Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public

Facial Expressions of Emotion in Children with Cleft Lip and Palate

OBJECTIVE

To examine the facial movements children with cleft lip and palate (CLP) employ to express basic emotions. Ability of observers to interpret facial expressions of children with CLP was also considered.

DESIGN

Prospective case-control design.

SETTING

Outpatient craniofacial anomalies clinic.

PATIENTS

Twenty-five children with CLP (age 8 to 12) and 25 age/sex-matched controls.

OUTCOME MEASURES

Children were video recorded making facial expressions representing anger, disgust, fear, happiness, sadness, and surprise. Magnitude of children's facial movements was quantified and compared using OpenFace. Subsequently, emotion videos were presented to 19 adults who were asked to identify the emotion conveyed in each facial expression. Accuracy of emotion recognition was compared across groups.

RESULTS

Compared with controls, children with CLP employed significantly (P < .05) smaller magnitude superior and lateral perioral movements to express disgust (Cohen's d = .50), happiness (Cohen's d = 1.1), and fear (Cohen's d = .93). For disgust and sadness, children with CLP employed significantly greater magnitude movements of the nose and chin, presumably to compensate for reduced perioral range of motion. For anger, happiness, and sadness, children with CLP employed smaller magnitude movements of the upper face when compared with controls. Observers identified disgust (OR = 1.26), and fear (OR = 2.44) significantly less accurately in children with CLP when compared with controls.

CONCLUSIONS

Children with CLP employed different facial movements to express certain emotions. Observers less accurately identified some emotions conveyed by facial expressions in children with CLP when compared with controls, likely due in part to differences in facial movements. Future research should explore the implications of these differences for social communication.

Evaluation of nasolabial esthetics in 8- to 12-year-old patients with cleft lip and palate by healthcare professionals in Northeast Thailand

Objective

To assess the aesthetics of the nasolabial appearance of patients with cleft lip and palate aged 8-12 years by experienced and inexperienced professionals.

Methods

A cross-sectional study was conducted on 32 patients with cleft lip and palate, who underwent surgery and follow-up treatment at the Cleft Center. The research tools included a parent-completed survey providing GO graphic data and two-dimensional frontal view photographs of patients from both left and right sides. The aesthetic of the lip, nose, and nasolabial region was evaluated by an experienced and inexperienced medical professional team in groups of four individuals. In addition, data analysis was performed using descriptive statistics, mean values, standard deviations, Cronbach's alpha reliability coefficient, and the Wilcoxon signed-rank test.

Results

The average age of patients was 10.32 years, mainly male (65.63%), had unilateral cleft lip and palate (62.50%), and underwent bone grafting (96.88%). Regarding the assessment in three aspects, the aesthetic score assessed by experienced evaluators is fair level (2.64 ± 1.09) with an acceptable value of 0.73. In contrast, the inexperienced evaluator showed a high level (2.43 ± 0.83) with a high inter-rater reliability acceptable value of 0.60. Inexperienced evaluators showed higher scores for the lip and nasolabial region than experienced evaluators, which was statistically significant (p-values < 0.01).

Conclusions

The inexperienced evaluators showed significantly higher scores for appearance than experienced evaluators. This result can improve surgical techniques in future procedures to meet the needs of patients seeking lip and nasolabial appearance corrections across different age groups.

Association between sex of the individual with untreated cleft lip and social judgement made by lay persons: A cross-sectional study

OBJECTIVE

To assess whether there is an association between an individual's sex and social judgements made by lay persons regarding untreated cleft lip.

MATERIALS AND METHODS

Lay individuals over 18 years old were recruited through an application to respond online to two questionnaires: a sociodemographic survey and the Brazilian Version of Lay Persons' Social Judgements about Cleft-lip Scale (B-LSojCleft-S). B-LSojCleft-S comprises 14 items evaluating social judgements made by laypersons concerning different types of untreated cleft lips in teenagers. The 14 items are linked to 8 images featuring untreated cleft lips and 1 image without a cleft (control). Higher scores represented more favourable social judgements. Independent samples t-test, paired, and multiple linear regression were conducted (P < 0.05). The study assessed judgements of untreated cleft lips in male and female adolescents using the B-LSojCleft-S.

RESULTS

The mean age of the 217 participants was 37.78 ± 12.39 years, predominantly women (72.7%), married (47.7%), with a monthly income below three minimum wages (35.6%) in the majority of cases. Significantly higher social judgement scores were observed in the control group (no cleft) compared to any type of cleft (P < 0.001), with similar scores obtained for the same types of clefts with female or male images (P > 0.05). The participant's sex is associated with social judgement scores (F [1, 214] = 6.318, P = 0.013; adjusted R2 = 0.024), with females making more favourable judgements than males (P < 0.05).

CONCLUSIONS

Individuals with cleft lips receive more negative social judgement scores, regardless of their own sex. Women make better social judgements than men.

Questionnaire survey on public awareness of cleft lip with/without palate in Mongolia

The frequency of cleft lip with/without palate (CL/P) in the Mongolian population is approximately 1 in 1314 live births. This research aims to disseminate information about this congenital disability to the public to better understand CL/P, and people's fissures, and review administrative measures, as there is a lack of research in this area. A questionnaire survey was conducted using Google Forms, with 1000 Mongolian participants. Most participants (86.7%) said they had knowledge of the word, whereas 86.2% said they had knowledge of the condition. Most participants' answers were question-related disadvantages of CL/P patients, including statements such as "It's uncomfortable in human relationships" and "It makes an uncomfortable impression on the person you meet the first time." The results of this study revealed that most Mongolians were aware of CL/P and are concerned about patients. However, the causes of CL/P in the general population remain unknown, and further research is needed in this area.

Primary rhinoplasty in patients with bilateral cleft lip: Longitudinal results and comparison between closed and semi-open approaches

BACKGROUND

Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty.

METHODS

Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed.

RESULTS

In the comparative analysis at preschool age, semi-open rhinoplasty significantly improved the typical nasal deformities, including transversely oriented wide nostrils, short columella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age.

CONCLUSION

This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.

Perceived Effects of Orthognathic Surgery versus Orthodontic Camouflage Treatment of Convex Facial Profile Patients

Increased facial profile convexity has a common occurrence in the population and is a primary reason for seeking orthodontic treatment. The present study aimed to compare the perceived changes in facial profile appearance between patients treated with combined orthognathic/orthodontic treatment versus only orthodontic camouflage treatment. For this reason, 18 pairs of before- and after-treatment facial profile photos per treatment group (n = 36 patients) were presented to four types of assessors (surgeons, orthodontists, patients, laypeople). Ratings were recorded on 100 mm visual analogue scales depicted in previously validated questionnaires. All rater groups identified minor positive changes in the facial profile appearance after exclusively orthodontic treatment, in contrast to substantial positive changes (14% to 18%) following combined orthodontic and orthognathic surgery. The differences between the two treatment approaches were slightly larger in the lower face and the chin than in the lips. The combined orthodontic and orthognathic surgery interventions were efficient in improving the facial appearance of patients with convex profile, whereas orthodontic treatment alone was not. Given the significant influence of facial aesthetics on various life aspects and its pivotal role in treatment demand and patient satisfaction, healthcare providers should take these findings into account when consulting adult patients with a convex facial profile.

A new digital measurement system for assessing the lip in patients with cleft lip and palate (CLP)

Objective

In order to better and more objectively assess and compare the aesthetics of the lip, we offer an inovative, digital measurement method.

Patients and method

Patients were divided into 2 groups:a) patients with unilateral CLP andb) patients with bilateral CLP.Based on standardised photos from 3 different directions, lip symmetry and aesthetics were assessed. A new digital measurement system was used, which was integrated into a proven clinical programme. Different symmetry indices were compared with a non-cleft control group. In addition, the function was investigated and a standardised questionnaire was used.

Results

In total, 92 patients with operated CLP could be recruitetd and showed significant residual asymmetry compared to the control group with 49 patients. The results were more symmetrical in group b) than in group a). In contrast, scar width and scar aesthetics as well as orofacial function were better in group a). The preoperative cleft width showed a positive correlation with the postoperative scar width and scar aesthetics. Socioeconomic factors were not related to surgical outcome. Satisfaction of affected children and parents correlated with objectively assessed scar aesthetics and function. There was no correlation between satisfaction and symmetry or cleft width or scar width.

Conclusion

The presented measurement system can be used excellently and effectively in clinical routine, especially for the inexperienced examiner, for fast and yet detailed, objective recording of findings. The measurement results can be analyzed comparatively and interpreted predictively for diagnostics, planning and therapy.

A novel measurement system for assessing the nose in patients with cleft lip and palate (CLP)

Objective

The presented study shows a new and innovative method to determine nasal asymmetries in a simple way in patients with cleft lip and palate (CLP) in order to plan corrective surgery.

Design

86 non-syndromic patients with cleft lip and palate were divided into 2 groups: a) patients with unilateral cleft lip and palate b) patients with bilateral cleft lip and palate.

Patients

follow-up of hospital records of 86 patients aged 2-18 years.

Main outcome

Based on standardised photos of the nose from 3 different directions, the nose symmetry was assessed. A new digital measurement system was used, which is integrated into proven clinical programmes. These were compared with a control group. In addition, a mirror fog test and a standardised questionnaire were used.

Result

The overall results showed a good symmetry of the nose postoperatively, as well as a high satisfaction of the patients and their parents. Profile and angle measurements showed a better result.

Conclusio

The presented measurement system and especially the Cleft Lip Component Symmetry Index (CLCSI) allows an individual and very effective assessment of the symmetry of the nose as well as a control of the growth in patients with CLP. The method is easy to apply in daily practice, even for untrained practitioners.

Orthodontic Treatment of Patients With Clefts: Satisfaction and Psychological Aspects

To assess parents' satisfaction with cleft child's facial appearance and function; compare these findings with orthodontist (expert) satisfaction and evaluate influence of various factors on satisfaction.

Cross-sectional study.

Sixty-three parents of non-syndromic patients with clefts (ages 7-20 years), and an orthodontist, completed the Cleft Hearing, Appearance and Speech Questionnaire. Two scores were produced: cleft-associated, and non-cleft-associated features. Additional open questions were presented to the parents.

Both parents and orthodontist gave high satisfaction scores (mean: 8.4 & 8.2, respectively), significantly correlated, for the cleft-associated features (P < .001). Parents were least satisfied with appearance of teeth, then nose, then lips. Scores did not vary significantly with age and sex of patients. Higher parents' satisfaction was found in the unilateral cleft lip + alveolus (UCL + alveolus) group, compared with the unilateral cleft lip and palate (UCLP), regarding cleft-associated features, and compared with cleft palate (CP), regarding non-cleft-associated features (P < .05). Greater parents and orthodontist satisfaction were found when parents' education was >12 years. Parents of Jewish ethnicity showed higher satisfaction, compared with parents of non-Jewish ethnicity. Patients requiring future surgery received lower scores. Parents satisfaction was directly correlated to socioeconomic status.

The following factors appear to lower parents' satisfaction: [1] cleft severity, [2] hearing or speech of CP/BCLP patients, [3] requirement for further surgery, and [4] low socioeconomic status.

Severe cases may require additional explanation to parents in order to lower expectations. A more thorough explanation may be required in patients of lower socioeconomic status.

Long-Term Nasolabial Appearance Post-Unilateral Cleft Lip Repair in a Single Center: A Descriptive Study

Introduction Modern treatments still aim to keep the impact of surgical intervention low and the outcome of surgeries as good as a surgeon can. Assessing the long-term nasolabial appearance of patients who underwent cleft lip (CL) repair surgery is one of the methods of evaluating the outcomes of cleft surgery. Methods This is a retrospective cross-sectional descriptive study of data records of unilateral CL patients. The data records of all patients who underwent unilateral CL repair by the reconstructive science unit at Hospital Universiti Sains Malaysia (HUSM) within the first two years of their lives and whose current age is 14 years or above were accessed and analyzed. Results The data records of 50 patients were analyzed, including 13 (26%) males and 37 (74%) females. The surgeons opined that 28% of the patients had an acceptable nasolabial appearance, while there were 10 (20%) patients whose nasolabial appearance was considered unacceptable by the reviewing surgeons. Fifteen (30%) patients were described as having an acceptable lip appearance with secondary nasal deformity, and 11 (22%) patients had an acceptable nasal appearance with secondary lip deformity. There were no surgical modifications or postoperative complications among the patients. None of our variables reported a significant association with long-term nasolabial appearance. Conclusion The long-term evaluation of the nasolabial appearance in individuals with CL following surgical correction significantly improves the service and care provided to patients to achieve optimum results. Although our results showed no relationship between gender, age at operation, type or diagnosis of cleft, and family history and long-term nasolabial appearance, frequent assessments will enhance surgical results.

Factors affecting hand cosmesis and the aesthetic impact of surgery on congenital hand differences in Finland

We assessed the appearance and cosmetic impact of surgery in congenitally different hands in Finland. A questionnaire was sent to 1165 respondents (786 female) with a mean age of 33 years (range 3-84). Participants were shown nine image pairs and seven pairs of pre- and postoperative images twice in a random order and asked to choose the more cosmetically pleasing one. We found that the appearance and number of fingers had an important aesthetic role, with higher number and more normal appearing digits consistently scoring higher than its counterpart (range 59-99%). Postoperative appearances were perceived as better than preoperative ones in syndactyly (98%), thumb duplication (92%), cleft hand (93%) and radial dysplasia (99%). Toe transfer and pollicization had little impact on cosmesis. This study demonstrated that surgery could improve cosmesis in congenitally different hands and overall, most respondents prefer an appearance that is as close as possible to normality. Level of evidence: IV.

The Use of Validated Visual Scales in Plastic Surgery: Where Are We Now?

BACKGROUND

The assessment of the human body, whether for aesthetic or reconstructive purposes, is an inherently visual endeavor. Ideally, reproducible, prompt, and cost-effective systems of visual evaluation would exist that can provide validated assessments of the aesthetic endpoints of treatment. One method to accomplish a standardization of the appreciation of visual endpoints is the use of visual scales. The goal of this systematic review is to summarize and evaluate the use of validated visual scales within aesthetic medicine, dermatology, and plastic and reconstructive surgery.

METHODS

A literature search was performed with a defined search strategy and extensive manual screening process. The Medical Outcomes Trust guidelines for visual scales in medicine were used, with special attention paid to each study's validation metrics. The review process identified 44 publications with validation data of sufficient quality from an initial survey of 27,745 articles. All rating scales based on imaging other than standardized clinical photographs were excluded.

RESULTS

The review demonstrates that validated visual assessment in plastic surgery is incomplete. Within specific subfields of aesthetic medicine and dermatology, many of the ( n = 20) facial aging scales were well-validated and demonstrated high reliability. Publications ( n = 8) focused on the evaluation of facial clefts demonstrated heterogeneity in the methods of validation and in overall reliability. Within the areas of breast surgery ( n = 9), body contouring ( n = 2), and scarring ( n = 5), the scales were variable in the methods used and the validation procedures were diverse. Scales using a visual guide tended to have better interrater (kappa = 0.75) and intrarater reliability (kappa = 0.78), regardless of the specific area of interest.

CONCLUSIONS

The fields of aesthetic medicine, and aesthetic and reconstructive plastic surgery require assessment of visual states over time and between many observers. For these reasons, the development of validated and reliable methods of visual assessment are critical. Until recently, the use of these tools has been limited by their time-consuming nature and cost.

Visual perception of repaired cleft lip scarring face associated with different malocclusions via eye-tracking

Background. This study aimed to evaluate the visual facial perception in response to scars associated with repaired cleft lip (CL) on a male adolescent patient, as assessed via eye-tracking. Methods. Index of orthodontic treatment need (IOTN) malocclusions, grades 1, 5, and 8 were added to the frontal view facial image of an adolescent male model showing asymmetries of the nose and upper lip after CL surgery using the software Photoshop CS5® software. The eye movements of 91 laypeople observers were tracked by an Eye Tribe infrared sensor connected to OGAMA© software. A Kruskal–Wallis test was used to identify differences in total fixation time and time until the first fixation for the areas of interest. A visual analog scale (VAS) of attractiveness was also used in the study. Statistical analysis was performed adopting a significance level of P<0.05. Results. The area of interest (AOI) were found to be the mouth and teeth, which were more focused on gazed at than any other area, regardless of the grade of IOTN. For observers of different ages, there were significant differences in the time until the first fixation on the scar of the repaired CL region for IOTN grade 1 (P=0.007). Images showing IOTN grade 1 repaired CL regions received the highest VAS scores. The older the age, the greater the tendency to give a higher VAS score for the same malocclusion. Conclusion. The presence of a CL scar on the upper lip did not attract the eye of laypeople observers of different ages, regardless of the degree of malocclusion in the non-smile image. The age of the observers did influence the perception of attractiveness, with older observers giving higher scores than younger ones. As the severity of the malocclusion increased, they were found to be less attractive.

Likert scale vs visual analog scale for assessing facial pleasantness

INTRODUCTION

This study aimed to compare the 2 most commonly used methods for assessing facial pleasantness, the Likert scale and the visual analog scale (VAS).

METHODS

For assessing facial pleasantness, an album was assembled containing the front and profile view facial photographs of 10 patients (5 females, 5 males) who sought orthodontic treatment representing each of the different sagittal and vertical facial discrepancies (straight profile, convex profile, concave profile, long faces, and short faces). The facial pleasantness of the patients was judged by 3 groups of 90 evaluators (47 females and 43 males): 30 orthodontists (mean age, 32.41 years), 30 oral maxillofacial surgeons (mean age, 36.83 years), and 30 laypeople (mean age, 36.83 years). The evaluators judged the facial pleasantness using VAS and a 5-point Likert scale. At the end of the evaluation, the evaluators completed a questionnaire about their preferred scale. Analysis of variance and Tukey and Kruskal-Wallis tests were used to compare the data from VAS and Likert scale, respectively. The Spearman correlation coefficient was used to estimate the correlation between the 2 scales. Fisher transformation and z-statistic were used to estimate the correlation among the evaluator groups. In all tests, a 5% statistical significance level was adopted.

RESULTS

Both scales presented similar answers; only VAS values for the scores of pleasant and very pleasant according to the Likert scale could not be distinct. Most evaluators preferred the Likert scale as they found it easier to convey their opinion than VAS.

CONCLUSIONS

Although both scales can be used to assess facial pleasantness, the Likert scale seems more appropriate as the evaluators preferred it because of its simplicity.

Advantages of using toothpaste containing propolis and plant oils for gingivitis prevention and oral cavity hygiene in cleft lip/palate patients

BACKGROUND

The anti-inflammatory and antibacterial action of preparations used during oral hygiene procedures is particularly important in patients with oral cleft. Few reports have been published assessing the influence of natural products on the state of the oral cavity in patients with oral cleft. The aim of this study was to assess the effect of toothpaste containing Polish propolis and plant oils on oral cavity health in patients with oral cleft treated orthodontically.

MATERIALS AND METHODS

A total of 50 patients aged 9-16 years old (20 females, 23 males) were selected and randomly assigned into two groups. Group (A) received toothpaste with Polish propolis, tea tree oil, menthol, and rosemary oil. Group (B) received toothpaste without active ingredients (placebo). A baseline assessment was followed by an oral hygiene index (OHI, debris OHI-D, and calculus OHI-C component) and gingival bleeding index (GBI) after 35 days. The methodology of the oral condition assessment included the presence of cleft malformation as a dysmorphic of the anterior maxilla segment.

RESULTS

In group A, improvement in oral cavity hygiene assessed for incisors and molars was found (OHI-T p = 0.011). For the gingival condition, a decrease in the gingival bleeding index - total (GBI-T p = 0.002), as well as for the incisors (GBI-I p = 0.007) and molars (GBI-M p = 0.017) was found.

CONCLUSIONS

This research confirms the biological effectiveness of toothpaste with Polish propolis and plant oils. These results may be clinically useful for improving preventative oral care and for control of oral infectious diseases during orthodontic treatment in patients with oral cleft.

Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques

BACKGROUND

Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques.

METHODS

Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry.

RESULTS

Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups.

CONCLUSIONS

This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.

The Slavcleft: a three-center study of the outcome of treatment of cleft lip and palate. Nasolabial appearance

Background

There is a multitude of protocols of treatment of cleft lip and palate (CLP) worldwide differing in number of operations, surgical techniques, and timings of surgeries. Despite, facial appearance in subjects with CLP is rarely ideal and residual stigmata are easy to notice in many patients irrespective of the protocol. The prospective controlled investigations are optimal for comparing effectiveness of treatment protocols. Because prospective studies are very challenging to perform in CLP field, it is reasonable to retrospectively assess different surgical protocols to identify the promising ones and then to test them in a prospective way.

Methods

Our objective was to assess the nasolabial appearance in a preadolescent Slavic population with unilateral cleft lip and palate (UCLP) by using the 0-200 numeric scale with reference photographs. Patients treated in Warsaw, Poland (n = 32), Prague, Czech Republic (n = 26) and Bratislava, Slovakia (n = 17) were included in this retrospective study. Each cleft center used a unique surgical protocol. Two panels of professional raters (n = 7) and laypeople (n = 10) scored blindly the nasolabial esthetics on cropped frontal and profile images with cropped reference photograph present on the same slide. Intra- and inter-rater agreement was assessed with Cronbach's alpha, intraclass correlation coefficients, t-tests, and Bland-Altman plots. Inter-group differences were evaluated with one-way ANOVA and regression analysis.

Results

The agreement within and between raters was acceptable. We found that patients treated in Warsaw, Prague, and Bratislava showed comparable nasolabial appearance on frontal and profile photographs when judged by both professional raters (p > 0.05) and laypeople (p > 0.05). Regression analysis did not identify influence of gender, group (i.e., Warsaw, Prague, and Bratislava), age at lip repair, surgeon, and age at photographic assessment on esthetic outcome (p > 0.05).

Conclusion

This study showed that none of the surgical protocols showed superiority to produce good nasolabial appearance.

Public Perception of a Normal Head Shape in Children With Sagittal Craniosynostosis

: A question that remains unanswered is at what level of surgical correction does the public perceive a head shape to be "normal" or "acceptable?" For most cases of non-syndromic asymptomatic craniosynostosis, the parents desire for surgical correction is to improve the cosmetic appearance of head shape. At the time of this writing, the intraoperative surgeons' perspective of what constitutes an acceptable head shape is the target for surgical correction. In introducing an improved objectively cosmetic goal, an appropriate outcome measure would be to assess what the general public considers a normal or acceptable head shape in children with craniosynostosis.

METHOD

Twenty-two unique images were presented via an online crowdsourcing survey of a severe case of non-syndromic sagittal craniosynosis gradually corrected to an age and gender matched normalized head shape. Participants were recruited via the Sick Kids Twitter account. Participants were invited to rate the head shapes as "normal" or "abnormal."

RESULTS

The 538 participants completed the online survey. Participants were able to reliably and consistently identify normal and abnormal head shapes with a Kappa Score >0.775. Furthermore, participants indicated that a correction of 70% is required in order for the cranial deformity to be regarded as "normal." This threshold closely reflects a normal Cranial Index, which is a widely used morphometric outcome in craniosynostosis.

CONCLUSION

Crowdsourcing provides an ideal method for capturing the general population's perspective on what constitutes a normal and acceptable head shape in children with sagittal craniosynostosis. Laypersons are able to reliably and consistently distinguish cranial deformities from a "normal" head shape. The public indicates a threshold correction of 70% in sagittal craniosynosis to regard it as a "normal" head shape.

Facial attractiveness of cleft patients: a direct comparison between artificial-intelligence-based scoring and conventional rater groups

OBJECTIVES

To evaluate facial attractiveness of treated cleft patients and controls by artificial intelligence (AI) and to compare these results with panel ratings performed by laypeople, orthodontists, and oral surgeons.

MATERIALS AND METHODS

Frontal and profile images of 20 treated left-sided cleft patients (10 males, mean age: 20.5 years) and 10 controls (5 males, mean age: 22.1 years) were evaluated for facial attractiveness with dedicated convolutional neural networks trained on >17 million ratings for attractiveness and compared to the assessments of 15 laypeople, 14 orthodontists, and 10 oral surgeons performed on a visual analogue scale (n = 2323 scorings).

RESULTS

AI evaluation of cleft patients (mean score: 4.75 ± 1.27) was comparable to human ratings (laypeople: 4.24 ± 0.81, orthodontists: 4.82 ± 0.94, oral surgeons: 4.74 ± 0.83) and was not statistically different (all Ps ≥ 0.19). Facial attractiveness of controls was rated significantly higher by humans than AI (all Ps ≤ 0.02), which yielded lower scores than in cleft subjects. Variance was considerably large in all human rating groups when considering cases separately, and especially accentuated in the assessment of cleft patients (coefficient of variance-laypeople: 38.73 ± 9.64, orthodontists: 32.56 ± 8.21, oral surgeons: 42.19 ± 9.80).

CONCLUSIONS

AI-based results were comparable with the average scores of cleft patients seen in all three rating groups (with especially strong agreement to both professional panels) but overall lower for control cases. The variance observed in panel ratings revealed a large imprecision based on a problematic absence of unity.

IMPLICATION

Current panel-based evaluations of facial attractiveness suffer from dispersion-related issues and remain practically unavailable for patients. AI could become a helpful tool to describe facial attractiveness, but the present results indicate that important adjustments are needed on AI models, to improve the interpretation of the impact of cleft features on facial attractiveness.

Validating the Asher-McDade score to assess facial aesthetic outcomes in 22 consecutive complete bilateral cleft lip repairs

Most scoring systems used to assess facial aesthetics in cleft patients tend to lack consistency, and the absence of an internationally agreed system makes comparison challenging. The most widely used and validated tool is the five-point Asher-McDade index. We note that there are currently no reports (to our knowledge) of its use for scoring outcomes after bilateral cleft lip repair. To validate it for this use, the aim was to describe the outcomes of 22 consecutive bilateral cleft lip repairs assessed using this scale. A retrospective review was undertaken of 22 consecutive patients with bilateral cleft lip repairs performed at our centre. Each patient underwent bilateral advancement rotation repair with a vomer flap on one side at three months followed by repair of the remaining hard palate and an intravelar veloplasty three months later. Standardised photographs were taken five years after repair and were cropped to isolate the nasolabial component. Eleven members of the cleft multidisciplinary team were asked to rate each image on a five-point Likert scale. Statistical analysis was performed using a two-way ANOVA test and intraclass correlation coefficient to interrogate intraobserver and interobserver variance. A total of 22 consecutive patients with complete bilateral cleft lips were photographed. The overall mean (range) score for the repairs was 3.2 (4.3 - 1.8). Two-way ANOVA demonstrated that inter-rater variability accounted for just over 10% (11.23% of the total variance, p < 0.0001). As predicted, the single biggest factor affecting score variability was the patient's appearance, which accounted for 44.51% of the total variance between scores (p < 0.0001). Intraobserver variance was not found to be significant, accounting for 0.33% of the total variance (p = 0.0006). We demonstrate that the Asher-McDade scoring system is a valid tool to use when assessing bilateral cleft lip repairs. Variance in the patient's score was significantly related to a true difference in appearance, with only a small percentage of differences being due to intraobserver and interobserver variation.

Evaluation of Divine Proportions in Face and Smile of Patients With Unilateral Cleft Lip and Palate

INTRODUCTION AND AIM

The facial view of patients with cleft lip and palate greatly affects their psychological well-being and usually leads to introspection. The aim of this study was to compare the face and smile of cleft lip and palate patients and normal population with divine proportion.

METHOD

In this retrospective study, 20 female patients (14-25 years) with unilateral cleft lip and palate, who referred to Orthodontic Department of Mashhad School of Dentistry, were selected. The control group consisted of 10 normal female persons with ideal face and normal occlusion. After scanning photographs of full face, profile, and smile views of them, the divine proportions were measured by Photoshop software. Then the data were entered into SPSS software version 22 and analyzed using 2 sample independent t test. P value less than 0.05 were considered as significant.

RESULTS

In the study group all proportions were significantly less than the golden proportion. Ls-Rcus/Rch-Rcus and Ls-Lcus/Lch-Lcus had the least difference and Sn-Sm/N-Sn and Sn-Sm/Sm-Me had the most. In the control group, all proportions except Ls-Lcus/Lch-Lcus and Ls-Rcus/Rch-Rcus, were less than the golden proportion. Sn-Sm/N-Sn had the most difference and N-Sn/Sm-Me had the least.Approximately all proportions in cleft patients were significantly different from normal population. Ls-Lcus/Lch-Lcus had the highest difference between study and control group; however, Tr-Sn/Tr-Me in both groups were equal.

CONCLUSIONS

The differences between facial indices in cleft lip and palate patients, normal people and golden proportion were significant. As facial proportions of normal people in the authors' study were also different from divine proportions, the authors can conclude that to reach acceptable esthetic results, the authors can approximate patients to normal populations. Unfortunately, the patients with large bone defects, cannot reach to the "esthetic" divine proportion even after reconstructive surgery.

Autologous versus prosthetic nasal and auricular reconstruction - patient, professional and layperson perceptions

The aim of this study was to retrospectively evaluate the perceptions of aesthetic outcome following the autologous and prosthetic reconstruction of nasal and auricular defects among patients, professionals (oral and maxillofacial surgeons and ear, nose and throat surgeons) and people unfamiliar with reconstructive surgery. The influence of anatomical subunits on the overall perception of nasal and auricular reconstructions was also determined. A total of 119 patients treated for nasal and auricular defects between 1997 and 2016, with a minimum follow-up period of 6 months, were selected, and photographs of 77 of these patients (65%) were presented in a digital survey and reviewed using a standardized questionnaire. No clinically relevant correlations were found between the age or gender of patients (as well as those of the respondents) and their scores. Prosthetic reconstructions of nasal and auricular defects were considered advantageous over autologous reconstructions in terms of the subjective aesthetic outcome in the view of the professionals, in particular oral and maxillofacial surgeons; however, the patients judged both techniques to be equally effective in terms of aesthetics. No anatomical subunits were found to have a significant impact on the overall match of a nasal or auricular reconstruction with the patient's face.

Appearance of congenital hand anomalies

Background and objective:

Impact of appearance of congenital hand anomalies has not previously been reported. The purpose of this study was to describe the common perception about how different congenitally malformed hands look.

Methods:

We developed a questionnaire in a game format to evaluate the appearance of different hands. Altogether 1450 (954 females) 4- to 84-year-old residents (296 children) of two European and one Asian (n = 102) country were asked to rate the appearance of different looking hands on a five-point pictorial Likert-type scale. Standardized photographs of the dorsal aspect of 17 different congenitally malformed non-operated hands and a normal hand were presented to respondents. Significance of age, gender, nationality, and profession of the respondents was assessed.

Results:

The respondents’ ranking order of the hands was nearly consistent. The normal hand (mean = 4.43, standard deviation = 0.85, Md = 5) and clinodactyly (mean = 4.37, standard deviation = 0.86, Md = 5) were perceived to have the best appearance. Symbrachydactyly (mean = 1.42, standard deviation = 0.68, Md = 1) and radial club hand (mean = 1.40, standard deviation = 0.68, Md = 1) received the lowest scores. Adults rated the appearance of hands higher than children regarding 14 hands, females higher than men regarding 15 hands, and Europeans higher than Asians in 4 hands (p < 0.05, respectively). Europeans rated four-finger hand (mean = 3.21, standard deviation = 1.18, Md = 3) better looking than six-finger hand (mean = 2.92, standard deviation = 1.18, Md = 3, p < 0.005), whereas Asians gave higher scores to six-finger hand (mean = 2.66, standard deviation = 1.26, Md = 3) compared to four-finger hand (mean = 2.51, standard deviation = 1.14, Md = 2). Medical doctors and nurses gave higher scores compared to the other profession groups, school children, and high school students in five hands (p < 0.05).

Conclusions:

A normal hand is perceived distinctly better looking than most congenitally different hands. Different malformations’ appearance was ranked very coherently in the same order despite of participants’ age, gender, nationality, or profession. Asians seem to prefer an additional digit to a four-finger hand.

Evaluation of nasolabial aesthetics by different groups in operated unilateral cleft lip and palate

AIM

The aim of this study is to evaluate and to compare the perception of nasolabial aesthetic by experienced professionals, inexperienced professionals, cleft patients and laypersons in children with unilateral cleft lip and palate (UCLP) using the Asher-McDade Scoring System.

MATERIALS AND METHODS

In this retrospective study, 75 patients who applied to Ege University, Faculty of Dentistry, Department of Orthodontics and whose primary surgery operations were completed in Ege University, Faculty of Medicine Department of Plastic and Reconstructive Surgery, were evaluated from the extra-oral and profile photographs. All photographs were arranged according to Asher-McDade Scoring System and evaluated by 4 different groups. 5 people were evaluated in each group consisting of experienced professionals, inexperienced professionals, cleft patients and the laypersons. Nasal form, nasal deviation, vermilion border and nasal profile were evaluated in 5 different categories according to Asher-McDade Scoring System. Statistical analyzes were performed using STATA 11 and MEDCALC software. G Power, Fleiss Kappa, Weighted Kappa and Friedman statistical analyzes were performed for determination of number of individuals, interobserver and intraobserver reliability and comparison of scoring between groups, respectively.

RESULTS

In this study, the interobserver agreement was found to be between 0.75 and 0.80 that shows a high degree of reliability. In the comparision made between the groups; experienced professionals and inexperienced professionals; there was moderate agreement in nasal profile scoring (WK 0.2857) (-0.9673/0.6596). There was agreement between experienced professionals and cleft patients in mostly vermilion border (WK 0.5454) (-0.1643/1.0000). There was no agreement between vermilion border between inexperienced professionals and cleft patients (WK 0.9230) (-1.0000/-0.2878), and compliance with the nasal profile mostly (WK 0.5454) (-0.1643/1.0000). There was a similar insignificant agreement between experienced and inexperienced professionals, cleft patients among the laypersons, at all values (WK 0,0000) (-0.0000/0.0000). According to the scoring results of the photographs for experienced professionals; nasal form, nasal deviation, vermilion border and nasal profile were evaluated as bad and close the bad (4.00±0.00, 3.80±0.44, 3.80±0.44, 3.60±0.54); it was found fair and near the bad for inexperienced professionals (3.00±0.00, 3.00±0.00, 3.40±0.54 3.20±0.44) and close the bad for cleft patients (3.60±0.54, 3.80±0.44, 3.80±0.44, 3.40±0.54). But it was found to be acceptable and good for laypersons (2.00±0.00, 2.00±0.00, 2.40±0.54, 1.40±0.54). Laypersons showed statistically significant difference in the evaluation of nasal form, nasal deviation and nasal profile from the cleft patients (P<0.05), while they showed statistically significant difference in all the score from the experienced professionals (P<0.05, P<0.01).

CONCLUSION

The aesthetic appearance of nasolabial region is one of the important tools to evaluate the success of the treatment in patients with CLP. The success of primary surgery has one of the most important effects for nasolabial aesthetics on patients with clefts. As a result of the study, the evaluation of cleft patients was found to be similar to that of experienced professionals and lower than that of inexperienced professionals and the laypersons. This result shows us that patients with CLP have higher awareness of self-perception, but these patients may have psychosocial problems ranging from low self-esteem to social isolation risk.

The Effect of Cleft Orthognathic and Nasal Reconstruction on Perceived Social Traits

The investigators hypothesized that a layperson’s social perceptions of an adolescent cleft lip and palate (CL/P) patient are more favorable after orthognathic surgery and definitive nasal reconstruction.

Facial esthetic outcome of functional followed by fixed orthodontic treatment of class II division 1 patients

OBJECTIVES

To assess the perceived facial changes in class II division 1, convex profile patients treated with functional followed by fixed orthodontic appliances.

SUBJECTS AND METHODS

The study sample consisted of 36 pairs of pre- and post-treatment photographs (frontal and profile, at rest) of 12 patients treated with activator, 12 with twin-block, and 12 controls with normal profiles, treated without functional appliances. All photographs were presented in pairs to 10 orthodontists, 10 patients, 10 parents, and 10 laypersons. Visual analog scale (VAS) ratings of changes in facial appearance were assessed.

RESULTS

The patient groups were similar in sex distributions, age, and treatment duration. The different rater groups showed strong to excellent agreement. There were no significant differences among treatment groups (F = 0.91; P = 0.526; Wilks lambda = 0.93), raters (F = 1.68; P = 0.054; Wilks lambda = 0.83), and when testing the combined effect of treatment and rater on the results (F = 0.72; P = 0.866; Wilks lambda = 0.85). The raters detected slightly more positive changes in the activator and twin-block groups, compared to the control group, regarding the lower face and the lips, but these findings did not reach significance. Furthermore, their magnitude hardly exceeded 1/20th of the total VAS length.

LIMITATIONS

Retrospective study design.

CONCLUSIONS

The perceived facial changes of convex profile patients treated with functional, followed by fixed orthodontic appliances, did not differ from those observed in normal profile patients, when full-face frontal and profile photos were simultaneously assessed. Consequently, professionals should be skeptical regarding the improvement of a patient's facial appearance when this treatment option is used.

Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons

BACKGROUND

Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision.

METHODS

Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05.

RESULTS

The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44).

CONCLUSIONS

All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.

Comparison of professional and laypeople evaluation of nasolabial esthetics following unilateral cleft lip repair

Objectives:

The objective is to know the extent of agreement of clinicians’ perception of nasolabial esthetic compared to that of laypeople (parents).

Materials and Methods:

This was a prospective study of comparison of clinician's perception of nasolabial esthetics with that of laypeople following surgical repair of UCL. Participants were recruited from the Cleft Clinic of the Lagos University Teaching Hospital, and surgical repair of the cleft was performed under general anesthesia. Surgical evaluation was done through direct clinical evaluation using the modified form of the Christofides’ criteria by laypeople and professionals.

Results:

A total of 48 cleft participants were enrolled in the study. The evaluation of the lip by both the laypeople and professionals was similar, and there was no difference (0.588) in their rating. However, there was a significant disagreement (P = 0.001) between them in the nose assessment.

Conclusion:

Neither the solitary opinion of the professionals nor that of the laypeople is satisfactory in the evaluation of facial esthetics; both are equally important, especially in the assessment of nasal esthetics. However, opinion of either the laypeople or the professional might be enough in the evaluation of the lip esthetics.

Lay People Esthetic Evaluation of Primary Surgical Repair on Three-Dimensional Images of Cleft Lip and Palate Patients

Background and Objectives: Previous literature has disclosed that facial attractiveness affects the esthetic evaluation of nose and lip deformity on frontal and lateral photographs. However, it has never been debated if the removal of the external facial features on three-dimensional (3D) models ("cropped assessment bias") could provide a considerable usefulness in the interpretation and comparison of the results. Additionally, it has been assumed on two-dimensional (2D) studies that esthetic assessment biases with respect to observer gender, and it is not acknowledged if and to the extent that "gender assessment bias" may be influenced by a three-dimensional layout. The aim of this study is to investigate if facial traits and observers' gender may affect the esthetic ratings of unilateral cleft lip and palate (UCLP) patients after soft tissue reconstruction. Materials and Methods: Three-dimensional images of ten UCLP patients' images were acquired before the intervention (T0), one-month (T1) and six-months (T2) postoperative. Geomagic^® software (version 2014; 3D Systems, Rock Hill, SC, USA) was used to remove the external facial features of 3D surface models. Five-point scale developed by Asher-McDade et al. was used to rate both nasolabial attractiveness and impairment for full-face (FF) and cropped-face (CF) 3D images. Forty-three judges (21 males, 22 females) were enrolled for the esthetic evaluation. Intraclass correlation coefficient (ICC) was used to test intra- and inter-examiner reliability; a value of 0.7 was set as the minimum acceptable level of reliability. Results: When comparing the 2 sets of observations (FF and CF), the ICC ranged from 0.654 to 0.823. Concerning gender assessment bias, the ICC ranged from 0.438 to 0.686 and from 0.722 to 0.788 for males and females, respectively. Concerning inter-examiner reliability, ICC for questions 2-7 ranged from 0.448 to 0.644 and from 0.659 to 0.817 at T0 and T2, respectively. Conclusions: The removal of external facial features provides subtle differences on the esthetic assessment of UCLP patients. Moreover, based on our data, examiners' gender differences may affect esthetic assessment of UCLP patients. Despite the subjectivity of esthetic judgments, a reliable, validated and reproducible scoring protocol should consider the influence of gender differences on 3D esthetic assessment of UCLP patients.

Is There a Correlation Between Nasolabial Appearance and Dentoalveolar Relationships in Patients With Repaired Unilateral Cleft Lip and Palate?

OBJECTIVE

To determine whether a relationship exists between the aesthetic scores given to photographic records of the nasolabial region of patients with repaired unilateral cleft lip and palate (UCLP) and the 5-Year Olds' Index scores of study models for the same participants.

DESIGN

Retrospective study.

SETTING

University of Bristol Dental Hospital, United Kingdom.

PARTICIPANTS

Patients with nonsyndromic UCLP previously enrolled in the Cleft Care UK (CCUK) Study.

METHODS

The CCUK participants, who had both study models and photographs (frontal and worm's eye view), were identified and their records retrieved. These were rated by 2 consultants and 2 senior registrars in orthodontics. The 5-Year Olds' Index was used to score the study models, and at a separate sitting, a 5-point Likert scale was used to score the cropped frontal and worm's eye view photographs of the same children. The results were analyzed using intraclass correlation coefficients and Cohen κ.

MAIN OUTCOME MEASURES

Correlation between the aesthetic scores of the photographic views and the concordant 5-Year Olds' Index scores of the study models.

RESULTS

The intraclass correlation coefficient scores showed very poor agreement between the photographic views and their concordant study models. The level of inter- and intra-rater reliability was strongest when scoring the study models.

CONCLUSIONS

There was no agreement between the scores given to various photographic views and their corresponding study models. Scoring the study models using the 5-Year Olds' Index was the most reliable outcome measure for this age-group.

Do Cleft Lip and Palate Types Affect Health-Related Quality of Life of Adolescents?

The adolescent with oral cleft must deal with the process of body changing and the psychological implications caused by morphological, functional, and esthetic impairments of the cleft itself. This study aimed to evaluate whether the cleft lip and palate types affects health-related quality of life of adolescents through Short-form Health Survey (SF-36) questionnaire. Fifty-seven adolescents (29 males and 28 females; mean age 15 years and 11 months ± 1 year and 2 months) were divided into 2 groups: Group 1-single cleft-unilateral or bilateral CL or CP; Group 2-complex cleft-unilateral or bilateral cleft lip and palate. The participants filled in SF-36 questionnaire to verify their functional, physical, and mental well-being profile. Spearman test assessed SF-36 scores correlation with age. Mann-Whitney U test verified the differences between genders and cleft types. Linear regression models were used to analyze confounding factors (age and gender). P was set at <0.05. The different SF-36 domains weakly correlated with age, ranging from -0.07 (P = 0.60) for the social aspects and 0.31 (P = 0.02) for general health. Females had statistically lower SF-36 scores than males in the domains Bodily pain (P = 0.02), Vitality (P < 0.001), and Mental Health (P < 0.001). G1 showed lower scores in the domains Limitations due to Emotional Problems (P = 0.008) and Mental Health (P = 0.036). However, when the confounding factors (age and gender) were analyzed, the oral cleft type did not affect health-related quality of life (P > 0.05). Considering the age and gender, the cleft lip and palate types did not affect the health-related quality of life of adolescents.

Conscious Perception of Facial Asymmetry in a Unilateral Cleft Lip Model

OBJECTIVE

Lip asymmetry after a unilateral cleft lip repair can be perceived as an unsatisfactory result. The objective of this study is to determine the degree of upper lip asymmetry and/or nasal alar hooding required for recognition of asymmetry in a simulated model of unilateral cleft lip.

DESIGN

A model of unilateral cleft lip was created using digital morphing software to simulate asymmetries in vermilion height and nasal hooding in photographs of children. Volunteers were shown photographs for different time intervals and with varying degrees of asymmetry. Ability to detect facial asymmetry was recorded and analyzed.

SETTING

This study was conducted by surveying layperson volunteers in public community settings.

PARTICIPANTS

108 layperson volunteers were randomly surveyed.

MAIN OUTCOME MEASURES

The primary outcome measure was a reported lip or nose asymmetry by the volunteers. Proportions and corresponding 95% confidence intervals were obtained to estimate the probability of reporting an asymmetry at 3- and 10-second intervals.

RESULTS

After 3- and 10-second exposure, labial asymmetry was perceived by ≥50% of subjects at 2 mm (62%, P = .001) and 1 mm (89%, P < .0001), respectively. Nasal asymmetry was detected by <50% of subjects at 3 seconds, but ≥50% perceived a 3-mm alteration at 10 seconds (64%, P < .0001). Photographs with combined nasal and labial modification did not lower the threshold for asymmetry perception compared to either deformity alone.

CONCLUSIONS

This study is the first to determine a predictable millimeter threshold for perceived asymmetry in cleft lip deformity using a digital model.

Development and Application of a Novel Patient-Reported Outcome Measure on QoL and Facial Aesthetics-A Study on South Indian Population

BACKGROUND

The goal of cleft therapy has progressed from simply correcting the deformity to uplifting the patient's quality of life (QoL). At the end of comprehensive treatment, a patient with cleft lip and palate (CLP) should report with satisfactory QoL scores in all domains such as aesthetics, speech, function, and psychology.

OBJECTIVE

To develop and validate a novel, disease-specific questionnaire designed in 2 regional languages to assess the QoL in young adult patients with CLP of South India following comprehensive treatment.

METHODS

A preliminary questionnaire was created from the literature review and patient interviews, considering regional sociodemographic conditions. The questionnaire was then validated by subject experts and pilot tested. The resultant tool was implemented on patients at treatment completion. Data collected were assimilated for statistical evaluation.

RESULTS

The questionnaire was deemed reliable (Cronbach α = .854 and test-retest reliability, κ = 0.8) and was administered to 100 young adult patients with CLP (mean age: 22 years). A large majority (83%) of the population felt more confident about themselves, with positive responses to familial relations, social interaction, and self-image. About 25% of the patients faced problems with speech regularly, while a majority of patients did not face problems with chewing and swallowing. Nearly 60% of patients were fully satisfied with their facial appearance, while others had concerns about their lip and nose aesthetics. The results were descriptive of the local population.

CONCLUSIONS

Most patients achieved satisfactory QoL in all domains following comprehensive multispeciality therapy. The novel tool is simple, reliable, and can be adapted to homogenous population groups.

Aesthetic perceptions and psychosocial impact of malocclusion: comparison between cleft and non-cleft patients and their parents

Objective

To evaluate the influence of dentofacial attractiveness using the 'Psychosocial Impact of Dental Aesthetics Questionnaire' (PIDAQ), Satisfaction with Life Scale (SWLS) and Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN) in patients with cleft lip/palate (CLP), and non-cleft orthodontic patients (Non-CLP) and their parents.

Materials and methods

Eighty patients (aged 11-19 years) comprising 40 CLP and 40 non-CLP were administered the PIDAQ and SWLS questionnaires to be rated individually by the patients, along with IOTN-AC rated by the patients and their parents, respectively. The subjects were also sub-divided according to their age, i.e. pre-adolescent and adolescent.

Results

The PIDAQ subpart scores for aesthetic concern differed between the two groups, with a significantly (P < 0.02) lower scoring for the CLP group. The adolescent CLP group scored more negatively than the pre-adolescent group in the dental self-confidence and social impact sub-parts of PIDAQ. No significant differences were observed for satisfaction with life. The parents' IOTN-AC score for both groups was significant (P < 0.05) greater than the patient's score, especially for adolescent subjects.

Limitations

Non-condition specific questionnaires with restrictive sampling sizing and non-inclusion of parameters like stress coping mechanism etc.

Conclusion

The parents rated the malocclusion of their child more critically than the child itself. A majority of the CLP group had a problem in identifying themselves using the IOTN-AC as no photo existed depicting a Class III or edge-to-edge malocclusion. Attitudes, especially perceptions of the aesthetics of front teeth, are crucial factors influencing patient's psychological self-concept, social confidence, and treatment need in CLP patients and non-CLP patients, having more relevance as the patient matures towards adolescence and adulthood.

Facial and midfacial symmetry in cleft patients: Comparison to non-cleft children and influence of the primary treatment concept

PURPOSE

Patients with cleft lip, alveolus and palate (CLAP) may suffer from marked asymmetry with an impact on attractiveness and psychosocial aspects. The aim of this study was to assess symmetry in CLAP patients compared to non-cleft controls of similar age with regard to cleft type and treatment concept.

MATERIALS AND METHODS

In CLAP patients with different cleft forms and in healthy non-cleft subjects (control group) a three-dimensional stereophotogrammetric face scan was performed and an objective 3D asymmetry index (AI) was calculated for the whole face, the midface, the upper lip and the nose.

RESULTS

In total, 305 patients were included: 140 CLAP patients (90 male, 50 female, mean age 9.9 ± 3.6 years) and 165 controls (87 male, 78 female, mean age 8.7 ± 2.1 years). In general, CLAP patients showed significantly higher asymmetry than controls, with the most severe asymmetry found in unilateral complete CLAP. Patients treated according to an actual concept considering reconstruction of all affected muscular systems had a significant lower and more favourable AI than patients not treated according to this concept (p < 0.05).

CONCLUSION

An adequate treatment concept is essential to achieve better results concerning symmetry in CLAP, but symmetry values of healthy non-cleft controls are not reached.

Difference and Commonness Among CLP, NON-CLP Patients and Their Parents Seeking for Orthodontic Treatment: A Questionnaire Applying Q Methodology to Investigate Motives

PURPOSE

Based on Q methodology, this study investigated the motivation of orthodontic treatment for patients and their parents. Through investigation, this paper attempts to explore the motivational factors of CLP and NON-CLP children and their parents, which are different or general.

PATIENTS AND METHODS

Q methodology involves 4 phases. (1) Interviews of CLP (N=5), NON-CLP (N=5) patients generated 30 statements (Q-set 1) and CLP (N=5), NON-CLP (N=5) patients' parents produced 36 statements (Q-set 2) about different reasons to pursue orthodontic care. (2) P-set: recruitment participants. The sample comprised 40 CLP patients (G1) and 40 NON-CLP patients (G2) aged 9-16 years, 40 CLP patients' parents (G3) and 40 NON-CLP patients' parents (G4) wanting their children to have orthodontic treatment. (3) Q-sort: 4 groups ranked statements in order of comparative significance using enforced distribution grids (G1, G2 ranked Q-set 1; G3, G4 ranked Q-set 2). (4) Analysis: using the PQMehtod 2.35 vision to analyze data.

RESULTS

Three factors in each group were identified as representing the most widespread views of the majority of the participants, described as G1: (1) aesthetics, (2) preparation for other oral treatments, (3) timely. G2: (1) admiration of others, aesthetics, (2) oral function, (3) oral hygiene and improvement of smile. G3: (1) worrying about the future of children, parents' responsibilities, children's feelings; (2) mental health, timely; (3) parents' responsibilities, ready for treatment. G4: (1) aesthetics, children's will; (2) future problems, timely; (3) timely, parents' responsibility and no need to worry about physical problems.

CONCLUSION

CLP and NON-CLP patients and parents have different orthodontic treatment motives, yet, they still shared 3 global motivation themes, respectively. Consideration of these motives may help clinicians develop their treatment discussions with patients and parents, which could consequently improve their cooperation and may achieve a more satisfactory outcome.

Development of the Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Pilot Study

Objective:

To develop the “Submental Nasal Appearance Scale” (SNAS), which is an easy-to-use objectified tool to represent a cleft surgeon’s standard for assessment of the nasal appearance from the submental perspective.

Design:

Eighty-five photographs of patients with unilateral complete cleft lip and palate were selected and cropped, displaying the submental view. Sixty-one photographs were used to develop 5 sets of reference photographs. Three cleft surgeons graded 24 photographs with these sets and subjectively graded the overall nasal appearance as well. Internal agreement for both methods was calculated, as well as correlation between them. The SNAS was created, by only using the combination of sets that showed the highest reliability and correlation.

Setting:

Boston Children’s Hospital, Boston, Massachusetts.

Patients:

Six- to 9-year-old patients with unilateral complete cleft lip and palate.

Results:

The intrarater and interrater reliability was 0.84 and 0.79, respectively, for the SNAS and 0.76 and 0.62, respectively, for the overall appearance assessment. The correlation was 0.74 between the methods.

Conclusions:

The SNAS is a reliable tool that reflects a cleft surgeon’s standard and could be used independently or in combination with existing rating scales using the frontal and/or lateral view, for assessment after cleft lip repair.

Nasolabial aesthetics of patients with repaired unilateral cleft lip and palate: A comparison of three rating methods in two countries

OBJECTIVES

The study aimed to compare nasolabial aesthetics of patients with unilateral cleft lip and palate (UCLP) treated in Vietnam and Estonia using three rating methods: five-point aesthetic index, a visual analogue scale (VAS), and reference scores method.

METHODS

A total of 56 patients with repaired UCLP (23 from Vietnam and 33 from Estonia) were included in this cross-sectional study. Patients' facial and profile photographs were cropped to reveal the nasolabial region and coded. Five examiners rated nasolabial aesthetics of the patients using three methods: five-point aesthetic index, 100 mm VAS, and reference scores method. Intraclass correlation coefficients were used to evaluate intrarater and interrater reliabilities.

RESULTS

The five-point aesthetic index had a higher reliability than VAS and reference scores method. The least aesthetic feature among Vietnamese and Estonian patients was nasal symmetry and nasolabial profile respectively. No differences in nasolabial aesthetics were found between Vietnamese and Estonian patients regardless of the rating methods (p > 0.05) except for nasal symmetry.

CONCLUSIONS

The five-point aesthetic index seems to produce more reproducible results. There were no significant differences in nasolabial aesthetics between the two countries. Overall average nasolabial appearance results were obtained using different treatment protocols in the two countries.

Factors affecting subjective appearance evaluations among patients with congenital craniofacial conditions: An application of Cash's cognitive-behavioural model of body image development

Satisfaction with appearance is of central importance for psychological well-being and health. For individuals with an unusual appearance, such as congenital craniofacial anomalies (CFA), appearance evaluations could be especially important. However, few, if any papers have presented a comprehensive synthesis of the factors found to affect subjective satisfaction with appearance among children, adolescents, and adults born with a CFA. Further, only a handful of craniofacial studies have applied psychological theories or models to their findings, resulting in an overall lack of guidance for researchers in the field. This paper summarises the literature pertaining to satisfaction with appearance among those affected by CFAs, and examines the extent to which Cash's cognitive-behavioural model of body image development (2012) fits with this literature. Given the overlap between factors of interest in the field of CFAs, and in the area of body image more broadly, a closer collaboration between the two research fields is suggested.

Evaluation of Facial Appearance in Patients with Cleft Lip and Palate by Laypeople and Professionals: A Systematic Literature Review

Objective

To identify whether laypeople and professionals rate the facial appearance of patients with cleft lip and palate (CLP) similarly based on viewing full facial images.

Design

Several electronic databases were searched. A hand search was performed among reference lists and relevant journals. Studies that assessed the full facial appearance of patients with CLP based on two-dimensional (2D) photographs, 3D images, or clinical examination by laypeople and professionals using a visual analog scale (VAS) or a categorical rating scale were included. Two authors independently assessed articles using methodologic-quality scoring protocol.

Result

Eleven articles were included in qualitative synthesis, including four high-level and seven moderate-level papers. Three studies found that laypeople were more critical than professionals, three found there was no significant difference between laypeople and professionals, and five reported that professionals were more critical than laypeople when assessing facial appearance of patients with CLP.

Conclusions

It still remains unknown whether laypeople are more or less critical than professionals when rating facial appearance of patients with repaired CLP. Professionals are more familiar with the esthetic outcomes and difficulties of treating patients. The opposite maybe true for laypeople; this disparity between what is achievable by professionals and what is expected by laypeople may be a source of dissatisfaction in facial appearance outcome. Further well-designed studies should be carried out to address this question and the clinical significance of the difference in rating scores for patients with CLP.

Patient and parent reported outcome measures in cleft lip and palate patients before and after secondary alveolar bone grafting

European and Northern American healthcare authorities increasingly encourage the use of Patient Reported Outcome Measures (PROMs) that complement clinical and laboratory assessments to help holistically evaluate reconstructive outcomes. This is the first study to evaluate PROMs in cleft lip/palate patients who have, or have not, undergone secondary alveolar bone grafting (SABG).A PROMs study was conducted; 40 consecutive consenting cleft lip/palate children between 8 and 14 years old were included. Twenty patients did, and 20 patients did not, have SABG. PROMs scores from children and parents in the 2 groups were compared.Forty patients completed the trial. No significant differences in total score from the Chang Gung Short Form-15 (CGSF-15) were found between children and their parents. Children with SABG reported no more oral-nasal regurgitation than children without SABG, but tended to report more nasal obstruction. There were no statistically significant differences in parent reported outcomes between the 2 groups.Cleft lip/palate patients who underwent SABG reported significantly less nasal regurgitation and more nasal obstruction compared to those patients who did not undergo SABG.

Electromyographic analysis of superior orbicularis oris muscle function in children surgically treated for unilateral complete cleft lip and palate

PURPOSE

The aim of this study was to assess the electrical activity of the superior orbicularis oris muscle in children surgically treated for unilateral complete cleft lip and palate (UCCLP).

MATERIAL AND METHODS

The sample comprised 45 patients 6.38-12.68 years of age with UCCLP and 40 subjects 6.61-11.71 years of age with no clefts. Electromyographical (EMG) recordings were taken with a DAB-Bluetooth Instrument (Zebris Medical GmbH, Germany) in the rest position and during saliva swallowing, lip protrusion and reciprocal compression of the lips, as well as while producing the phonemes /p/, /b/, and /m/ combined with the vowel /a/.

RESULTS

The electrical activity of the upper lip during saliva swallowing and lip compression was significantly greater in the cleft group. Similar resting level activity was observed in both groups. During the production of the /p/, /b/, and /m/ phonemes combined with the vowel /a/ the results showed no significant differences in the EMG activity between children with UCCLP and noncleft subjects.

CONCLUSION

Patients with UCCLP have abnormal upper lip function characterized by increased activity of the superior orbicularis oris muscle during saliva swallowing and lip compression, and this may affect facial morphology.

Perceived facial changes of Class II Division 1 patients with convex profiles after functional orthopedic treatment followed by fixed orthodontic appliances

INTRODUCTION

The aim of this research was to investigate the perceived facial changes in Class II Division 1 patients with convex profiles after functional orthopedic treatment followed by fixed orthodontic appliances.

METHODS

Pretreatment and posttreatment profile photographs of 12 Class II Division 1 patients treated with activators, 12 Class II Division 1 patients treated with Twin-block appliances, and 12 controls with normal profiles treated without functional appliances were presented in pairs to 10 orthodontists, 10 patients, 10 parents, and 10 laypersons. The raters assessed changes in facial appearance on a visual analog scale. Two-way multivariate analysis of variance was used to evaluate differences among group ratings.

RESULTS

Intrarater reliability was strong in most cases (intraclass correlation coefficients, >0.7). The internal consistency of the assessments was high (alpha, >0.87), both within and between groups. The raters consistently perceived more positive changes in the Class II Division 1 groups compared with the control group. However, this difference hardly exceeded 1/10th of the total visual analog scale length in its highest value and was mostly evident in the lower face and chin. No significant differences were found between the activator and the Twin-block groups.

CONCLUSIONS

Although the raters perceived improvements of the facial profiles after functional orthopedic treatment followed by fixed orthodontic appliances, these were quite limited. Thus, orthodontists should be tentative when predicting significant improvement of a patient's profile with this treatment option.

Crowdsourcing as a Novel Method to Evaluate Aesthetic Outcomes of Treatment for Unilateral Cleft Lip

BACKGROUND

Lack of convenient and reliable methods to grade aesthetic outcomes limits the ability to study results and optimize treatment of unilateral cleft lip. Crowdsourcing methods solicit contributions from a large group to achieve a greater task. The authors hypothesized that crowdsourcing could be used to reliably grade aesthetic outcomes of unilateral cleft lip.

METHODS

Fifty deidentified photographs of 8- to 10-year-old subjects (46 with unilateral cleft lip and four controls) were assembled. Outcomes were assessed using multiple pairwise comparisons that produced a rank order (Elo rank) of nasal appearance and, on a separate survey, by Asher-McDade ratings. Both surveys were repeated to assess reliability. A group of expert surgeons repeated the same tasks on a smaller subset of photographs.

RESULTS

The authors obtained 2500 and 1900 anonymous, layperson evaluations by means of crowdsourcing on each Elo rank and Asher-McDade survey, respectively. Elo rank and Asher-McDade scores were highly reproducible (correlation coefficients, 0.87 and 0.98), and crowd evaluations agreed with those by expert surgeons (0.980 and 0.96 for Elo rank and Asher-McDade score, respectively). Crowdsourcing surveys were completed within 9 hours, whereas the expert surgeons required 3 months. On further analysis of their cleft subject sample set, the authors found that greater initial cleft severity was associated with worse aesthetic outcome.

CONCLUSIONS

Outcomes assessed by crowds were reliable and correlated well with expert assessments. Crowdsourcing allows acquisition of massive numbers of layperson assessments on an unprecedented scale, and is a convenient, rapid, and reliable means of assessing aesthetic outcome of treatment for unilateral cleft lip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Facial Aesthetic Outcomes of Cleft Surgery: Assessment of Discrete Lip and Nose Images Compared with Digital Symmetry Analysis

BACKGROUND

High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores.

METHODS

Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program.

RESULTS

Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking.

CONCLUSIONS

Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate

PURPOSE

Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision.

METHODS

The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children.

RESULTS

In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41).

CONCLUSIONS

Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.