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Trephination of the skull is an old surgical procedure practised in both the Old and New Worlds from the Neolithic period 7,000 years ago up to the present. Four methods (scratching, cutting, drilling and circling) were used for therapeutic or ritual (magical) reasons, predominantly in older males. The survival rate was between approximately 25% and 75%, the drilling and especially cutting being most dangerous. Macroscopic, CT and histopathological examination of three trephined skulls from the collection of Hrdlicka's Museum of Man, Charles University, revealed two types of bone defect. In the first type the margin of the defects was covered by the cortical bone of identical structure as the cortical bone on the inner and outer surface of the surrounding skull bones. These cases probably represent defects that healed in living persons for a long time, and consequently new cortical bone developed (skull No. 1). However, congenital origin of defects of this type cannot be excluded. The second type of defects, without cortical bone cover at the hole margin, could be caused by trauma in the post mortem period or may have been performed during the people's lifetimes--if they died shortly after their skull damage, so the healing period was too short for the formation of new cortical bone (skull No. 2 and 3).

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Norms of the motion of the joints of the adult hand are presented. Examined were 100 males and 100 females aged 20-25 years. All of them were university students in whom the hand was not affected by work or other one-sided activities and so its motion could be considered as the optimal (left-handed students were not included in this series). The passive and active flexions and hyperextensions were measured in all fingers of both hands as well as in the wrist. In the latter were measured in addition both active ductions. The results may serve for an assessment of deviations in joint motion of the hand in inborn malformations and other diseases, sequelae of injuries, during rehabilitation and evaluation of the effect of working and other manual activities etc. Differences in motion of the individual joints of the same type and differences between the right and the left side and both sexes were assessed as well.

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Roentgencephalometry was used for the assessment of the development of clinically important facial characteristics in complete unilateral cleft lip and palate during the prepubertal and pubertal period. Thirty-one patients aged 8 and 11 years and 30 patients aged 11 and 14 years were examined repeatedly. All of them were operated upon and orthodontically treated with the same methods. An unfavorable development of facial convexity, sagittal jaw relations, configuration of the soft profile, and of the prominence of the upper lip occurred during both periods. An improvement of overjet that was attained during the prepubertal period showed a renewed impairment during the period of puberty. The impairment was not caused by the higher facial growth rate, but was attributable to the exhaustion of the compensation and adaptation mechanisms of the dentoalveolar component of the upper jaw produced by the preceding orthodontic therapy. The development of sagittal jaw relations and of facial rotation was not related to the initial patterns of these characteristics, but the possibility of an improvement of the inclination of upper incisors and of overjet was influenced by their initial pattern. During the prepubertal period the development of overjet was not related to the development of sagittal jaw relations or of mandibular growth rotation, as was the case during puberty.

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On the basis of an assessment of cranial anteroposterior X-ray films in 38 normal adult males were analyzed facial asymmetries at the frontal plane. It was demonstrated that facial asymmetries are of a fluctuating type with the slightest asymmetries in the region of the upper face, somewhat larger deviations of mandibular characteristics and with most marked asymmetries in the region of the cranial vault. Thus neither of the two sides of the face predominates significantly over the other side. The differences are only of individual character.

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The length of the cervical spine in a series of 206 adult males with cleft lip and/or palate and 50 normal controls was measured. The patients were divided into five subgroups according to the type and extent of the cleft. The shortening of the spine was most marked in bilateral cleft lip and palate patients (complete), less marked in unilateral cleft lip and palate patients, and was slight in isolated cleft palate patients. Complete isolated cleft palate and cleft lip was not associated with a shortening of the spine. A shortening of the cervical spine in less extensive types of isolated cleft palate was suggestive of the participation of the spine in their development, while in cleft lip and palate a simultaneous exposure to a teratogenic agent or any other developmental error during early stages of embryogenesis could explain the concomitant occurrence of spine anomalies. Patients with cleft lip and palate associated with a short spine also had a shorter mandibular ramus, which could be suggestive of simultaneous damage to both structures during morphogenesis. This relationship was not demonstrated in isolated cleft palate that developed in later stages of embryogenesis. In these cases a short spine itself could not have impaired the growth potential of the mandible, yet it could have mechanically induced the development of cleft palate. These observations are in agreement with the present state of knowledge on the development of orofacial clefts as shown in experimental animals.

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Roentgen-cephalometric studies were carried out in 26 adult males with complete bilateral cleft lip and palate. They were subdivided two times in two subgroups, with and without premaxillary setback, and with and without prolongation of the columella. The subgroups were compared mutually, as well as with a group of controls including 50 males matched in age. Premaxillary setback during childhood resulted in a more marked retrusion of the maxilla in adulthood. A simultaneous slighter oral slope of the premaxilla led to a normalization of the upper face height. Skeletal deviations acted on the configuration of the soft profile, in particular of the nasolabial transition: the slope of the columella towards the profile was reduced and so was the nasolabial angle. Thus the region appeared more markedly sunken. This surgical procedure should be used only in an exceptional situation in a small or posteriorly rotated mandible. Prolongation of the columella resulted in an excessive nasal depth. This was not caused by an adequate elevation of the tip of the nose which corrected a flattening of the tip, but rather by the sunken upper lip. An unfavourable effect exerted also a larger deepening of the nasolabial transition after a prolongation of the columella. However a slighter prolongation of the columella did not allow a sufficient elevation of the nasal tip. It is therefore necessary to seek a compromise.

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For analysis of facial asymmetry (signed, absolute, relative) a group of 720 normal children aged 6-18 years was examined. Twelve direct dimensions measured on both sides of the face were assessed. The results revealed that the extent of facial asymmetry is the same in both sexes and does not change with age. Facial asymmetries have mostly a fluctuating character, usually with slight predominance of the right side. With the help of double standard deviations of signed asymmetry, the range of normal asymmetry for lateral facial dimensions was determined as 4-5 mm. The definition of the borderlines or normal and abnormal asymmetries may be of practical value in some medical disciplines.

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Mixed longitudinal and cross-sectional roentgen-cephalometric data were used for studies of the growth and development of the face in unilateral complete cleft lip and palate from the time of primary palatoplasty up to adulthood. The results were compared with the data obtained in controls at the age of 5 years and in adults. The vertical growth of the upper and lower face exceeded its sagittal growth. The lower face showed a higher growth rate in both directions than did the upper face. The depth of the maxilla showed the lowest growth rate. The height of the upper lip increased very little as well. The most important deviation in facial development consisted of the deficient growth of maxillary depth and the prolongation of the lower face. Both these deviations develop predominantly after palate surgery and the former resulted in a gradual retrusion of the maxilla, a flattening of the face, and impairment of sagittal jaw relations. The reduction of upper face height, the posterior position of the maxilla, and the shortening of the mandible (both of the body and ramus) represented, on the contrary, early changes. The a persisting posterior rotation of the mandible, changes in the shape of the mandible, and vertical disproportion of the face increased with age, the steep slope of the mandibular body remaining at the level ascertained in early childhood. An improvement in the occlusion of incisors was obtained prior to the age of 12 years, but it regressed during the period of puberty. The prominence of the upper lip gradually decreased and the lip was short.

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X-ray cephalometric studies were carried out in 114 adult males with cleft lip and with or without cleft palate. According to the type and extent of the cleft they were subdivided into 4 groups and were compared with a control group of 50 normal males matched in age. Investigated were the parameters of the skeletal and soft facial profile. The results showed that cleft lip alone is associated with deviations of local character concerning only soft tissues within the oronasal region. The ascertained deviations included a flattening of the nose, reduction of the height, concavity and prominence of the upper lip, increased height of the upper lip vermilion and a more horizontal slope of the columella leading to a reduction of the nasolabial angle. Cleft lip and palate was associated with deviations of global character related predominantly to the extent of retrusion of the upper and lower jaw. The skeletal profile was altered and its deviations were reflected by changes of the soft profile. Of the deviations of soft tissues per se were most important the flattening of the nose and reduction of the height and thickness of the upper lip, which underlined the presence of retrocheilia. Maxillary retrusion was more marked in complete than in incomplete unilateral clefts, while mandibular retrusion and maxillary dentoalveolar retroinclination were more marked in bilateral than in unilateral clefts. Occlusion was always impaired. In unilateral involvement, especially in complete clefts the more horizontal slope of the columella resulted in a marked reduction of the nasolabial angle. Incomplete clefts, similarly as cleft lip alone were not associated with a reduction of thickness of the upper lip and showed an increase of the vermilion height. Because of the persisting protrusion of the premaxilla bilateral clefts were accompanied by only a slight flattening of the skeletal profile and by an excessive nasal depth after the prolongation of the columella. The nasolabial angle was unchanged. The concavity of the upper lip was reduced in complete unilateral and bilateral clefts. Certain characteristics of the oronasal region disclosed a similarity between incomplete cleft lip and palate (in unilateral involvement) and cleft lip alone, however global deviations (due to skeletal changes) were identical with those recorded in complete clefts.

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X-ray cephalometry was used for the assessment of the configuration of the skeletal and soft tissue profile in 81 adult males with isolated cleft palate. They were assessed in three subgroups, i. e. with complete and incomplete clefts and with clefts of the soft palate alone and were compared with a matched group of controls consisting of 50 normal males, as well as with the situation in the earlier examined series with unilateral cleft lip and palate. In isolated cleft palate both the upper and lower jaws were retruded. The maxilla was most markedly retruded in incomplete clefts and most slightly in clefts of the soft palate alone, while the mandible showed the smallest degree of retrusion in complete clefts. The configuration of the skeletal profile was similar as in unilateral cleft lip and palate, yet positive overjet was on the average restored in all types of isolated cleft palate. A more favourable configuration of the profile was present in patients with cleft soft palate alone, in the absence of an impairment of sagittal jaw relations. Changes in the configuration of the soft profile were due mainly to skeletal deviations. The retrusion of skeletal framework of the middle face was to a large degree masked by the larger thickness of the upper lip, in complete clefts also of the lower lip. Therefore the prominence of the upper lip was only slightly impaired and slight flattening of the face occurred only in complete clefts. The more horizontal slope of the columella resulted in a reduction of the nasolabial angle. Some deviations from the described pattern occurred in clefts of the soft palate alone (steeper slope of the upper lip with an unchanged nasolabial angle, normal thickness of the upper lip a. o.). The findings are suggestive of a differing facial physiognomy in isolated cleft palate.

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Roentgencephalometry was used for the assessment of the growth and development of the face during prepubertal and pubertal periods in children with complete unilateral cleft lip and palate treated with the same methods. The first series included 16 boys and 15 girls, the second series consisted of 15 boys and 15 girls examined repeatedly at the beginning and at the end of the follow-up period. There were no definite differences in the growth rate of the face between the two periods of age. Therefore, the deterioration of overjet during puberty could be due to the depletion of the compensation and adaptation mechanisms after the previous orthodontic treatment rather than to the enhanced growth rate. As compared to other facial dimensions a lower growth rate showed during both periods the length of the anterior base, the depth of the maxilla and in particular the height of the upper lip. Developmental changes of variables of shape and position proceeded similarly during both periods of age. An exception represented the rotation of the mandible and the inclination of upper incisors. During the prepubertal period the lower jaw showed a very slight posterior rotation, while during puberty an anterior growth rotation was present. A rapid improvement of the proclination of upper incisors was attained only during the prepubertal period. It was accompanied by an improvement of overjet. However, during the period of puberty there was a renewed deterioration of overjet. A marked retrusion of the maxilla developed already in the prepubertal period. During both periods occurred an identical impairment of sagittal jaw relations and of the upper lip prominence, accompanied by a flattening of the facial profile and reduction of the nasolabial angle. The prominence of the nose increased, the angle of the cranial base remained unchanged. Intersexual differences were not demonstrated in any studied characteristics.

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Mixed-longitudinal roentgencephalometric data were used for the determination of differences between the configuration and development of the face in complete and incomplete unilateral cleft lip and palate at the age of 8 to 12 years. As compared to incomplete clefts patients with complete clefts had a reduced height of the upper face and thus also of the face as a whole and an increased width of the nasal cavity. These findings were in agreement with the situation in adults, but contrary to adults we failed to disclose any difference in the depth of the maxilla and thus there were also no differences of the retrusion of the upper jaw, sagittal jaw relations, facial convexity, occlusion of incisors and the prominence of the upper lip. The thickness of the upper lip did not differ as well. The global results showed that the differences between facial configuration in these two types of clefts were much smaller up to the onset of puberty than in adults. Throughout the investigated period of time the growth and development of the investigated parameters proceeded identically in both forms of clefts. The reduction of upper face height in complete clefts confirmed an early, probably prenatal origin of this deviation from normal.

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A morphometric assessment of the nasopharynx was carried out on 194 X-ray films of adult males with cleft lip and/or palate. According to the type and extent of the cleft they were subdivided into seven groups and compared with a control group of 50 normal males matched in age. The findings showed a reduction of the nasopharyngeal airway in all groups with cleft palate, which corresponded to the decrease in depth of the nasopharyngeal bony framework without participation of soft tissues. In cleft lip and palate the decrease was due exclusively to the posterior displacement of the maxilla, in isolated cleft palate it was due to several factors and was less marked. The height of the bony nasopharynx and the thickness of the nasopharyngeal posterior wall tissues remained unchanged in all types of clefts. In cleft palate the length of the velum was always reduced with a slighter reduction of the height of the body of the sphenoid bone. No changes were found in cleft lip alone. Pharyngeal flap surgery failed to influence the anteroposterior position of the maxilla or nasopharyngeal parameters. The length of the soft palate was not changed after this procedure, but the velum was displaced in posterior direction and its distance from the pharyngeal posterior wall was significantly reduced. The reduction was so marked that it could limit the air flow capacity of the airways. In individuals without pharyngeal flap surgery the velum was displaced in the anterior direction and its position could be influenced by the pushback of the mandible.

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The method of multiple correlations was used to assess the interrelations between basic characteristics of the facial bony framework and the cranial base. The study was based on x-ray measurements in 50 normal adult males, and the result disclosed the extent to which the variability of the investigated characteristics was determined by the variability of several combined facial parameters. The characteristics of shape and position of individual facial structures were more closely interrelated than characteristics of size. The lowest degree of association was shown by the parameters of the cranial base, which confirmed its independent development. The highest degree of interrelations was shown by the parameters of shape and position of the lower jaw, which characterized the marked adaptation and compensation capacity of the mandible. Some of these relations were causal. The present findings could be useful in orthodontic therapy and during anthropologic reconstructions.

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Lateral X-ray films of the skull obtained in 50 normal adult males were used for studies of correlations between 26 characteristics of the size, shape, and position of the face and nine characteristics of the neurocranium in all mutual combinations. The results disclosed that the relations between individual cranial components were regulated by certain principles. The correlations between size dimensions were mostly slight; a closer relationship showed some characteristics of the shape and position. The most important variable exerting an effect on the configuration of the skull as a whole represented the angle of the cranial base which produced the rotation of the neurocranium and the face and thus acted on a series of other correlations. Of some importance as well was the length of the mandibular ramus acting on the shape and position of the lower jaw and on the vertical maxillomandibular relations. The close relationship between the anteroposterior position of both jaws was due to compensation mechanisms rather than to the identical size of both jaws. On normalization of the disturbed saggital jaw relations, the dentoalveolar components of both jaws as well as the subalveolar component of the mandible participated equally. In vertical direction the lower face showed a certain developmental independence. The discussed interrelations formed the basis for studies of the mechanisms regulating the intracranial development and the changes occurring in various anomalies, as well as for understanding the compensation and adaptation abilities of individual cranial components.

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