Growth-related changes of skeletal and upper-airway features in bilateral cleft lip and palate patients

Comparison of Nasopharyngeal Airway Volume in Cleft Lip and Palate Patients With Normal Individuals Using Cone Beam Computed Tomography

This study aimed to compare nasopharyngeal airway volume in cleft lip and palate patients with normal individuals using Cone Beam Computed Tomography (CBCT). In this cross-sectional study, 40 CBCT scans of 9 to 12-years-old patients were enrolled and divided into 3 groups: normal individuals (n=16), unilateral cleft lip and palate (UCLP, n=14) and bilateral cleft lip and palate patients (BCLP, n=10). Superior and middle pharyngeal airway volumes and nasal width were measured and compared between 3 groups. ANOVA and χ 2 tests were used for statistical comparison. P <0.05 was considered significant. Superior airway volume was not significantly different between the 3 groups ( P =0.36). However, there was a significant difference between the 3 groups regarding middle pharyngeal volume ( P =0.49) and nasal width ( P =0.021). There was not a significant difference in the upper and middle pharyngeal volume and also nasal width between the 2 sexes. Considering different dimensions of evaluation of the pharyngeal airway volume of cleft lip and palate patients, the evaluation of airway volume is essential during orthodontic or orthognathic surgical treatments that expand or protect the maxilla.

Reconstruction of Oronasal Fistula with Tongue Flap: A Cleft Palate Report

Oronasal fistula can persist after conventional secondary alveolar bone graft surgery, which may lead to functional issues, such as regurgitation of fluids from the oral to the nasal cavity. This manuscript describes a clinical case of a patient with a bilateral cleft lip and palate that underwent tongue graft surgery for closure of an oronasal fistula after three failed local mucosa flap surgeries. The multidisciplinary treatment was comprised of orthodontic treatment, mucosa and alveolar grafts for palate closure and aesthetic rehabilitation of the anterior maxillary teeth. Smile aesthetics were noticeably improved, enhancing the patient’s self-perception and confidence.

Correction of a prominent premaxilla in a juvenile with a bilateral cleft lip and palate using a novel, hybrid function regulator, the FR-BCPPm, followed by preadjusted fixed appliances: A 20-year follow-up

A seven-year-old boy with a repaired bilateral cleft lip and palate, presented with a severe skeletal II base and an extremely prominent premaxilla. He had grossly incompetent lips with lower lip trapping, an 18.5-mm overjet, a deep overbite, markedly retroclined lower incisors, bilateral crossbites and 12-mm-wide alveolar gaps together with 6-mm vertical steps between the extruded premaxillary incisors and the posterior teeth. Before the eruption of the permanent canines, there was an urgency to approximate the opposing cleft alveolar margins and to level the split maxillary occlusal plane, in order to facilitate the successful insertion and subsequent consolidation of secondary alveolar bone grafts.A new functional appliance was therefore designed to achieve this objective, which drew components from Fränkel's FR I and FR III function regulators. Together with a couple of novel components, it created a hybrid appliance, namely the function regulator for juveniles with a bilateral cleft and a prominent premaxilla: the FR-BCPPm.The patient was treated with this appliance and a nocturnal headgear at 7-13 years, together with a concomitant quad helix appliance followed by a transpalatal arch and bilateral bone grafts. He was then treated non-extraction up to the age of 17 years with preadjusted fixed appliances to correct his residual, crowded Class II malocclusion.The marked improvement in his occlusion, dentofacial appearance and his perioral function after a decade of treatment was then followed up over 20 years, during which time mild relapse of the incisor overjet and moderate recurrence of the lower anterior misalignment was noted two years after treatment.While no further relapse was observed at the four-year post-treatment review, by 20 years after treatment, a little further misalignment of the lower anterior teeth was noted, half of which was deemed to be attributable to age-related maturation.

Pharyngeal airway space changes and stability following an extended LeFort-I osteotomy advancement in cleft lip and palate and non-cleft lip and palate patients: A long term comparison study

PURPOSE

The aim of this study was to evaluate effects of extended maxillary advancement osteotomy on pharyngeal airway space (PAS) in mid-facial deficient cleft lip and palate (CLP) patients and mid-facial deficient non-CLP patients.

METHODS

Pharyngeal airway space (PAS) of 10 CLP and 10 non-CLP patients with the mean age of 19 years 10 months was measured on digitized lateral cephalograms taken shortly before maxillary advancement operation with Quadrangular Le Fort I osteotomy (QLF-I) (T0), early post-operative, (T1) and long term post-operative (T2). Two way repeated analysis of variance, independent samples t-test and correlations tests were used for statistical analysis of airway and skeletal changes.

RESULTS

Total PAS depth and area was significantly increased after the advancement and was stable in long term post-operative period for CLP and non-CLP patients. Nasopharyngeal and velopharyngeal airway space depth and area was statistically increased at T1 and T2 for both groups. Oropharyngeal airway depth and area showed no significant statistical difference at any of the time points. The effect of QLF-I osteotomy on (PAS) was similar in both CLP and non-CLP patients.

CONCLUSIONS

Nasopharyngeal, velopharyngeal, and total pharyngeal airway space depth and area increased after maxillary advancement with the QLF-I osteotomy; this increase was stable in long term follow up. Maxillary advancement with the QLF-I technique had no significant effect on oropharyngeal airway space depth and area in both CLP and non-cleft patients.

Craniofacial Growth Analysis of Individuals With and Without Cleft Lip and Palate in Colombia

INTRODUCTION

Craniofacial growth is a dynamic and unpredictable process influenced by genetic and environmental factors, presenting phenotypic and gender differences.

OBJECTIVE

Evaluate the differences in craniofacial growth and development in a group of Colombian individuals with complete unilateral and bilateral cleft lip and palate (CLP) and without CLP, classified by gender and age.

SETTING AND SAMPLE POPULATION

Five hundred forty-one profile radiographs of 126 patients with unilateral CLP, 126 with bilateral CLP, and 289 without CLP. All patients of affected groups had a history of CLP correction surgery without nasoalveolar molding with orthopedic and orthodontic treatments.

MATERIALS AND METHODS

This cross-sectional study was performed comparing 8 cephalometric measurements on radiographs, 5 linear/3 angular. Analysis was performed by median and interquartile range for all cephalometric measurements. Comparison between the groups was performed using Kruskal-Wallis and Mann-Whitney U, with a 95% confidence.

RESULTS

Significant differences between the groups of patients with and without CLP, between types of clefts and genders. The skeletal structures of patients with CLP were smaller than those of control but improved with growth. Patients with unilateral CLP presented flat profiles and predominant class III malocclusions, while patients with bilateral CLP, at early ages, were class II and in the prepubertal stage, the values were progressively negative until the end of the growth period, suggesting class III. Patients with CLP presented posteroinferior rotation of the mandible, vertical measurements increased, and deflection of the cranial base.

CONCLUSION

Given their growth alterations, patients with CLP benefit from orthopedic and orthodontic treatment.

Skeletal Maturation in Patients With Cleft Lip and/or Palate: A Systematic Review

OBJECTIVE

The objective of this systematic review was to evaluate the evidence regarding skeletal maturation in patients with cleft lip and/or palate (CL/P) and to investigate whether the skeletal maturation is delayed in these patients.

DESIGN

Systematic review.

METHODS

Electronic and manual searches of scientific literature were conducted in 4 databases (MEDLINE, Embase, Cochrane Library, and Web of Science). Cohort studies that compared the skeletal maturation of patients with CL/P with that of children without CL/P were eligible for inclusion. The quality of included cohort studies was assessed using the Newcastle-Ottawa Scale.

PATIENTS AND PARTICIPANTS

Patients of any sex and ethnicity with CL/P and children without CL/P were included in this systematic review.

MAIN OUTCOME MEASURES

Difference in skeletal maturation between patients with CL/P and patients without CL/P.

RESULTS

Thirteen retrospective cohort studies were included in this systematic review. Ten studies were considered of high quality and 3 were considered of general quality. The results of the included studies comparing skeletal maturation of patients with CL/P and children without CL/P were heterogeneous.

CONCLUSION

Heterogeneity of skeletal maturation assessment methods, chronological age, sex, cleft type, and race may influence the final results of clinical studies on skeletal maturation in patients with CL/P. Overall, there is limited evidence to determine whether the skeletal maturation level of patients with CL/P is delayed compared to that of normal children. Further studies are needed to determine the skeletal maturation patterns in patients with CL/P.

Pharyngeal airway, hyoid bone, and soft palate changes after Class II treatment with Twin-block and Forsus appliances during the postpeak growth period

INTRODUCTION

This study aimed to compare cephalometrically the pharyngeal airway, hyoid bone, and soft palate (SP) changes after Class II malocclusion treatments using Twin-block (TWB) and Forsus Fatigue Resistant Device (FFRD) (3M Unitek Corp, 3M Dental Products, Monrovia, Calif) during the postpeak growth period.

METHODS

Forty-two patients with Class II malocclusion treated during the postpeak growth period were randomly and retrospectively included in this study. These patients were divided into 2 treatment groups: TWB and FFRD. The skeletal, dental, pharyngeal airway, hyoid bone position, and SP measurements were obtained from the lateral cephalometric radiographs taken at the beginning and at the end of the treatment. Paired-samples and independent-samples t tests were used for the intragroup and intergroup comparisons, respectively.

RESULTS

In the TWB group, the SNB (°), Md1-NB (mm), Md1-NB (°), and McNamara upper and lower pharyngeal airway dimensions significantly increased, whereas the ANB (°), AD1-Ba (mm), AD2-H (mm), adenoidal nasopharyngeal area, and SP angle decreased (P < 0.05). In the FFRD group, the SNB (°), Md1-NB (mm), Md1-NB (°), Ptm-Ba (mm), and McNamara upper airway dimensions significantly increased, whereas the ANB (°), AD2-H (mm), and interincisor angle decreased (P < 0.05). Moreover, there were statistically significant differences in the Md1-NB angles and SP thicknesses between the 2 groups (P < 0.05).

CONCLUSIONS

The effects of TWB and FFRD treatment on the airway during the postpeak growth period were similar. However, the FFRD caused a greater mandibular incisor protrusion.

Three-Dimensional Analysis of the Pharyngeal Airway Volume and Craniofacial Morphology in Patients With Bilateral Cleft Lip and Palate

OBJECTIVE

This study aimed to determine the correlations between the craniofacial morphology and pharyngeal airway volume in patients with complete bilateral cleft lip and palate (BCLP).

DESIGN

Retrospective study.

SETTING

Tertiary hospital.

PARTICIPANTS

Twenty-seven patients with complete BCLP and 27 class I control patients, aged 10 to 14 years.

MAIN OUTCOME MEASURE

The pharyngeal airway volume and craniofacial morphology were evaluated using cone-beam computed tomography. Measurements were compared between groups and any correlations were identified.

RESULTS

A significantly smaller total pharyngeal airway volume (TPV), oropharyngeal airway volume, and upper (UOPV) and lower (LOPV) oropharyngeal airway volume were found in patients with BCLP than in class I control patients, with no difference in the nasopharyngeal volume between groups. Furthermore, the craniofacial morphology measurements of N-Me, S-Go, Or-C, Ptm-C, Me-C, Co-Go, Go-Me, Ptm-Or, N-S-Ar, and Ar-Go-Me significantly differed between the BCLP and control groups (all P < .05). Multiple regression analysis indicated that Ptm-C and Me-C; Ptm-C, Or-C, and Me-C; and Me-C explained 20.3%, 38.9%, and 17.1% of the variations in TPV (P = .025), UOPV (P = .002), and LOPV (P = .018), respectively.

CONCLUSIONS

Total pharyngeal airway volume, TPV, OPV, UOPV, and LOPV were significantly smaller in patients with BCLP than in class I controls. In patients with BCLP, the maxilla showed inhibited sagittal development and a retrograde position; moreover, the pharyngeal airway volume was weakly associated with the position of the maxilla and mandible relative to the coronal plane.

Effects of the long-term use of maxillary protraction facemasks with skeletal anchorage on pharyngeal airway dimensions in growing patients with cleft lip and palate

Objective

To investigate the effects of the long-term use of a maxillary protraction facemask with miniplate (FM-MP) on pharyngeal airway dimensions in growing patients with cleft lip and palate (CLP).

Methods

The study included 24 boys with CLP (mean age, 12.2 years; mean duration of FM-MP therapy, 4.9 years), divided into two groups according to the amount of A point advancement to the vertical reference plane (VRP): Group 1, > 4 mm; Group 2, < 2 mm; n = 12/group. After evaluating the skeletodental and airway variables using lateral cephalograms acquired before and after FM-MP therapy, statistical analyses were performed.

Results

Group 1 showed greater forward and downward displacements of the posterior maxilla (posterior nasal spine [PNS]-horizontal reference plane [HRP]; PNS-VRP), greater increase in ANB, more forward tongue position (tongue tip-Pt vertical line to Frankfort horizontal plane), and greater increase in the oropharynx (superior posterior airway space [SPAS]; middle airway space [MAS]) and upper nasopharynx (PNS-adenoid2) than did Group 2. While maxillary advancement (A-VRP and PNS-VRP) correlated with increases in SPAS, MAS, and PNS-adenoid2, downward displacement of the PNS (PNS-HRP) correlated with increases in SPAS, MAS, PNS-adenoid1, and PNS-adenoid2, and with a decrease in vertical airway length (VAL). Mandibular forward displacement and decrease in mandibular plane correlated with increases in MAS.

Conclusions

FM-MP therapy had positive effects on the oropharyngeal and nasopharyngeal airway spaces without increases in VAL in Group 1 rather than in Group 2. However, further validation using an untreated control group is necessary.

Upper airway in children with unilateral cleft lip and palate evaluated with computational fluid dynamics

INTRODUCTION

Children with unilateral cleft lip and palate (UCLP) exhibit snoring and mouth breathing. They are also reported to show obstructive sleep apnea syndrome. However, their upper airway ventilation condition is not clearly understood. Therefore, this study was performed to evaluate upper airway ventilation condition in children with UCLP with the use of computational fluid dynamics.

METHODS

Twenty-one children (12 boys, 9 girls; mean age 9.1 years) with UCLP and 25 children (13 boys, 12 girls; mean age 9.2 years) without UCLP who required orthodontic treatment underwent cone-beam computed tomography (CBCT). Nasal resistance and upper airway ventilation condition were evaluated with the use of computational fluid dynamics from CBCT data. The groups were compared with the use of Mann-Whitney U tests and Student t tests.

RESULTS

Nasal resistance of the UCLP group (0.97 Pa/cm³/s) was significantly higher than that of the control group (0.26 Pa/cm³/s; P < 0.001). Maximal pressure of the upper airway (335.02 Pa) was significantly higher in the UCLP group than in the control group (67.57 Pa; P < 0.001). Pharyngeal airway (from choanae to base of epiglottis) pressure in the UCLP group (140.46 Pa) was significantly higher than in the control group (15.92 Pa; P < 0.02).

CONCLUSIONS

Upper airway obstruction in children with UCLP resulted from both nasal and pharyngeal airway effects.

Craniofacial Morphology in Patients With Opitz G/BBB Syndrome

OBJECTIVE

To compare the cephalometric characteristics of patients with and without Opitz G/BBB syndrome type I.

DESIGN

Cross-sectional, case-control study.

SETTING

Tertiary cleft center in Brazil.

PARTICIPANTS

Eighteen individuals with Opitz G/BBB syndrome with complete bilateral cleft lip and palate (BCLP), compared to 18 individuals with nonsyndromic complete cleft lip and palate and 18 individuals without malformations, matched for gender and age.

INTERVENTIONS

Pretreatment lateral cephalograms of all patients were manually traced and digitized for achievement of linear and angular measurements.

MAIN OUTCOME MEASURES

Analysis of variance or Kruskal-Wallis followed by Tukey tests were used for intergroup comparisons at a significance level of P < .05.

RESULTS

Individuals with Opitz G/BBB syndrome exhibited alterations in SNGn, P-Co, and N'-Pr/Po-Or that were not attributable to BCLP. Co-Go, Sella-Nasion-Supramentale, ANB (maxillo-mandibular relationship), and anterior nasal spine-posterior nasal spine (ANS-PNS)/U1A-U1T were significantly different in both G/BBB and BCLP groups compared to control, but not different between G/BBB and BCLP groups. Anterior nasal spine-posterior nasal spine/Go-Gn, ANS-PNS, V-Upper pharyngeal wall, and U-lower pharyngeal wall were different in nonsyndromic BLCP compared to nonsyndromic controls and Opitz G/BBB group.

CONCLUSION

Patients with Opitz G/BBB syndrome exhibited some unique cephalometric alterations compared to patients with nonsyndromic complete BCLP and controls.

The Electrical Activity of Masseter and Anterior Temporal Muscles in Patients With Unilateral Cleft Lip and Palate

This study aimed to determine the electrical activity of masseter and anterior temporal muscles in patients with unilateral cleft lip and palate (CLP) and compare it with healthy volunteers. The study involved 20 female patients (mean age 20 ± 4 years) with unilateral cleft lip and palate who had undergone lip and palate surgery in childhood and finished the first-phase orthodontic therapy with level and align teeth. Twenty age- and sex-matched volunteers with no cleft lip and palate were involved as controls. Electromyographic (EMG) signals of masseter and anterior temporal muscles were recorded at rest position, during swallowing and during maximum bite force (MBF). EMG signals at different test conditions were compared between the cleft and noncleft sides of CLP patients and between CLP patients and healthy individuals. The EMG potentials of masseter (rest, swallowing, MBF) and temporal (rest, MBF) muscles were significantly higher in the cleft than the noncleft side of CLP patients (P value <0.001). Generally, patients with unilateral cleft lip and palate experienced a significant increase in the electrical activity of the masseter and temporal muscles in both sides compared to the control group (P <0.05). In conclusion, patients with unilateral cleft lip and palate exhibit overall greater masticatory muscle activity compared to healthy individuals. The asymmetric masticatory function in subjects with unilateral cleft lip and palate may be associated with severe consequences such as asymmetric facial growth, implying the importance of early diagnosis and orthodontic treatment to achieve a favorable environment for balanced facial growth in CLP affected patients.

Upper airway features of unilateral cleft lip and palate patients in different growth stages

OBJECTIVES

To compare growth-related changes of skeletal and upper airway features of unilateral cleft lip and palate subjects (UCLP) with non-cleft control (NCC) subjects by using lateral cephalograms.

MATERIALS AND METHODS

The sample comprised 238 subjects, collected cross-sectionally, divided into 2 groups: 94 with UCLP, and 144 NCC, subdivided into 4 groups according to their growth stages by using cervical vertebral maturation stage (CVMS). The subgroups were defined as early childhood (stage 1), prepubertal (stage 2: CVMS I and II), pubertal (stage 3: CVMS III and IV), and postpubertal (stage 4: CVMS V and VI).

RESULTS

The maxilla was more retrognathic at stages 2, 3, and 4 in females with UCLP. The mandible was more retrognathic in UCLP at stage 1 in males, and stages 2 and 3 in females. ANB (angle between NA plane and NB plane) was significantly smaller in UCLP subjects at stage 4 for both sexes. A vertical growth pattern was seen in UCLP subjects except males at stages 2 and 3, and females at stage 2. Posterior airway space was significantly narrower at all stages in males and after stage 1 in females. Middle airway space was significantly wider at all stages in females and after stage 1 in males. Epiglottic airway space was significantly narrower in males at stage 3.

CONCLUSIONS

Age- and sex-dependent differences in skeletal morphology and upper-airway widths of the UCLP subjects were identified when compared with controls.

Upper airway asymmetry in skeletal Class III malocclusions with mandibular deviation

The purpose of this study was to investigate the relationship between bilateral differences of upper airway and mandibular morphologic patterns in subjects with skeletal Class III mandibular deviation. 47 skeletal Class III (ANB < 0°) adult patients with and without mandibular deviation were divided into 2 groups. Bilateral differences of minimum cross-sectional area, mean cross-sectional area, volume of subdivisions (nasopharynx, palatopharynx, glossopharynx, hypopharynx) were assessed paired t test. Stepwise linear regression analysis and Pearson correlation coefficients were computed between a significant pair of upper airway variables and a pair of mandibular deviation variables to examine the quantitative relationship between the upper airway asymmetry and mandibular deviation. The mean cross-sectional area and the volume of palatopharynx on the deviated side in mandibular deviated group was significantly smaller than non-deviated side. The asymmetry index of the palatopharyngeal volume showed significant correlations with CRA asymmetry (r = 0.49) and Ramus asymmetry (r = 0.54). However, in the glossopharyngeal and hypopharyngeal segment, the mandibular deviated group showed significant asymmetry, characterized by larger mean cross-sectional area and volume in deviated side. The asymmetry index of the glossopharyngeal volume and hypopharyngeal volume showed significant correlations with CRA asymmetry (r = 0.42), Me-s (r = 0.72) and Me-s (r = 0.67) respectively.