Clinical observations of cleft lip and palate

Arch Symmetry in Patients Without and With Cleft Lip and Palate After Orthodontic/Rehabilitative Treatment-A Stereophotogrammetry Study

To evaluate and compare the dental arch symmetry of individuals with and without cleft lip and palate after orthodontic/rehabilitation treatment.

Cross-sectional study.

Tertiary cleft center in Brazil.

Fifty-five participants aged between 18 and 30 years were divided into 3 groups according to treatment. Patients that received either a fixed partial denture (FPD) or implant-supported crown (ISC) in the cleft area or only orthodontic treatment, noncleft patients (NC).

An analysis was performed using digitized dental casts scanned by laser and software. The following linear measurements were evaluated: incisor-canine; canine-molar; incisor-molar; surface and volume of the palatal region.

Three-way ANOVA was used to compare the study factors: group (FPD/ISC/NC) and side (right/left) followed by the Tukey test to verify their interaction (α = .05).

The results showed statistically significant differences among groups for the maxillary linear measurements canine-molar and incisor-molar, but not for incisor-canine. No statistically significant differences were found regarding the side for the maxillary measurements, while the factor interaction showed similarity only for incisor-canine. The mandibular measurements showed no statistical differences among groups, sides, or factor interactions. In surface and volume, all values in patients with cleft presented lesser than in without cleft patients.

Regardless of the rehabilitation, arch symmetry can be achieved in the incisor-canine dimension in the cleft area.

Arch Asymmetry in Patients With Cleft Lip and Palate After Rehabilitation Treatment Using Stereophotogrammetry

ABSTRACT

Arch asymmetry in cleft patients is a current problem that interdisciplinary treatment aims to solve. This research proposed to analyze the final rehabilitation, according to the arch symmetry of these patients. Thirty-five patients aged between 18 and 30 years, rehabilitated with a fixed partial denture or implants in the cleft area. The analysis was performed using digitalized dental casts with a laser model scanner (R700TM; 3Shape A/S, Holmens Kanal 7, 1060, Copenhagen/Denmark), analyzed with a Vectra Analysis Module software program (VECTRA H1; Canfield Scientific, 4 Wood Hollow Road, Parsippany, NJ 07054). Three linear measurements were evaluated, incisal-canine, canine-molar, and incisal-molar distance. The Student t test was applied to test the significance (P = 0.05) of an observed sample by correlation coefficient test (r-value). Female patients showed a significant correlation in arch symmetry. According to the rehabilitation treatment, patients who received implants showed a high correlation and significant symmetry at all maxillary distances. Finally, according to the cleft side in the maxillary dimensions, even though the majority of patients had clefts on the left side, only patients with a cleft on the right side showed symmetry in this area. Patients rehabilitated with implants in the cleft area showed a more symmetrical maxillary arch than those restored with fixed partial dentures.

Cephalometric analyses for cleft patients: a statistical approach to compare the variables of Delaire's craniofacial analysis to Bergen analysis

Objectives

Cephalometric analyses using lateral craniofacial radiographs are common diagnostic procedures for evaluating skeletal patterns. However, in patients with pronounced abnormalities like cleft lip and palate, standard cephalometric analyses and landmarks may not be suitable. This study aims to clarify whether the inclusion of landmarks less compromised by the cleft defect or located outside the cleft area results in a different cephalometric assessment of the viscerocranium. Delaire’s whole-skull analysis and Bergen analysis were examined for similarities and underlying common observations.

Materials/methods

Based on the cephalometric evaluation of 217 patients with different types of non-syndromal cleft formation, Delaire and Bergen analysis were compared using three statistical methods: correlation analysis, factor analysis, and cluster analysis. Reproducibility was assessed by Bland–Altman plots, intraclass correlation coefficients, mean absolute differences, and coefficients of variability.

Results

Although Delaire analysis and Bergen analysis are based on different concepts and landmarks, a majority of corresponding variables was found. Certain aspects of craniofacial base relation and craniospinal articulation are only assessed by Delaire analysis. All but one variable showed very good reproducibility.

Conclusions

The inclusion of landmarks less compromised by or located outside the cleft area does not result in variables that provide a different assessment of the viscerocranial area.

Clinical Relevance

The findings contradict the concept of invalidity of landmarks compromised by the cleft defect or located within the affected cleft area. Within the scope of its viscerocranial field of view, Bergen analysis appears to be on a par with Delaire analysis in the diagnosis of cleft patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04006-3.

WNT/β-catenin signaling plays a crucial role in myoblast fusion through regulation of nephrin expression during development

Skeletal muscle development is controlled by a series of multiple orchestrated regulatory pathways. WNT/β-catenin is one of the most important pathways for myogenesis; however, it remains unclear how this signaling pathway regulates myogenesis in a temporal- and spatial-specific manner. Here, we show that WNT/β-catenin signaling is crucial for myoblast fusion through regulation of the nephrin (Nphs1) gene in the Myog-Cre-expressing myoblast population. Mice deficient for the β-catenin gene in Myog-Cre-expressing myoblasts (Ctnnb1^F/F;Myog-Cre mice) displayed myoblast fusion defects, but not migration or cell proliferation defects. The promoter region of Nphs1 contains the conserved β-catenin-binding element, and Nphs1 expression was induced by the activation of WNT/β-catenin signaling. The induction of Nphs1 in cultured myoblasts from Ctnnb1^F/F;Myog-Cre mice restored the myoblast fusion defect, indicating that nephrin is functionally relevant in WNT/β-catenin-dependent myoblast fusion. Taken together, our results indicate that WNT/β-catenin signaling is crucial for myoblast fusion through the regulation of the Nphs1 gene.

The Dlx5-FGF10 signaling cascade controls cranial neural crest and myoblast interaction during oropharyngeal patterning and development

Craniofacial development depends on cell-cell interactions, coordinated cellular movement and differentiation under the control of regulatory gene networks, which include the distal-less (Dlx) gene family. However, the functional significance of Dlx5 in patterning the oropharyngeal region has remained unknown. Here, we show that loss of Dlx5 leads to a shortened soft palate and an absence of the levator veli palatini, palatopharyngeus and palatoglossus muscles that are derived from the 4th pharyngeal arch (PA); however, the tensor veli palatini, derived from the 1st PA, is unaffected. Dlx5-positive cranial neural crest (CNC) cells are in direct contact with myoblasts derived from the pharyngeal mesoderm, and Dlx5 disruption leads to altered proliferation and apoptosis of CNC and muscle progenitor cells. Moreover, the FGF10 pathway is downregulated in Dlx5^-/- mice, and activation of FGF10 signaling rescues CNC cell proliferation and myogenic differentiation in these mutant mice. Collectively, our results indicate that Dlx5 plays crucial roles in the patterning of the oropharyngeal region and development of muscles derived from the 4th PA mesoderm in the soft palate, likely via interactions between CNC-derived and myogenic progenitor cells.

TGFβ regulates epithelial-mesenchymal interactions through WNT signaling activity to control muscle development in the soft palate

Clefting of the soft palate occurs as a congenital defect in humans and adversely affects the physiological function of the palate. However, the molecular and cellular mechanism of clefting of the soft palate remains unclear because few animal models exhibit an isolated cleft in the soft palate. Using three-dimensional microCT images and histological reconstruction, we found that loss of TGFβ signaling in the palatal epithelium led to soft palate muscle defects in Tgfbr2(fl/fl);K14-Cre mice. Specifically, muscle mass was decreased in the soft palates of Tgfbr2 mutant mice, following defects in cell proliferation and differentiation. Gene expression of Dickkopf (Dkk1 and Dkk4), negative regulators of WNT-β-catenin signaling, is upregulated in the soft palate of Tgfbr2(fl/fl);K14-Cre mice, and WNT-β-catenin signaling is disrupted in the palatal mesenchyme. Importantly, blocking the function of DKK1 and DKK4 rescued the cell proliferation and differentiation defects in the soft palate of Tgfbr2(fl/fl);K14-Cre mice. Thus, our findings indicate that loss of TGFβ signaling in epithelial cells compromises activation of WNT signaling and proper muscle development in the soft palate through tissue-tissue interactions, resulting in a cleft soft palate. This information has important implications for prevention and non-surgical correction of cleft soft palate.

Evaluation of pterygomaxillary anatomy using computed tomography: are there any structural variations in cleft patients?

PURPOSE

Structural characteristics of the pterygomaxillary region in patients with cleft lip and palate (CLP) have not been fully investigated. This study aimed to evaluate the regional anatomy of the pterygomaxillary junction of patients with CLP using computed tomography.

MATERIALS AND METHODS

The pterygomaxillary structures of patients with unilateral or bilateral CLP were compared with those of a control group using axial computed tomography. The thickness and width of the pterygoid plate, the distance from the greater palatine foramen to the lateral pterygomaxillary junction, the lateral and medial pterygoid plate lengths, and the maxillary posterior transverse width were investigated with axial computed tomography just beneath the level of the inferior nasal concha and approximately 3 to 5 mm above the nasal floor. The difference between the cleft and noncleft sides or the right and left sides of each group and the measurement differences between the groups were statistically compared.

RESULTS

The study group was composed of 14 patients with unilateral CLP and 6 with bilateral CLP, and the control group were 20 age- and gender-matched patients with skeletal Class III without CLP. Patients with unilateral CLP and those with bilateral CLP were statistically equivalent for all radiographic variables. In patients with CLP, the width of the pterygomaxillary region and the greater palatine foramen region were on average 1.5 to 1.8 mm larger than in control patients (P < .05). Lateral pterygoid plate length and maxillary posterior transverse width were similar in the 2 groups. However, the patients with CLP showed a 2.3-mm shorter medial pterygoid length (P < .05).

CONCLUSION

Patients with CLP had larger and thicker pterygomaxillary dimensions, and the results imply that careful attention to pterygomaxillary anatomy is needed in patients with CLP undergoing Le Fort I surgery.

Experience with presurgical nasal molding in infants with cleft lip and nose deformity

BACKGROUND

Nasal deformity in infants with nasolabial clefts persists if it is not actively corrected. Some surgeons repair the nose simultaneously with the lip. Nonsurgical nasal molding with mechanical support performed in the early neonatal period has proved to be an effective alternative to surgical correction.

METHODS

At the author's institution, for the past 4 years, infants with nasal asymmetry have been treated by presurgical nasal molding performed with a stent fixed to a conventional passive orthopedic plate. The efficiency of this method was evaluated retrospectively using photographs obtained at least 1 year after lip repair. Sixteen pairs of children were studied. One child of each pair had received the treatment with the stent, and the other one had been treated using the classic method of presurgical orthopedics with no stent; the diagnosis and remaining therapy were the same for both children. Nine maxillofacial surgeons and 22 students of dental medicine were asked to decide which nose of each pair was more symmetrical.

RESULTS

Seventy-five percent of students and 70 percent of surgeons found that the nasal stent nose was more symmetrical than its classically treated counterpart. Statistical analysis of the results revealed highly significant agreement between the two groups of evaluators.

CONCLUSIONS

Children who underwent presurgical treatment with a nasal stent had more symmetrical noses several years after lip repair than children treated by the classic method of preoperative orthopedics. Use of the modified appliance did not present major problems for the parents, but their cooperation is necessary. Treatment should start as soon as possible after birth, regardless of the width of the cleft.

Midfacial morphology in children with unilateral cleft lip and palate treated by different surgical protocols

The purpose of this study was to compare cranio-facial, particularly midfacial morphology, in two groups of children with complete unilateral cleft lip and palate (UCLP) treated at two different cleft centres (Hannover. Germany and Brussels, Belgium) following different surgical treatment protocols. A total of 62 children (40 males; 22 females) with non-syndromic UCLP were included in this study at approximately the age of 10. The Hannover group comprised 36 children, who had repair of the lip at a mean age of 5.83 +/- 1.16 months, followed by repair of the hard and soft palate at a mean age of 29.08 +/- 4.68 and 32.25 +/- 4.29 months. respectively. The Brussels group consisted of 26 children who underwent surgical treatment according to the Malek protocol: the soft palate was closed at a mean age of 3.04 +/- 0.20 months, followed by simultaneous repair of the lip and hard palate at a mean age of 6.15 +/- 0.68 months. Midfacial morphology was evaluated by means of cephalometric analysis according to Ross. The children in the Hannover UCLP group did not differ significantly from those in the Brussels group in the anteroposterior dimension of the midface. However, the maxillary plane was significantly more open in the Brussels group due to less posterior vertical maxillary development.

Imaging of cartilage and mimic muscles with MRI: anatomic study in healthy volunteers and patients with unilateral cleft lip and palate

OBJECTIVE

The aim of the study was to visualize different soft tissues in the perioral, nasal, and paranasal region by means of magnetic resonance imaging (MRI) in patients with unilateral cleft lip and palate (UCLP).

DESIGN

In this descriptive study, images of different MRI systems were assessed and compared.

METHOD

MRI was applied in five consecutive patients operated on for UCLP who underwent secondary lip and nasal correction, two patients who had not had UCLP operations, and five healthy volunteers as controls. The mimic muscles, vessels, and nasal cartilages were evaluated.

RESULTS

It was possible to visualize different parts of the paranasal and perioral mimic muscles and their interlacement in the upper lip. The nasal cartilages were also visible, and the changes after operation were demonstrated.

CONCLUSIONS

MRI shows differentiated visualization of soft tissues in the cleft region and their changes after surgery. It is a valuable tool in the preoperative planning and postoperative follow-up in patients with UCLP.

Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate

Cleft lip and palate affects the child in many ways, particularly appearance, dental arch relationships, growth of the face, and speech development. The key to successful care is management in a multidisciplinary team adhering to a well-designed protocol, and careful audit of results. We present the intermediate outcome audit of 15 patients with complete bilateral and unilateral cleft lip and palate whose condition was managed in a multidisciplinary team according to a strict protocol. We give the results observations of operations of a single surgeon's functional primary surgery over a 6-year period in terms of dental arch relationships, cephalometric analyses, aesthetic assessments, and speech analysis. The results show good early facial growth, with dental arch relationships appropriate for the age and group; we found only minor speech discrepancies, with no patients requiring pharyngoplasty. The results show the importance of multidisciplinary management, the value of keeping to sound surgical protocols, and functional techniques in cleft lip and palate surgery. Our study includes the neglected group of children who have bilateral cleft lip and palate, and it conforms to the style of pan-European projects.

Current knowledge in cleft lip and palate treatment from an orthodontist's point of view

The aim of this review was to put new clinical research findings into proper perspectives relative to previously accepted knowledge on treatment of patients with cleft lip and palate. The first part of the paper deals with various aspects of infant orthopedic treatment, such as its influence on primary surgery, maxillary arch form and dimensions, feeding, psychological situation of the parents and speech development. Following parts analyze general maxillofacial growth outcome after surgery and also maxillofacial growth in relation to particular surgical procedures (palatal repair, periosteoplasty/gingivoplasty, bone grafting). The last part of the review discuss the effects of certain orthodontic/orthopedic treatment approaches as well as the role of dental implants in treatment of cleft lip and palate patients.

Growth sites and growth mechanisms at risk in cleft lip and palate

A newborn with some kind of facial cleft displays certain characteristics of the nose, upper lip, and jaw caused by abnormal influence on specific growth sites and growth mechanisms. Treatment, particularly surgery, attempts to counteract this aberrant development, for both functional and aesthetic reasons. However, not infrequently, therapy impedes future midfacial growth to a greater or lesser degree. To better understand the varying growth influence, this article aims to review certain aspects of growth of the middle third of the face in both normal and cleft subjects. The normal elongation of the maxilla, to give space for the molars, is usually not affected by lip surgery but rather by scar tissue from palatal repair. The displacement of the upper jaw in relation to the vomer is recognized. Early surgery should therefore avoid affecting the growth of the vomero-(pre)maxillary suture if possible. Periosteal growth, necessary for the development of dentoalveolar structures, might be affected by scar tissue from palatal repair. Different ways to reduce the development of palatal scars and their negative effects on growth are discussed.

Effect of primary surgery for cleft lip and palate on mid-facial growth

Surgery for cleft lip and palate is known to have an effect on growth and development of the mid-face. This paper studies the outcomes in 34 consecutive 10-year-old patients with unilateral cleft lip and palate. Clinical observations of the importance of both surgical technique and the influence of cranial base morphology on maxillo-mandibular position are discussed.

The management of soft tissue facial wounds

The physiological and physical principles involved in the management of facial lacerations are reviewed. Because there have been no previously published descriptions of the actual problems encountered in clinical practice in A & E Departments, a prospective clinical survey of 100 consecutive patients with facial lacerations repaired by oral & maxillofacial house surgeons was undertaken and a series of lacerations was studied in detail. These included periorbital, nasal, labial and neck injuries. High magnification revealed irregularity of wound margins in almost all cases, frequent localised ischaemia, necrosis, localised dehiscence and infection or inadequate closure. Because all of these problems are likely to increase scarring and deformity, this study suggests the need for a re-appraisal of the management of facial lacerations, particularly in relation to local skin edge excision, prevention of infection, and the use of magnification during closure.