In 51 cadavers, the scapholunate ligament was exposed through a dorsal approach, incised at its scaphoid insertion, and repaired using 1 of 3 techniques: 2 single-loaded suture anchors, 2 double-loaded suture anchors, or 2 transosseous sutures. Twenty-four repaired specimens underwent load to failure (LTF) testing using tensile distraction on a servo-hydraulic machine. Twenty-seven specimens underwent cyclical testing to measure gap formation at the scapholunate joint. The mode of failure was suture pullout through the substance of the ligament in 22specimens, failure at the bone suture interface in 1, and anchor pullout in 1. Double-loaded anchor repairs demonstrated a significantly higher mean ultimate LTF compared with single-loaded anchor (91 N vs 35 N) and transosseous (91 N vs 60 N) repairs. Transosseous repairs demonstrated a higher mean ultimate LTF compared with single-loaded suture repairs (60 N vs 35 N). After 300 cycles, the average gap for the transosseous repair group was double that for the single- and double-loaded repairs, although not statistically significant. Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. On cyclic loading, transosseous repairs demonstrated the greatest gap formation with no measurable difference between single- and double-loaded repairs. In a cadaveric model for primary repairs, double-loaded suture anchors demonstrated the highest LTF and offer a similar but unproven performance invivo.

Compared Craniometry in Dry Bones of the Anomalous Cranium.

The increase in the cranium can be caused by conditions like hydrocephalus, aneurism, hemorrhagic and ischemic stroke; however, these cause a secondary increase in the skull only in the childhood. Quantitative and morphological disproportions of anatomic structures are considered anatomical variations and have forensic importance. Therefore, the aim of this study is to characterize the craniometry and cranioscopy of the referred atypical part as well as enumerate the wormian bones seen with the naked eye on a dry cranium found at the Anatomical Center II of José do Rosário Vellano University ‐ Alfenas, Brazil. The object of study is in good handling conditions, fully dry and treated accordingly to the local procedure. Full cranial measurements were carried out, especially the measurement of the circumference, anteroposterior and latero‐lateral diameter, using an analog caliper rule, Castro Viejo compass and tape‐measure. We found a measurement of 60.2 cm for the circumference, 27.4 cm for the latero‐lateral diameter and 33.0 cm for the anteroposterior diameter. Furthermore, there were 60 wormian bones in the skull and a hole that, probably, indicated the absence of one more suture bone. Pathological investigation was performed by means of magnetic resonance and x‐ray to search for complications inside the cranium, as well as highlight the mastoid cells. Given the fact, it is concluded that the cranium is an anatomical variation rarely found, both by the size of the diameter and circumference, and the number of sutural bones, constituting a forensic data for future studies.

Outcome of a One-Stage Tensile Stress Surgical Technique and Early Postoperative Rehabilitation in the Treatment of Neglected Achilles Tendon Rupture

The present study evaluated the effect of single-stage internal traction combined with early postoperative active rehabilitation and the yurt bone suture method, a new surgical technique, on the clinical outcomes after surgical repair of Achilles tendon. A total of 51 patients with neglected Achilles tendon rupture who underwent the yurt bone suture treatment also participated in an accelerated postoperative rehabilitation program. The clinical outcome was evaluated for 18 weeks using the Leppilahti scoring system, bilateral ultrasound examination, and computed tomography examination. The ultrasound and computed tomography examinations revealed that Achilles tendon elongation and adhesion occurred in none of the patients. All the patients could perform the single leg heel raise exercise for a mean of 30 ± 7.6 seconds at 12 weeks postoperatively. In addition, the patients could participate in sport exercises and heavy physical activities by around 13 weeks postoperatively. The mean Leppilahti score was 85.8 ± 3.7 at 8 weeks postoperatively, and it had increased to 96.1 ± 3.2 and 100.0 ± 0.0 at 12 and 18 weeks, respectively, after the operation. The 1-stage internal traction technique, combined with early postoperative active rehabilitation and the yurt bone surgical technique, resulted in good clinical outcomes for the treatment of neglected Achilles tendon rupture.

Bone suture: Useful aid in apical repositioning full thickness mucoperiosteal flap during dental implant surgery, Technical Note

Increasing attached gingiva around dental implants has beneficial effects in maintaining health and esthetic around the implants. Palatal incision, partial thickness flap and finally apical repositioning the elevated flap is the solution. In the case that the reflected flap is full thickness, such as the need for osteoplasty in the buccal bone or removal of internal fixative devices (screws or miniplate) then preventing the coronal movement of the flap is difficult. Bone suture that is creating a hole in the bone for fixing soft tissue to it is beneficial.

Bone suture and lateral sinus lift surgery.

Bone suture in lateral sinus lift has four indications. Three of them depend on creating a hole in the lateral maxillary sinus wall above the antrostomy window for securing the elevated medial maxillary sinus membrane to manage perforated Schneiderian membrane. Covering the buccal antrostomy window with the buccal fat pad (BFP) for better nourishment of the inserted graft and as an alternative for bone tags in fixation of collagen membrane has been reported previously. A new indication for firmly anchoring the BFP to the medial maxillary sinus wall as the last resort for the management of perforated Schneiderian membrane is explained in this article.

Pyknodysostosis: A rare case report

Pyknodysostosis is a rare autosomal recessive disorder characterized by the postnatal onset of short limbs, short stature, and generalized hyperostosis along with acro-osteolysis with sclerosis of the terminal phalanges, a feature that is considered essentially pathognomonic. Other features include persistence of fontanelles, delayed closure of sutures, wormian bones, absence of frontal sinuses, and obtuse mandibular gonial angle with relative mandibular prognathism. Here, we report a case of pyknodysostosis found to be having the classical features during intraoral examination and general physical examination.

Radiology of Osteogenesis Imperfecta, Rickets and Other Bony Fragility States.

This section gives an overview of radiological findings in bony fragility states, with a special focus on osteogenesis imperfecta (OI) and rickets. Conventional radiological assessment of bone density is inaccurate and imprecise and only reliably detects severe osteopaenia. However, other aspects of bone structure and morphology can be assessed, and it is possible to distinguish between osteopaenic and osteomalacic states. OI is a heterogeneous group of disorders of type 1 collagen formation and processing that are characterised by varying degrees of bony fragility, with presentations varying from perinatal lethality to asymptomatic. Radiological diagnosis of severe forms is usually straightforward, but that of milder disease may be challenging because specific features are often absent. However, a multidisciplinary approach is usually successful. Features of OI, including Wormian bones, skull base deformities, vertebral involvement and long bone fractures and deformities, are reviewed in this section. Rickets is best defined as a disorder of the growth plate characterised by the impaired apoptosis of hypertrophied chondrocytes. Vitamin D deficiency is a common cause of rickets. The patho-anatomical basis of radiological findings in rickets is reviewed and illustrated. Rickets is frequently accompanied by hyperparathyroidism and osteomalacia. Rickets used to be classified as calciopaenic or phosphopaenic but is now referred to as parathyroid hormone or fibroblast growth factor 23 mediated, respectively [1]. The radiological features of the two forms are reviewed.

Cleidocranial Dysplasia-A Case Report

Cleidocranial dysplasia is a rare congenital disease. It is characterized by autosomal dominant inheritance pattern which is caused due to mutations in the Cbfa1 gene (Runx2) located on chromosome 6p21. It primarily affects bones which are formedby intra-membranous ossification and have equal sex distribution. It is also known as Marie and Sainton disease, Mutational dysostosis and cleidocranialdysostosis. The skeletal deformities of cleidocranial dysplasia are characterized by partial or complete absence of clavicles, late closure of the fontanels, presence of open skull sutures and multiple wormian bones. This rare syndrome is of utmost importance in dentistry due to presence of multiple supernumerary teeth, facial bones deformities and deranged eruption patterns. We are reporting a classical case of cleidocranial dysplasia in 20 year old patient.

Paramastoid apophysis: case report

AbstractThe aim of this study was to report a case of a paramastoid apophysis of a human skull, identified during routine lessons at the Laboratory of Human Anatomy, Federal University of Pernambuco and Recife-PE, Brazil. The skull used in this study showed a morphological variation present only on the right side of the occipital bone, which had a height of 18.10 mm and had a facet joint with the transverse process of the atlas, being identified as paramastoid apophysis. Other anatomical variations in skull were found as: presence of sutural bone along the lambdoidal suture and persistent metopic suture. Thus, this study will be important for the health sciences and those who keep interest in pathologies associated with atlanto-occipital joint, because the description of the structures that deviate from the normal organogenesis resulting from disorders: hereditary basis or not, has a practical interest that prints the modification to the arrangement of the constituent elements of the region and possible functional alterations resulting therefrom.

Hajdu-Cheney syndrome: a review.

Hajdu Cheney Syndrome (HCS), Orpha 955, is a rare disease characterized by acroosteolysis, severe osteoporosis, short stature, specific craniofacial features, wormian bones, neurological symptoms, cardiovascular defects and polycystic kidneys. HCS is rare and is inherited as autosomal dominant although many sporadic cases have been reported. HCS is associated with mutations in exon 34 of NOTCH2 upstream the PEST domain that lead to the creation of a truncated and stable NOTCH2 protein with enhanced NOTCH2 signaling activity. Although the number of cases with NOTCH2 mutations reported are limited, it would seem that the diagnosis of HCS can be established by sequence analysis of exon 34 of NOTCH2. Notch receptors are single-pass transmembrane proteins that determine cell fate, and play a critical role in skeletal development and homeostasis. Dysregulation of Notch signaling is associated with skeletal developmental disorders. There is limited information about the mechanisms of the bone loss and acroosteolysis in HCS making decisions regarding therapeutic intervention difficult. Bone antiresorptive and anabolic agents have been tried to treat the osteoporosis, but their benefit has not been established. In conclusion, Notch regulates skeletal development and bone remodeling, and gain-of-function mutations of NOTCH2 are associated with HCS.

Study of variations of bony pattern and presence of wormian bone at pterion in dry human skulls

Pterion is an important bony landmark of skull present on norma larteralis. Variations of bony pattern at pterion are common and are of clinical importance. Present study was carried out in Department of Anatomy IIMS and R to find out variations at pterion in dry human skull of north Indian origin. We utilized 60 dry human skulls for the study. The pattern of pterion and presence of sutural was observed. Spheno parietal was the commonest type of pterion in both left (86.7%) and right (91.7%) side of skull, stellate type was found in (5%) of skulls and frontotemporal was found in 3.3% of left and right each. Sutural bone was present in 5% skulls on the left side. Variation in pattern of pterion and presence of sutural bones are important from surgical and radiological point of view.

Variations in the squamous part of the occipital bone in medieval and contemporary cranial series from Bulgaria.

The squamous part of the occipital bone is a place of many different variations. They are a result of faulty ossification in the occipital squama or due to the presence of sutural bones in the lambda region. As their differentiation is intricate because of the various criteria used, the issue of their recognition in the adult skull still remains difficult even though they can be clearly distinguished at a younger age. The aim of the present study was to compare the frequency of interparietal, preinterparietal and sutural bones in the lambda region in medieval male and female cranial series as well as between medieval and contemporary male series from Bulgaria. We also discuss the development of the occipital squama in order to set clearer criteria for further differentiation of such variations in the adult skull. In the reviewed 3 cranial series, the variations in the squamous portion of the occipital bone were observed with a low frequency. The incidence of preinterparietal bones was more common than the interparietal ones. The sutural bones in the lambda region were numerous in the series. No statistically significant sex or intergroup differences were established. So even if these anatomical variations are relatively rare, the understanding of them is of significance for many disciplines like anthropology, comparative and developmental anatomy, clinical and forensic medicine.

Three dimensional visualisation and morphometry of bone samples studied in microcomputed tomography (micro-CT).

This article highlights the utility of micro-computed tomography (micro-CT) for characterisingmicroscale bone morphology. For this purpose we tested selected samplesof the human bones (Wormian bone, rib, lumbar vertebra) to reconstruct externaland internal morphological features. Selected bony samples were investigatedusing a micro-CT scanner (Skyscan 1172, N.V., Aartselaar, Belgium). The imageresolution of scans varied from 5 to 27 μm/pixel depending on the bone sample.We used CTvox software (by Skyscan) to perform volume rendering of the samples.Further, 3-dimensional geometrical models were reconstructed using theCTvol application. Such models enabled graphical distinction between osseouscomponents of various morphology and were used to visualise the Haversian canalsystem inside the compact bone of the rib. Applying a modified transfer functionfor volume rendering we presented the overall morphology of the Wormian boneand small vascular channels penetrating its interior. As an example of quantitativeanalysis based on micro-CT scans we compared the trabecular structure of thelumbar vertebrae with CTAn software. Significant differences in percent bonevolume (BV/TV) were determined. Micro-CT was found to be a very accurate andhelpful method to study small anatomical structures of the bones in micro scale.

Effects of low-intensity pulsed ultrasound on bone formation after the expansion of the inter-premaxillary suture in rats: a histologic and immunohistochemical study

Abstract Background: Orthodontic maxillary expansion is a commonly-performed treatment approach to correct transverse maxillary deficiencies by separating the mid-palatal suture. To obtain a successful treatment result and prevent relapse, the expanded maxillary sutures require maintenance by means of qualified bone reorganisation. Aim: To assess the effects of low-intensity pulsed ultrasound (LIPUS) on sutural bone formation after the expansion of the inter-premaxillary suture in rats. Methods: Sixteen male Wistar rats, 6 to 8-week old, were used. The expansion appliance comprised a helical spring fabricated from 0.014 inch stainless steel wire (Dentaurum, Ispringen, Germany). The rats were divided into two equal groups and randomly assigned to the LIPUS treatment group or a sham-operation group. LIPUS was delivered via a 2.5 cm diameter ultrasound transducer (Exogen, Smith and Nephews, Inc., Memphis, TN, USA) for 20 minutes per day during 7 days of post-expansion retention. Following retention, the rats’ maxillae were surgically removed and histologic and immunohistochemical specimens were prepared and examined. Results: The number of osteoblasts and blood vessel dimensions in the ultrasound group increased but was not significant, compared with the control group. A statistically significant difference in osteocalcin, VEGF and TGF-β immunoreactivities (p < 0.01) was found in the area of the mineralising tissue. Only VEGF immunoreactivity was significant between two groups (p < 0.01) in the fibrous tissue area. Conclusions: The area of mineralising tissue in the LIPUS-applied group expressed activity markers for osteocalcin, VEGF and TGF-β compared with a surrounding area of fibrous tissue. Cellular activation in the LIPUS group was greater than that of controls. Therefore, LIPUS may be accepted as a useful approach to enhance sutural bone formation.

Multiple Wormian bones and their relation with definite pathological conditions in a case of an adult cranium.

Wormian bones, also known as intrasutural bones, are present as an anatomical variation in healthy individuals. However, a higher than the usual incidence can be an important feature of some congenital pathological conditions. In this study we describe a case of an adult cranium with multiple Wormian bones. The cranium was a single sample obtained from an archaeological excavation in Vinitsa, Northeastern Bulgaria, and probably dated in the Chalcolithic. The Chalcolithic is a period of human history connected with discovering and using of copper. Actually, it is a transitional phase between the Neolithic and the Bronze Age. In this case the Wormian bones are mostly large in size and arranged in a mosaic pattern in several cranial regions. The cranium also shows features such as dolichocrany, a moderate platybasia, a notch in the posterior margin of the foramen magnum, hypoplastic and asymmetrical frontal sinuses, underdeveloped mastoid air cells, hyperostosis cranii interna, moderate frontal bossing, a complete metopic suture, a delayed sutural closure, relatively small facial bones, an early loss of teeth, dental caries and hypoplastic enamel defects on two preserved molars. Differential diagnosis indicates that the combination of all these features shows a link with pathological conditions involving dysplasias with prominent membranous bone involvement and an increased bone density such as cleidocranial dysplasia and pyknodysostosis.

Incidental finding of cleidocranial dysplasia in an adolescent with head trauma

Cleidocranial dysplasia (CCD) is a rare autosomal dominant skeletal disease. It is characterized by partial or complete absence of clavicles, late closure of fontanels, presence of open skull sutures and multiple wormian bones and various craniofacial and dental abnormalities. The majority of craniofacial abnormalities become obvious during adolescence. Early diagnosis with preventive measures for various associated complications helps improve the quality-of-life of the patient. We hereby report an incidental finding of CCD in a 16-year-old young adolescent male with blunt head trauma and review the clinical and radiological features and associated orthopedic, dental and ENT complications of this rare disorder.

Clinical and functional rationale for the use of intraosseous composite materials-covered screw retainers for mandibular fracture osteosynthesis

Aim. To increase the effectiveness of mandibular fracture osteosynthesis by using the composite materials-covered intraosseous screw retainers with active combined cutting edge. Methods. 282 patients with mandibular fractures were examined and operated in the clinic of Oral and Maxillofacial Surgery and Dentistry of Samara State Medical University from 2011 to 2013. Surgeries were performed in 257 (91.1%) patients, including plate osteosynthesis - in 133 (47.2%), intraosseous composite materials-coated screw retainers - in 42 (14.9%), uncoated pins - in 65 (23.0%), bone sutures - in 17 (6.0%). Orthopedic and other methods of bone fragments fixation were used in 25 (8.9%) patients. Proposed composite materials-coated osteosynthesis retainer is a square pin with cutting angle of 60-80° and 4 longitudinal grooves of 5-10 mm. The main part is a two-tier helical ribbon with alternating cutting portions, wherein some areas have the same diameter as the main part of the retainer, and the others are 20-100 microns thinner and are covered with TiC0, 65+25% Ca10(PO4)OH2. RESULTS. A comparative analysis with the traditionally used methods was carried out. The main advantages of the proposed method are rigid fixation of mandibular bone fragments and optimal osteogenesis in complex treatment of patients with trauma. Conclusion. The use of the proposed method of mandibular fractures surgical treatment using intraosseous screw retainers with bioactive coating reduced the risk of complications and the length of hospital stay.

A one month old infant misdiagnosed with parietal bone fracture and child abuse (922.3)

INTRODUCTION. A month‐old female infant was brought to the emergency room because she would not take in fluids. Her mother indicated the infant had a birth history of a traumatic brain injury stemming from a difficult instrumental delivery. A nurse assigned to care for the infant observed what appeared to be blood on the right ear. She immediately alerted the pediatrician on duty of a possible case of child abuse. The pediatrician concurred and ordered an anterior‐posterior chest radiograph and anterior posterior and lateral skull radiographs. RESULTS. The chest radiograph was interpreted by the hospital radiologist as being positive for fractures of the ribs and the skull radiographs as being positive for bilateral parietal bone fractures without soft tissue swelling. Three‐dimensional computerized axial tomography was then performed and interpreted as positive for bilateral parietal bone fractures. Although the infant was not in acute distress, she was hospitalized with the suspected diagnosis of child abuse. An outside radiologist was consulted finding no evidence of fractures and/or swelling over the sites dictated by the hospital radiologist. The outside radiologist found an anomalous parietal bone suture misinterpreted as the parietal bone fracture. CONCLUSIONS. The purpose of this presentation is not to review the division of the parietal bone but to inform physicians and health professionals that anomalous parietal bone sutures are rare and often misdiagnosed as fractures.

Inca Bone in Human Skulls of the West Anatolian Population

** * SUMMARY: The Inca bones are rarely seen among other inter sutural bones and are accepted as variants of the normal. The incidence of the Inca bones has been rese arched in different populations. The aim of this study was to investigate the rate and types of the Inca bones in West Anatolian population. One hundred fifty-one skulls of West Anatolian subjects of unknown ages and sex were e xamined. None of the specimens showed signs of prior cranial surgery, bony malformation or trauma. The skulls were classified as adults with teeth eruption. The Inca bones were macroscopically determined and analysed. The samples were photoghraphed with Canon 400B (55 mm objective). We follow previous criteria and nomenclatures of the Inca bones. The incidence of Inca bones of examined skulls was 1.98% (3/ 151). We observed 1 incomplete lateral asymmetric, 1 complete undivided and 1 complete asymmetric bipartita Inca bones. Inca os sicles are accessory bones found in human skulls due to ossification failure. Inca bones can be used in personal identification by com paring the ante- and post-mortem radiographs. There are some regional variations in frequencies within each restricted geographical area. In the present study, the incidence of the Inca bones is 1.98% in West Anatolian population. The frequency of the Inca bones in the sk ulls belonging to Hellenistic Roman periods of Cyprus and Constantinople in Natural History Museum of Turkey was 1.59%. The variatio n in Anatolia’s population at different times and regions, because of the migrations, may cause the differences between frequencies in these studies. Evaluation of the presence of the Inca bones may be usefull in identification in forensic medicine and paleodermograph ical studies.