Hard palate-repair technique and facial growth in patients with cleft lip and palate: a systematic review

Intraoral Scanning Evaluation of Maxillary Arch Changes after Modified Sommerlad Palatoplasty for around Three Years

BACKGROUND

The purpose of this study was to investigate dental arch changes after modified Sommerlad palatoplasty in patients with cleft palate by intraoral scanning technique in children with early deciduous dentition.

METHODS

This study included 60 patients with nonsyndromic unilateral complete cleft lip with palate or cleft palate only treated by modified Sommerlad palatoplasty without relaxed excision before 18 months of age and 95 healthy controls without cleft. Three-dimensional images of the maxillary dental arches of all participants at age 3 to 4 years were obtained by intraoral scanning technique. Seven parameters (anterior dental arch width, middle dental arch width, posterior dental arch width, anterior palatal arch width, posterior palatal arch width, anterior dental arch length, and entire dental arch length) were measured.

RESULTS

Compared with the male group, the posterior palatal arch width distance of controls in the female group decreased significantly ( P = 0.039), and the middle dental arch width, posterior dental arch width, and posterior palatal arch width distance of female patients decreased ( P = 0.013, P = 0.002, P = 0.005, respectively). The anterior dental arch length and entire dental arch length distance of children in the unilateral complete cleft lip with palate group was shorter than those of children with cleft palate only ( P < 0.0001, P < 0.0001, respectively). The patient group showed decreased distance of anterior dental arch width, anterior palatal arch width, anterior dental arch length, and entire dental arch length, and increased distance of posterior dental arch width and posterior palatal arch width compared with the control group ( P = 0.0002, P = 0.002, P < 0.0001, P < 0.0001, P = 0.007, P = 0.027, respectively).

CONCLUSION

The results indicated that the modified palatoplasty group showed no growth inhibition in the middle or posterior dental arch width, or palatal arch width, but slight but significant inhibition in the length of the anterior and entire dental arch.

CLINICAL QUESTION/LEVEL OF EVIDNCE

Therapeutic, IV.

Two-stage palatal repair in non-syndromic CLP patients using anterior to posterior closure is associated with minimal need for secondary palatal surgery

OBJECTIVE

The aim of the present study was to assess the need for secondary palatal corrective surgery in a concept of palate repair that uses a protocol of anterior to posterior closure of primary palate, hard palate and soft palate.

METHODS

A data base of patients primarily operated between 2001 and 2021 at the Craniofacial and Cleft Care Center of the University Goettingen was evaluated. Cleft lips had been repaired using Tennison Randall and Veau-Cronin procedures in conjunction with alveolar cleft repair. Cleft palate repair in CLP patients was accomplished in two steps with repair of primary palate and hard palate first using vomer flaps at the age of 10-12 months and subsequent soft palate closure using Veau/two-flap procedures 3 months later. Isolated cleft palate repair was performed in a one-stage operation using Veau/two-flap procedures. Data on age, sex, type of cleft, date and type of surgery, occurrence and location of oronasal fistulae, date and type of secondary surgery performed for correction of oronasal fistula (ONF)and / or Velophyaryngeal Insufficiency (VPI) were extracted. The rate of skeletal corrective surgery was registered as a proxy for surgery induced facial growth disturbance.

RESULTS

In the 195 patients with non-syndromic complete CLP evaluated, a total number of 446 operations had been performed for repair of alveolar cleft and cleft palate repair (Veau I through IV). In 1 patient (0,5%), an ONF occurred requiring secondary repair. Moreover, secondary surgery for correction of VPI was required in 1 patient (0,5%) resulting in an overall rate of 1% of secondary palatal surgery. Skeletal corrective surgery was indicated in 6 patients (19,3%) with complete CLP in the age group of 15 - 22 years (n = 31).

CONCLUSIONS

The presented data have shown that two-step sequential cleft palate closure of primary palate and hard palate first followed by soft palate closure has been associated with minimal rate of secondary corrective surgery for ONF and VPI at a relatively low need for surgical skeletal correction.

Most Efficient and Meaningful Patient-Reported Appearance Assessment in Different Cleft Types and Age Groups with CLEFT-Q

BACKGROUND

The CLEFT-Q, a questionnaire developed and validated specifically for cleft patients, contains seven appearance scales. The International Consortium of Health Outcomes Measurement (ICHOM) has incorporated only some CLEFT-Q appearance scales in the Standard Set to minimize burden. This study evaluates which appearance scales provide the most meaningful information in the different cleft types at specific ages, for the most efficient cleft appearance outcome assessment.

METHODS

Within this international multicenter study, outcomes of the seven appearance scales were collected, either as part of the ICHOM Standard Set, or as part of the field test study performed to validate the CLEFT-Q. Analyses were performed in separate age groups and cleft types, and involved univariate regression analyses, trend analyses, t tests, correlations, and floor and ceiling effects.

RESULTS

A total of 3116 patients were included. Scores for most appearance scales showed a downward trend by age group, with the exception of the Teeth and Jaw scales. In all cleft types, several scales correlated strongly with each other. No floor effects were observed, but ceiling effects were found in several scales in different age groups, most often in the CLEFT-Q Jaw scale.

CONCLUSIONS

A proposition for the most meaningful and efficient appearance outcome assessment in cleft patients is made. It was composed so that recommendations are of value for different cleft protocols and initiatives. Suggestions for the use of scales in the ICHOM Standard Set at different ages are given, and also from a clinical perspective. Use of the CLEFT-Q Scar, Lips, and Nose scales will provide additional relevant information.

Impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate: a preliminary comparative study

OBJECTIVE

To estimate the impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate.

STUDY DESIGN

A Retrospective Cohort Study.

METHODS

A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate underwent primary palatoplasty (30 patients received the Sommerlad-Furlow modified technique without relaxing incision (S.F-RI group), and 30 received Sommerlad-Furlow modified technique with relaxing (S.F+RI group) with no significant difference found between them regarding the cleft type, cleft width, and age at repair. While the other 30 were healthy noncleft participants with skeletal class I pattern as a Control group. The control group (C group) was matched with the patient groups in number, age, and sex. All participants had lateral cephalometric radiographs at least 5 years old age. The lateral cephalometric radiographs were taken with the same equipment by the same experienced radiologist while the participants were in centric occlusion and a standardized upright position, with the transporionic axis and Frankfort horizontal plane parallel to the surface of the floor. A well-trained assessor (S. Elayah) used DOLPHIN Imaging Software to trace twice to eliminate measurement errors. All the study variables were measured using stable landmarks, including 12 linear and 10 angular variants.

RESULTS

The mean age at collection of cephalograms was 6.03 ± 0.80 in the S.F+RI group, 5.96 ± 0.76 in the S.F-RI group, and 5.91 ± 0.87 in the C group. Regarding cranial base, the results showed no statistically significant differences between the three groups in S-N and S-N-Ba. While the S.F+R.I group had a significantly shortest S-Ba than the S.F-R.I & C groups (P = 0.01 & P < 0.01), but there was no statistically significant difference between S.F-R.I & C groups (P = 0.71). Regarding the skeletal maxilla, there was no significant difference between the S.F+R.I and S.F-R.I groups in all linear measurements (N-ANS and S-PM) except Co-A, the S.F+R.I group had significantly shorter Co-A than the S.F-R.I & C groups (P =  < 0.01). While the angular measurement, S.F+R.I group had significantly less SNA angle than the S.F-R.I & C groups (P =  < 0.01). Regarding mandibular bone, there were no statistically significant differences in all linear and angular mandibular measurements between the S.F+R.I and S.F-R.I.groups. Regarding intermaxillary relation, the S.F+R.I group had significant differences in Co-Gn-Co-A and ANB compared to the S.F-R.I & C groups (P =  < 0.01). While there was no statistically significant difference in PP-MP between the three groups.

CONCLUSION

As a preliminary report, the Sommerlad-Furlow modified technique without relaxing incisions was found to have a good maxillary positioning in the face and a satisfactory intermaxillary relationship compared to the Sommerlad-Furlow modified technique with relaxing incisions.

A comparison of maxillofacial growth in Chinese children with isolated cleft palate treated with two different palatoplasty techniques without relaxing incisions: a preliminary study

OBJECTIVE

To assess the maxillofacial growth of patients with isolated cleft palate following the Sommerlad-Furlow modified technique and compare it with the effect of the Sommerlad technique.

STUDY DESIGN

A Retrospective Cohort Study.

METHODS

A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate (ISHCP) underwent primary palatoplasty without relaxing incision (30 patients received the Sommerlad-Furlow modified (S-F) technique and 30 received Sommerlad (S) technique). While the other 30 were healthy noncleft participants with skeletal class I pattern (C group). All participants had lateral cephalometric radiographs at least 5 years old age. All the study variables were measured by using stable landmarks, including 11 linear and 9 angular variants.

RESULTS

The means age at collection of cephalograms were 6.03 ± 0.80 (5-7 yrs) in the S group, 5.96 ± 0.76 (5-7 yrs) in the S-F group, and 5.91 ± 0.87 (5-7 yrs) in the C group. Regarding cranial base, the results showed that there were no statistically significant differences between the three groups in S-N and S-N-Ba. The S group had a significantly shortest S-Ba than the S-F & C groups (P = 0.01), but there was no statistically significant difference between S-F and C groups (P = 0.80). Regarding skeletal maxillary growth, the S group had significantly shorter Co-A, S- PM and significantly less SNA angle than the C group (P =  < 0.01). While there was no significant difference between S-F & C groups (P = 0.42). The S group had significantly more MP-SN inclination than the C group (P =  < 0.01). Regarding skeletal mandibular growth, there were no statistically significant differences in all linear and angular mandibular measurements between the three groups, except Co-Gn of the S group had a significantly shorter length than the C group (P = 0.05). Regarding intermaxillary relation, the S-F group had no significant differences in Co-Gn-Co-A and ANB as compared with the C group. The S group had significantly less ANB angle than S-F & C groups (P = 0.01 & P =  < 0.01). In addition, there were no significant differences in all angular occlusal measurements between the three groups.

CONCLUSION

As a preliminary report, Sommerlad-Furlow modified technique showed that maxillary positioning in the face tended to be better, and the intermaxillary relationship was more satisfactory than that in Sommerlad technique when compared them in healthy noncleft participants.

Comparison of Maxillofacial Morphology Between Modified Furlow's and Modified two-Flap Palatoplasty in Orofacial Clefts During the Primary Dentition Period

OBJECTIVE

To assess the effect of two palatoplasty procedures, modified Furlow's palatoplasty (F procedure) and modified two-flap palatoplasty (T procedure), on the maxillofacial morphology of unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) during the primary dentition period.

DESIGN

Retrospective cohort study.

SETTING

Department of Orthodontics, School of Dentistry, Showa University.

PARTICIPANTS

We enrolled 106 pediatric patients (63 boys, 43 girls; aged 4.43  ±  0.34 years) with non-syndromic orofacial clefts who underwent cheiloplasty and palatoplasty.

INTERVENTIONS

Patients were divided into four groups according to cleft type (BCLP or UCLP) and palatoplasty procedure type (F or T procedure).

MAIN OUTCOME MEASURES

Maxillofacial morphology was assessed by examining parameters on lateral cephalograms.

RESULTS

Multiple comparisons revealed significant differences among N-A, N-ANS, and ANS-PNS distances and SNA and ANB angles among the groups. There were significant differences in N-A, N-ANS, ANS-PNS, SNA, and SNB among the UCLP and BCLP groups. The calculated effect sizes were all within 0.3-0.5. The statistical power was as follows: N-A, 86.41%; N-ANS, 79.77%; ANS-PNS, 97.49%; SNA, 96.88%; and ANB, 99.25%.

CONCLUSIONS

Although UCLP and BCLP both exhibited differences in craniofacial distances and angles, the procedure type (either F or T procedure) had no significant effect on the maxillofacial morphology (as determined by lateral cephalograms). However, to rule out additional bias, patient-specific factors should be considered that may be affected by maxillofacial development when deciding surgical approaches.

Favorable Transverse Maxillary Development after Covering the Lateral Raw Surfaces with Buccal Fat Flaps in Modified Furlow Palatoplasty: A 3D Imaging-Assisted Long-Term Comparative Outcome Study

BACKGROUND

The pedicled buccal fat flap has recently been applied to cover the lateral raw surfaces during palatoplasty as an attempt to mitigate scar-induced transverse maxillary constriction during growth, but with no formal long-term comparative analysis. This 3D imaging-assisted study assessed its impact on posterior transverse maxillary development.

METHODS

Cone beam computerized tomography scans from patients with unilateral cleft lip, alveolus and palate who received buccal fat flap (buccal fat group; n=22) or Surgicel (Surgicel group; n=32) for covering lateral raw surfaces during modified Furlow palatoplasty at 9-10 months old and had reached 9 years old were retrieved for analysis. Patients with unilateral cleft lip and alveolus (non-palatoplasty group; n=24) were also included for comparison. Using 3D maxillary image models, linear (U6T-MSP and U6J-MSP) and area measurements were calculated for cleft and non-cleft posterior maxillary sides as well as for total posterior transverse maxillary dimension.

RESULTS

The buccal fat group had significantly (all p<0.05) wider dimensions compared with the Surgicel group for all transverse maxillary measurements on both the cleft and non-cleft sides, with exception for U6J-MSP and posterior palatal area parameters on the cleft side (p>0.05). The buccal fat group had significantly (all p<0.05) wider total transverse maxillary dimensions compared with Surgicel and non-palatoplasty groups.

CONCLUSION

Covering the lateral raw surfaces with buccal fat flaps resulted in less posterior transverse maxillary constriction compared with the Surgicel-based covering procedure.

Engineered mucoperiosteal scaffold for cleft palate regeneration towards the non-immunogenic transplantation

Cleft lip and palate (CL/P) is the most prevalent craniofacial birth defect in humans. None of the surgical procedures currently used for CL/P repair lead to definitive correction of hard palate bone interruption. Advances in tissue engineering and regenerative medicine aim to develop new strategies to restore palatal bone interruption by using tissue or organ-decellularized bioscaffolds seeded with host cells. Aim of this study was to set up a new natural scaffold deriving from a decellularized porcine mucoperiosteum, engineered by an innovative micro-perforation procedure based on Quantum Molecular Resonance (QMR) and then subjected to in vitro recellularization with human bone marrow-derived mesenchymal stem cells (hBM-MSCs). Our results demonstrated the efficiency of decellularization treatment gaining a natural, non-immunogenic scaffold with preserved collagen microenvironment that displays a favorable support to hMSC engraftment, spreading and differentiation. Ultrastructural analysis showed that the micro-perforation procedure preserved the collagen mesh, increasing the osteoinductive potential for mesenchymal precursor cells. In conclusion, we developed a novel tissue engineering protocol to obtain a non-immunogenic mucoperiosteal scaffold suitable for allogenic transplantation and CL/P repair. The innovative micro-perforation procedure improving hMSC osteogenic differentiation potentially impacts for enhanced palatal bone regeneration leading to future clinical applications in humans.

The Relationship Between Maxillary Growth and Speech in Children With a Unilateral Cleft Lip and Palate at 5 Years of Age

OBJECTIVE

This study sought to investigate the association between maxillary growth and speech outcomes for children with a repaired unilateral cleft lip and palate (UCLP) at 5 years of age.

PARTICIPANTS

In all, 521 children (180 females and 341 males) with a nonsyndromic complete UCLP, born between 2007 and 2012 in England, Wales, and Northern Ireland were included in this study.

OUTCOME MEASURES

Maxillary growth was analyzed using dental models scored by the 5-Year-Olds' index, and perceptual speech analyses were scored by the Cleft Audit Protocol for Speech - Augmented rating.

RESULTS

Forty-one percent of the children achieved good maxillary growth (scores 1 and 2 on 5-Year-Old' index). Fifty percent of the children achieved normal speech (achieving UK speech standard 1). Maxillary growth was not found to have an impact on speech outcome when described by the 3 UK National Cleft Lip and Palate Speech Audit Outcome Standards. Analysis according to individual speech parameters showed dentalizations to be less prevalent in children with good maxillary growth compared to fair and poor growth (P = .001). The remaining speech parameters within resonance, nasal airflow, and articulation categories were not significantly associated with maxillary growth.

CONCLUSION

The findings from this study suggest that children with a history of complete UCLP, who have poor maxillary growth, are not at a higher risk of having major speech errors compared to children with good or fair maxillary growth at 5 years of age.

Evaluation of fistula rates in three cleft palate techniques without relaxing incisions

The aim of the present study was to investigate the incidence of postoperative fistula formation from a hybrid cleft palate repair compared to that from two well-established techniques. We performed a modified technique, Sommerlad-Furlow (SF), which combined the repositioning of the levator veli palatini muscles as described by Sommerlad with the double opposing Z-plasty of Furlow to lengthen the soft palate. A retrospective cohort study was conducted to evaluate patients who underwent cleft palate repair utilizing SF, Sommerlad, or Furlow techniques with the incidence of palatal fistula as the target endpoint. A total of 1,164 patients were included in the present study and underwent the following techniques: 603 cases with SF, 244 cases with Furlow, and 317 cases with Sommerlad. In addition to not requiring relaxing incisions, SF advantages included a consistently lower fistula rate compared to that of the Sommerlad technique, as well as the lowest fistula rate in patients with both hard and soft palate clefts without a cleft lip (OR:2.62 95% CI: 1.35, 5.09). However, the differences among the three techniques did not reach statistical significance in terms of a bilateral or unilateral cleft lip/palate, or in patients with a soft palate only or a submucosal cleft palate(OR: 2.22,95% CI:0.77, 6.37). Based on the results of our study, the Somerlad-Furlow technique should be preferred whenever possible.

The Lima Surgical Protocol for Cleft Palate Repair

BACKGROUND

A cleft team experience addressing non-syndromic cleft palate and cleft lip and palate is presented. The purpose of the present study is to compare surgical outcomes using 2 different protocols for cleft palate repair provided by a cleft team in Lima, Perú.

METHODS

This is a comparative study between 2 groups of patients with non-syndromic cleft palate who were operated using different surgical protocols from 1999 to 2014. One hundred twenty-four children with non-syndromic isolated cleft palate and cleft lip and palate treated from 2007 to 2014 using a surgical protocol developed by our cleft team in Lima, Perú were compared with 145 children with cleft palate and cleft lip and palate treated by the same team using different protocol from 1999 to 2007. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency (VPI) and postoperative complications.

RESULTS

Statistical significant differences were observed between the 2 groups regarding the development of flap necrosis in favor of the Lima protocol. No significant difference in palatal fistula and VPI rate between the 2 protocols was found.

CONCLUSIONS

The Lima Surgical Protocol for cleft palate repair is an alternative strategy which uses the strengths of different surgical techniques based on the severity of the cleft. We observed better surgical outcomes using the Lima protocol with regards to postoperative complications in patients with non-syndromic cleft palate.

Oronasal Fistula Incidence Associated With Vomer Flap Repair of Cleft Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the incidence of oronasal fistulas (ONF) associated with primary repair of the anterior palate using a single-layered, superiorly based, vomer mucoperiosteal flap.

DESIGN

A systematic review of MEDLINE, PubMed, Cochrane, and Web of Science databases using the keywords: "vomer flap" and "cleft palate repair" were carried out. A meta-analysis was performed using random effect modeling with stratified analysis by syndromic diagnosis, number of surgeons, and mean age.

MAIN OUTCOME MEASURE(S)

Incidence of ONFs.

RESULTS

The meta-analysis included 9 studies with a total of 464 children who met inclusion criteria. The overall ONF rate was 3.0% (95% CI: 1.0-9.0). Fistula rates were not significantly different in studies that included syndromic patients compared to studies that did not, 5.0% (95% CI: 1.0-24.0) versus 3.0% (95% CI: 1.0-6.0), respectively. There was no significant difference between studies in which there was a single surgeon versus multiple surgeons, 3.0% (95% CI: 1.0-13.0) versus 4.0% (95% CI: 1.0-8.0), respectively. Age at the time of cleft repair showed no statistically significant difference in fistula rate when comparing children with a mean age less than 12 months to those greater than 12 months, 3.0% (95% CI: 1.0-5.0) versus 5.0% (95% CI: 1.0-28.0), respectively.

CONCLUSIONS

The vomer flap technique in cleft palate repair appears to be associated with a low ONF rate unaffected by syndromic diagnosis, number of surgeons, or patient age at time of repair.

Cleft Palate Repair: A Study Between Two Surgical Procedures

OBJECTIVE

The purpose of this study was to categorize and compare outcomes and sequels in 2 groups of patients born with unilateral and bilateral complete cleft lip/palate, having their primary cleft palate repair performed in our hospital, by the same surgical team, during 2 different periods of time, to establish which of the 2 surgical reconstructive strategies employed was more effective to decrease sequels.

MATERIAL AND METHODS

This is a randomized clinical trial including a total of 291, nonsyndromic patients, primary assisted in our Hospital, between 2002 and 2013, and operated by the same senior surgeon.Two groups of patients of similar characteristics were treated utilizing 2 different surgical procedures according to the considered period. Isolated palates, syndromic patients, secondary and adult cases were considered as exclusion critters. Surgical data was obtained from medical records, and clinical examinations. All the patients were cautiously evaluated by a team expert to verify results, evolution, and sequels.

RESULTS

Statistically significant differences in the total percentage of complications were found between both groups. Group A: 54.85% and Group B: 21.90% (P value < 0.001).Each complication was also considered by groups and estimated as follow: CONCLUSIONS:: Based on the results of our research, we can suggest the Carstens' variant plus the introduced modifications by the authors, as a useful surgical procedure to be utilized in primary complete unilateral or bilateral cleft palate repair to prevent post op common complications.

Innovative Molecular and Cellular Therapeutics in Cleft Palate Tissue Engineering

Clefts of the lip and/or palate are the most prevalent orofacial birth defects occurring in about 1:700 live human births worldwide. Early postnatal surgical interventions are extensive and staged to bring about optimal growth and fusion of palatal shelves. Severe cleft defects pose a challenge to correct with surgery alone, resulting in complications and sequelae requiring life-long, multidisciplinary care. Advances made in materials science innovation, including scaffold-based delivery systems for precision tissue engineering, now offer new avenues for stimulating bone formation at the site of surgical correction for palatal clefts. In this study, we review the present scientific literature on key developmental events that can go awry in palate development and the common surgical practices and challenges faced in correcting cleft defects. How key osteoinductive pathways implicated in palatogenesis inform the design and optimization of constructs for cleft palate correction is discussed within the context of translation to humans. Finally, we highlight new osteogenic agents and innovative delivery systems with the potential to be adopted in engineering-based therapeutic approaches for the correction of palatal defects. Impact statement Tissue-engineered scaffolds supplemented with osteogenic growth factors have attractive, largely unexplored possibilities to modulate molecular signaling networks relevant to driving palatogenesis in the context of congenital anomalies (e.g., cleft palate). Constructs that address this need may obviate current use of autologous bone grafts, thereby avoiding donor-site morbidity and other regenerative challenges in patients afflicted with palatal clefts. Combinations of biomaterials and drug delivery of diverse regenerative cues and biologics are currently transforming strategies exploited by engineers, scientists, and clinicians for palatal cleft repair.

Functional Validation of a New Alginate-based Hydrogel Scaffold Combined with Mesenchymal Stem Cells in a Rat Hard Palate Cleft Model

Background:

One of the major difficulties in cleft palate repair is the requirement for several surgical procedures and autologous bone grafting to form a bony bridge across the cleft defect. Engineered tissue, composed of a biomaterial scaffold and multipotent stem cells, may be a useful alternative for minimizing the non-negligible risk of donor site morbidity. The present study was designed to confirm the healing and osteogenic properties of a novel alginate-based hydrogel in palate repair.

Methods:

Matrix constructs, seeded with allogeneic bone marrow–derived mesenchymal stem cells (BM-MSCs) or not, were incorporated into a surgically created, critical-sized cleft palate defect in the rat. Control with no scaffold was also tested. Bone formation was assessed using microcomputed tomography at weeks 2, 4, 8, and 12 and a histologic analysis at week 12.

Results:

At 12 weeks, the proportion of bone filling associated with the use of hydrogel scaffold alone did not differ significantly from the values observed in the scaffold-free experiment (61.01% ± 5.288% versus 36.91% ± 5.132%; p = 0.1620). The addition of BM-MSCs stimulated bone formation not only at the margin of the defect but also in the center of the implant.

Conclusions:

In a relevant in vivo model of cleft palate in the rat, we confirmed the alginate-based hydrogel’s biocompatibility and real advantages for tissue healing. Addition of BM-MSCs stimulated bone formation in the center of the implant, demonstrating the new biomaterial’s potential for use as a bone substitute grafting material for cleft palate repair.

Early or delayed palatoplasty in complete unilateral cleft lip and palate patients? A systematic review of the effects on maxillary growth

The aim of this study was to review the effects of early and late hard palate repair on maxillary growth. PubMed, Scopus, Web of Science, LILACS, Cochrane Library CENTRAL databases, OpenGrey, Google Scholar, and Clinical Trials were searched using a PICO strategy, with terms related to unilateral cleft lip and palate (UCLP) and timing of repair. Methodological quality evaluation was carried out using the Fowkes and Fulton guidelines, and quality (or certainty) of evidence and strength of recommendations were evaluated using GRADE (grading of recommendations, assessment, development and evaluation). Five retrospective and non-randomized studies were included in the study. Folkes and Fulton assessment showed a high risk of bias in all articles and very low levels of certainty (GRADE). The results showed conflicting findings for comparisons of the effects of timing of repair of hard palate in UCLP. Two studies presented better maxillary growth in a group operated on later (18 months after birth), two presented no differences between the results, and another presented better results in the group operated on earlier than 18 months of age. At this point, it cannot be proven or refuted that postponing hard palate surgery brings benefits for maxillary growth. Studies included in this review did not show similar conclusions. Randomized clinical trials present some ethical issues that make them difficult to perform.

Spontaneous Bone Regeneration After Closure of the Hard Palate Cleft: A Literature Review

PURPOSE

A wide range of surgical techniques have been described for the treatment of palatal clefts. Some of these surgical procedures result in postoperative osteogenesis at the palatal fissure. The aims of this review were to discuss the current approaches to cleft palate surgery leading to spontaneous bone regeneration and to compare these different procedures. Moreover, the causes of bone regeneration, effects on maxillary growth, and factors affecting bone regeneration on the hard palate are discussed.

MATERIALS AND METHODS

The selected articles were found via MEDLINE and Web of Science. The keywords for the search were "cleft palate," "bone regeneration," "palatoplasty," "reconstructive surgical procedures," and "cleft palate surgery." Studies that examined the effect of primary palatoplasty on spontaneous bone regeneration in the hard palate in children were included in this review. Four articles were analyzed in the qualitative synthesis.

RESULTS

Because of differences in patient characteristics and evaluation methods, it was difficult to compare different surgical procedures. The use of a mucoperiosteal flap in combination with adequate closure of the mucosa is needed to obtain bone formation. The area with the largest amount of regenerated bone was located in the middle of the hard palate. In the literature, it was found that complete closure was considered unfavorable because of the negative effects on maxillary growth, but more studies are needed to confirm this. Of the factors that have been studied, only age turned out to be borderline relevant.

CONCLUSIONS

Only a few studies with small sample sizes have been published on bone regeneration in the hard palate. More research is needed to validate these findings.

Two Methods of Cleft Palate Repair in Patients With Complete Unilateral Cleft Lip and Palate

OBJECTIVE

The objective of this study was to compare the surgical outcome between 2 patient groups with complete unilateral cleft lip and palate who underwent different types of palatoplasty.

METHODS

This is a cohort study between 2 groups of patients with complete unilateral cleft lip and palate who were operated using different surgical techniques from 2008 to 2011. About 28 patients were operated using a primary lip nose repair with vomer flap for hard palate single-layer closure and delayed soft palate repair (modified Oslo protocol) and 32 patients were operated using our protocol in Lima. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency and evaluation of dental arch relationships (scored using the 5-year-olds' index).

RESULTS

Our comparative study observed statistically significant differences between the 2 groups regarding the presence of oronasal fistulas and velopharyngeal insufficiency in favor of our palatoplasty technique. A statistically significant difference was not found in functional vestibular oronasal fistula development between the studied techniques for unilateral cleft palate repair. This comparative study did not observe significant differences in dental arch relationships between the studied techniques.

CONCLUSION

In this study, better surgical outcome than modified Oslo protocol regarding oronasal fistulas and velopharyngeal insufficiency on patients with complete unilateral cleft lip and palate was observed. The results arising from this study do not provide evidence that one technique is enough to obtain better functional closure of the alveolar cleft and dental arch relationship at 5 years.

Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases

Cleft palate in dogs is a congenital defect that mostly leads to euthanasia of the affected puppy. If an attempt is made to raise the puppy, it is generally fed via an orogastric tube. Here, we describe the management of cleft palate in three puppies (two Boxers, one Collie) using a customised temporary prosthesis, which allowed the puppies to be bottle-fed and successfully raised by their owners (Cases 2 and 3) and the author (Case 1). The temporary palatal prosthesis was manufactured from a mouthguard intended for human children, which is made of thermoplastic silicone. The preparation procedure was simple and cost-effective. All puppies underwent corrective surgery at 5–6 months of age. After surgery, one of the Boxer puppies showed mandibular mesioclusion, while the other two showed no aberrations. All puppies gained the same amount of weight as their littermates, although the weight gain of the two Boxers was slower than that of their littermates. In summary, this case report describes an easy and effective way to raise puppies with cleft palate until corrective surgery can be performed.

Electromyographic Activity of the Masseter and Temporal Muscles in Patients With Nonsyndromic Complete Unilateral Cleft Lip and Palate: 2-Stage Versus 1-Stage Palate Repair

OBJECTIVE

To assess the electromyographic activity of the masseter and temporal muscles in cleft patients who underwent 1-stage palate repair versus 2-stage palate repair.

METHODS

Thirty-two patients with nonsyndromic complete unilateral cleft lip and palate operated by 2 different protocols for palate repair, 1-stage (group 1, n = 16) versus 2-stage with delayed hard palate closure (group 2, n = 16) were available in the retrospective longitudinal study. Standardized electromyographic records of the masseter and anterior portion of temporal muscles were obtained with 2 repetitions during mastication and rest.

RESULTS

No statistically significant (all P > 0.05) differences were observed in the electromyographic data between the groups 1 and 2.

CONCLUSION

There were similar electromyographic activity of masseter and temporal muscles during mastication and at rest after 1- and 2-stage palate closure.

Maxillary Growth in Cleft Lip and Palate Patients, With and Without Vomerine Flap Closure of the Hard Palate at the Time of Lip Repair: A Retrospective Analysis of Prospectively Collected Nonrandomized Data, With 10-Year Cephalometric Outcomes

OBJECTIVE

To assess the midterm effect on maxillary growth of vomerine flap (VF) closure of the hard palate, at the time of lip repair.

DESIGN

A retrospective analysis of prospectively collected nonrandomized data.

INTERVENTIONS

Consecutive participants with a unilateral cleft lip and palate (UCLP) were operated on, at 3 months of age, by the same surgeon. They were divided into 2 groups, those who had a VF and those who did not (non-VF).

SETTING

Participants were treated at 2 hospitals in the United Kingdom.

PARTICIPANTS

Twenty-eight participants in the VF group and 24 participants in the non-VF group attended follow-up at 10 years of age.

MAIN OUTCOME MEASURES

Standardized lateral cephalometric radiographs were taken at 10 years. Following tracing and digitization, parameters to assess the maxillary growth were analyzed.

RESULTS

No statistically significant differences were found in the anterior-posterior or vertical skeletal cephalometric parameters.

CONCLUSIONS

The results of this study support the statement that VF repair does not significantly affect maxillary growth in patients with a UCLP, when assessed cephalometrically at 10 years of age. It should be noted that at this age, growth is not yet complete.

Effect of Relaxing Incisions on the Maxillary Growth after Primary Unilateral Cleft Palate Repair in Mild and Moderate Cases: A Randomized Clinical Trial

BACKGROUND

The purpose of this study was to evaluate the association between the use of relaxing incisions and maxillary growth disturbance after primary palatoplasty in patients with unilateral cleft lip and palate.

METHODS

This is a prospective, randomized, double-blind controlled trial study with ethical committee approval between 2 groups of patients with unilateral cleft lip and palate who were operated on using the two-flap and one-flap techniques from 2008 to 2011. Two groups of patients with unilateral cleft lip and palate were operated on using the mentioned techniques by the Outreach Surgical Center Program Lima since 2008. Data collection was accomplished by evaluation of maxillary arch dimensions and dental arch relationships (scored using the 5-year-olds' index).

RESULTS

The mean score for the 5-year-olds' index was 2.57 for two-flap technique and 2.80 for one-flap technique without statistical significant differences (P = 0.71). Our comparative study did not find statistically significant differences in maxillary arch dimensions between the studied techniques for unilateral cleft palate repair. Good levels of agreement were observed according to the κ statistics.

CONCLUSIONS

The results arising from this clinical trial do not provide statistical evidence that one technique let us obtain better maxillary development than the other at 5 years. The use of relaxing incisions was not associated with maxillary growth impairment. A technique with limited relaxing incisions does not has better maxillary growth. Additional longer term study is necessary to confirm this preliminary report.

Multivariate analysis on unilateral cleft lip and palate treatment outcome by EUROCRAN index: A retrospective study

OBJECTIVES

This study is to evaluate the dental arch relationship and palatal morphology of unilateral cleft lip and palate patients by using EUROCRAN index, and to assess the factors that affect them using multivariate statistical analysis.

METHOD

A total of one hundred and seven patients from age five to twelve years old with non-syndromic unilateral cleft lip and palate were included in the study. These patients have received cheiloplasty and one stage palatoplasty surgery but yet to receive alveolar bone grafting procedure. Five assessors trained in the use of the EUROCRAN index underwent calibration exercise and ranked the dental arch relationships and palatal morphology of the patients' study models. For intra-rater agreement, the examiners scored the models twice, with two weeks interval in between sessions. Variable factors of the patients were collected and they included gender, site, type and, family history of unilateral cleft lip and palate; absence of lateral incisor on cleft side, cheiloplasty and palatoplasty technique used. Associations between various factors and dental arch relationships were assessed using logistic regression analysis.

RESULT

Dental arch relationship among unilateral cleft lip and palate in local population had relatively worse scoring than other parts of the world. Crude logistics regression analysis did not demonstrate any significant associations among the various socio-demographic factors, cheiloplasty and palatoplasty techniques used with the dental arch relationship outcome.

CONCLUSIONS

This study has limitations that might have affected the results, example: having multiple operators performing the surgeries and the inability to access the influence of underlying genetic predisposed cranio-facial variability. These may have substantial influence on the treatment outcome. The factors that can affect unilateral cleft lip and palate treatment outcome is multifactorial in nature and remained controversial in general.

One-flap Palatoplasty: A Cohort Study to Evaluate a Technique for Unilateral Cleft Palate Repair

Background:

The 2-flap palatoplasty technique is actually the approach most commonly used in the United States for cleft palate repair. This is a one-time surgery that enables closure under minimal tension, lowering rates of subsequent fistula development. However, its primary disadvantage is potential detriment to maxillary growth (due to extent of dissection on both sides of the cleft and raw lateral surfaces). Since 2007, a surgical technique using only one mucoperiosteal flap from the noncleft side has been performed by us, reducing the extent of the surgery and its potential nondesirable effects over the palate. The purpose of this study is to evaluate the utility of this technique for unilateral cleft palate repair.

Methods:

This is a retrospective, simple-blinded cohort study between 2 groups of 120 patients each with unilateral cleft palate who were operated on using the 2-flap and 1-flap techniques by the Outreach Surgical Center Program Lima from 2007 to 2012. Data collection was accomplished by physical examination to evaluate the presence or absence of a fistula and to evaluate the presence of hypernasality. Postoperative bleeding was also studied.

Results:

We have observed no increase in the rate of fistulas and velopharyngeal insufficiency between these 2 studied groups (P = 0.801 and P = 1.000).

Conclusions:

Use of a 1-flap technique for unilateral cleft palate repair allowed us to achieve results comparable to those of a 2-flap technique in terms of postoperative fistula development and hypernasal speech. Additional studies are required to evaluate the effect of this technique on palatal growth.

The efficacy of vomer flap for closure of hard palate during primary lip repair

BACKGROUND AND AIM

This study presents the institutional experience of the use of vomer flap for early closure of hard palate during unilateral complete cleft-lip repair. The purpose of this study was to determine the survival rate of the vomer flap and to investigate its effect on the subsequent palatoplasty.

PATIENTS AND METHODS

This retrospective analysis includes 101 non-syndromic patients with complete unilateral cleft lip who received a vomer flap for the closure of the hard palate during cleft-lip repair. Patients were aged 6 months to 28 years (median 1 year). Success rates of the vomer flaps were assessed clinically and through pre-operative photographs taken at the time of subsequent palate repair. Ninety-two patients returned for second-stage palate repair, and 74 patients with adequate post-operative follow-up information were statistically analysed.

RESULTS

Of the 101 patients who were operated with primary lip repair and simultaneous vomer flap, only 54 (52.4%) vomer flaps healed completely. Out of 92 patients who returned for subsequent palatoplasty, 71 (77.2%) were operated with the two-flap technique, and 19 (20.7%) received von Langenbeck repairs. Seven (9.1%) patients had a surgical complication. The failure of previous vomer repair and von Langenbeck surgical technique were identified as factors associated with post-operative complications.

CONCLUSIONS

We conclude that failed vomer flaps increased the risks of complications in the subsequent palate repair. Furthermore, efforts to use von Langenbeck technique rather than the two-flap technique also resulted in increased surgical complications. As a result, we have abandoned the use of the vomer flap with primary lip repair.