Toward reducing the surgical burden of care: Modern longitudinal life-changing concept in cleft care

Reducing delayed detection of isolated cleft palate-related deformity: a call for routine intraoral examination of newborns

OBJECTIVE

To provide healthcare professional-friendly practical recommendations for early detection of cleft palate-related deformities in newborns and offer an overview of managing these high-prevalent congenital abnormalities.

SOURCE OF DATA

PubMed, SciELO, Lilacs, Cochrane, ScienceDirect, and Scopus databases were reviewed for cleft- and diagnosis-related studies.

SUMMARY OF THE FINDINGS

Unfortunately, the global prevalence of delayed detection of cleft palate-related deformities remains unacceptably high, with over a quarter of cleft palates missed at birth. This delayed identification causes physical and psychological distress for patients and families, including feeding challenges and weight faltering. To improve cleft management, it is essential to adopt routine detailed, in-depth intraoral examination immediately after birth. It is recommended not only to finger-assisted palpate the intraoral structures but also to visually inspect the oral cavity from gingiva to uvula using a wooden tongue depressor and light-assisted examination. With timely diagnosis and referral to specialized care, pediatricians, nurses, speech therapists, and plastic surgeons provide life-changing treatments, including health care maintenance, anticipatory guidance, feeding support, primary surgical reconstruction, and age- and condition-specific protocols.

CONCLUSIONS

Encouraging neonatologists and pediatricians, who are the first to examine newborns, to actively investigate the intraoral region for cleft palate-related deformities is instrumental in optimizing therapeutic approaches and prioritizing age-phases in treatment. Their crucial role in early detection and referral can lead to transformative outcomes, impacting not only the future of the newborns by facilitating functional integration into society but also yielding positive effects on families and the health system.

Three-Dimensional Comparative Changes in the Pharyngeal Airway of Patients with Cleft after Two-Jaw Orthognathic Surgery

BACKGROUND

The present study evaluated the three-dimensional changes of the pharyngeal airway after orthognathic surgery (OGS) in patients with unilateral and bilateral clefts, and in unilateral cleft patients with and without pharyngeal flap (PF).

METHODS

Forty-five patients with unilateral or bilateral clefts undergoing OGS were enrolled. Cone-beam computed tomographic images were obtained before and after OGS. We measured the pharyngeal airway volumes, minimal cross-sectional area, and the horizontal displacement of facial landmarks.

RESULTS

The patients with bilateral cleft exhibited smaller initial velopharyngeal volume (unilateral, 8623 mm 3 ; bilateral, 7781 mm 3 ; P = 0.211), whereas the velopharyngeal volume increased significantly with a median of 744 mm 3 after OGS ( P = 0.031). The median horizontal displacement of A point was 2.9 and 2.6 mm among the patients with unilateral and bilateral clefts, respectively ( P = 0.276), and the median horizontal displacement of B point was -2.9 and -3.3 mm among patients with unilateral and bilateral clefts, respectively ( P = 0.618). The unilateral cleft patients with PF exhibited lower initial velopharyngeal volume (patients with a history of PF surgery, 7582 mm 3 ; patients without a history of PF surgery, 8756 mm 3 ; P = 0.129) and a lower increase in velopharyngeal volume (patients with a history of PF surgery, 437 mm 3 ; patients without a history of PF surgery, 627 mm 3 ; P = 0.739) after OGS.

CONCLUSIONS

Midface hypoplasia and the decrease in the velopharyngeal volume were more prominent among the bilateral cleft patients and the unilateral cleft patients with PF. After OGS, the velopharyngeal volume increased considerably among the bilateral cleft patients, but no considerable differences were noted among the unilateral cleft patients with PF.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series

BACKGROUND

Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG).

METHODS

A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated.

RESULTS

Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases.

CONCLUSION

The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Modified Medial Incision Small Double-Opposing Z-Plasty for Treating Veau Type I Cleft Palate: Is the Early Result Reproducible?

OBJECTIVE

An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach.

DESIGN

Retrospective single-surgeon study.

PATIENTS

Consecutive nonsyndromic patients (n  =  27) with Veau I cleft palate.

INTERVENTIONS

Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD).

MEAN OUTCOME MEASURES

Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n  =  24) was retrieved for comparison purposes.

RESULTS

Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively (P  =  .002). Age, presence of cleft lip, and cleft width were not associated (all P > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P  =  .546), age (10.2  ±  1.7 vs 9.6  ±  1.2 months; P  =  .143), rate of lateral incision (18.5% vs 4.2%; P  =  .195), and postoperative complication rate (0% vs 0%).

CONCLUSION

This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication.

Chang Gung Forum: An Exemplary Strategy for Implementing a Multidisciplinary Network of Experts in Craniofacial Anomalies

INTRODUCTION

The Chang Gung Forum has been dedicated to the care of craniofacial anomalies since 2000. This annual continuing medical education program focuses on orofacial cleft and surgery-first orthognathic surgery by providing up-to-date information and management guidelines. This study explored how the Chang Gung Forum has influenced medical perspectives, decisions, and practices in a multidisciplinary craniofacial team.

METHODS

Between 2000 and 2022, 20 Chang Gung Forums have been held. A questionnaire was distributed among 170 attendees who had participated in the forum more than once. The questionnaire collected information on the participants' experiences and levels of satisfaction with the educational program and whether or how it had influenced their clinical practice.

RESULTS

Valid responses from 86 attendees (response rate, 50.6%) who had participated more than once were collected and analyzed. The overall satisfaction rate of the Chang Gung Forum based on the respondents' most recent visits was 4.28 ± 0.63 out of 5. Of the respondents, 90.9% acknowledged changes in their clinical practice, with modifications in surgery plans and decisions being the most notable (48.5%). In addition, comprehension increased throughout years of attending the annual forum (P < 0.001).

CONCLUSION

The Chang Gung Forum has contributed markedly to the community of congenital craniofacial anomalies. The program will continue providing updated information and influencing the clinical decision-making of health care professionals.

Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study

BACKGROUND

Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature.

PATIENTS AND METHODS

A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis.

RESULTS

A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient.

CONCLUSION

Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Effect of body mass index on progressive bone mineral density in patients with cleft after secondary alveolar bone grafting

BACKGROUND

Although childhood obesity matters, the association between body mass index (BMI) and bone mineral density (BMD) progression in grafted tissue after secondary alveolar bone grafting (ABG) for children with cleft alveolus is scarcely studied. Accordingly, this study explored the influence of BMI on BMD progression after ABG.

METHODS

In total, 39 patients with cleft alveolus receiving ABG at the mixed dentition stage were enrolled. Patients were classified as underweight, normal weight, or overweight or obese according to age- and sex-adjusted BMI. BMD was measured in Hounsfield units (HU) from cone-beam computed tomography scans obtained 6 months (T1) and 2 years (T2) postoperatively. Adjusted BMD (HU_{grafted tissue}/HU_pogonion, BMD_a) was used for further analysis.

RESULTS

For underweight, normal-weight, and overweight or obese patients, BMD_aT1 values were 72.87%, 91.85%, and 92.89%, respectively (p = 0.727); BMD_aT2 values were 111.49%, 112.57%, and 113.10% (p = 0.828); and density enhancement rates were 29.24%, 24.61%, and 22.14% (p = 0.936). No significant correlation was observed between BMI and BMD_aT1, BMD_aT2, or density enhancement rates (p = 0.223, 0.156, and 0.972, respectively). For patients with BMI < 17 and ≥ 17 kg/m², BMD_aT1 values were 89.80% and 92.89%, respectively (p = 0.496); BMD_aT2 values were 111.49% and 113.10% (p = 0.216); and density enhancement rates were 23.06% and 26.39% (p = 0.573).

CONCLUSION

Patients with different BMI values had similar outcomes (BMD_aT1, BMD_aT2, or density enhancement rate) after our ABG procedure in the 2-year postoperative follow-up.

Craniofacial and three-dimensional palatal analysis in cleft lip and palate patients treated in Spain

Growth alterations have been described in patients operated on for oral clefts. The purpose of this work was to analyze the craniofacial and palate morphology and dimensions of young adults operated on for oral clefts in early childhood in Spain. Eighty-three patients from eight different hospitals were divided into four groups based on their type of cleft: cleft lip (CL, n = 6), unilateral cleft lip and palate (UCLP, n = 37), bilateral cleft lip and palate (BCLP, n = 16), and cleft palate only (CPO, n = 24). A control group was formed of 71 individuals. Three-dimensional (3D) digital models were obtained from all groups with an intraoral scanner, together with cephalometries and frontal, lateral, and submental facial photographs. Measurements were obtained and analyzed statistically. Our results showed craniofacial alterations in the BCLP, UCLP, and CPO groups with an influence on the palate, maxilla, and mandible and a direct impact on facial appearance. This effect was more severe in the BCLP group. Measurements in the CL group were similar to those in the control group. Cleft characteristics and cleft type seem to be the main determining factors of long-term craniofacial growth alterations in these patients. Prospective research is needed to clearly delineate the effects of different treatments on the craniofacial appearance of adult cleft patients.

The Effect of Arch Cartilage Graft and Tajima Reverse U Approach in the Secondary Reconstruction of Unilateral Cleft Lip Nasal Deformity

ABSTRACT

Secondary cleft lip nasal deformity is complicated with wide spectrum of defect and varied reconstructive procedures. There has been no unanimous solution for a given problem. In case of a localized alar depression in unilateral cleft lip nasal deformity, the conchal cartilage applied as arch graft was proposed. Patients were recruited from database of craniofacial center who received Tajima method and arch cartilage graft. Inclusion criteria were patients with unilateral cleft lip nasal deformity after skeletal maturity. Through a reverse U incision, the lower lateral cartilage was dissected and released from the skin and the contralateral cartilage. The harvested conchal cartilage graft was trimmed to 25 to 30 by 8 mm in size, and inserted as arch shape overlying the cleft side lower lateral cartilage. Transdomal fixation sutures were made. Outcome assessment was performed, and the nostril and alar dimensions were measured. Thirty-nine patients were eligible for evaluation of the surgical outcome. Majority of patients underwent simultaneous lip revision (97%). No surgery-related complications were noted in this series. Satisfaction to the nasal reconstruction was reported in 85% of patients. Further minor nasal revisions were performed in 6 patients (15%). Quantitative measurement showed statistically significant improvement in nostril height, alar height and alar width after the surgery. It is concluded that the Tajima reverse U approach plus arch cartilage graft is an effective method for secondary reconstruction of the unilateral cleft lip nasal deformity in selected patients presenting with cleft side alar depression.

Modified Unilateral Incomplete Cleft Lip Repair with Primary Nasal Overcorrection: A Muscle-Driven Technique

SUMMARY

Millard's rotation-advancement principle, first-described 60 years ago, continues to guide surgeons in reconstruction of the unilateral cleft lip. Modifications of the rotation-advancement repair are commonly used; however, distinction between the complete and incomplete forms of cleft lip has received less emphasis in surgical procedure descriptions. As a unilateral incomplete cleft lip could present with more tissue overall and a larger lip on the cleft side than a complete form of cleft lip, the authors have adopted a deformity-specific technical approach to treat each particular cleft form. This article highlights the 10 key steps for execution of a modified unilateral incomplete cleft lip repair using the rotation-advancement principle plus the "skin-follows-muscle" model. The intraoperative design and the reconstruction of the skin, muscle, vermilion, intraoral mucosal, and nasal elements are fully detailed in the accompanying videos.

Maintaining the space between the mandibular ramus segments during bilateral sagittal split osteotomy does not influence the stability

BACKGROUND/PURPOSE

Three-dimensional computer-assisted orthognathic surgery allows to simulate the space between the mandibular ramus segments, i.e. intersegmental gap, for the correction of facial asymmetry. The purposes of the study were to estimate the screws- and mandible bone-related changes from the early postoperative period to the period after the debonding and to measure the association between the intersegmental gap volume and the screws- and mandible bone-related changes.

METHODS

This cone-beam computed tomography (CBCT)-assisted retrospective study assessed the stability of the bicortical positional screw fixations in maintaining the space between the mandibular ramus segments after bilateral sagittal split osteotomy in correction of 31 patients with malocclusion and facial asymmetry. The primary predictor variable was the CBCT-based intersegmental gap volume at early postoperative period (T1). The primary outcome variables were CBCT-based screws- and bone-related measurement changes between the T1 and T2 (at debonding) periods.

RESULTS

No significant differences were observed in screws-related linear and angular measurements between T1 and T2 virtual models. Some of mandible bone-related linear and angular measurements had significant differences (P < 0.05) between the T1 and T2 images, but with no clinical repercussion such as need of revisionary surgery. The gap volume and the screws- and bone-related changes had no significant correlations.

CONCLUSION

This study contributes to the multidisciplinary-related literature by demonstrating that the bicortical positional screws-based fixation technique in maintaining the three-dimensional-simulated space between the mandibular ramus segments is a stable and clinically acceptable option for correction of facial asymmetry associated with malocclusion, regardless of intersegmental gap size.

Three-Dimensional Computer-Assisted Single-Splint 2-Jaw Cleft Orthognathic Surgery: Toward Patient-Centered Surgical Rationale

Skeletally mature patients with cleft lip and palate commonly present with skeletofacial deformities characterized by varying degrees of intrinsic and acquired dentoskeletal and soft tissue abnormalities. These abnormalities are associated with scarring from previous surgeries and the asymmetric midline and facial contour that impose challenges for adequate reconstruction. These patients frequently require 2-jaw orthognathic surgery to improve occlusal function and for correction of facial deformities. In this article, we have detailed a 3-dimensional computer-assisted single-splint 2-jaw orthognathic surgery technique as a surgical approach for cleft skeletofacial reconstruction, allowing for the surgery to be tailored according to the specific needs and requests of the patients. Further, we have addressed the multidimensionality and specificities of cleft treatment, the wide versatility, adaptability, and applicability of this technique, and the patient-centered rationale for the adoption of this method.

Patient- and 3D morphometry-based nose outcomes after skeletofacial reconstruction

Patient satisfaction with the shape and appearance of their nose after orthognathic surgery-based skeletofacial reconstruction is an important, but often overlooked, outcome. We assessed the nose-related outcomes through a recently developed patient-reported outcome instrument and a widely adopted 3D computer-based objective outcome instrument, to verify any correlation in the results produced by these tools. We collected FACE-Q nose appearance reports (2 scales) and 3D nasal morphometry (10 parameters) from patients with class III skeletal pattern and congenital cleft lip palate deformity (n = 23) or developmental dentofacial deformity (n = 23) after (>12 months) skeletofacial reconstruction. The cleft and dentofacial cohorts demonstrated significantly (p < 0.001) poorer satisfaction scores with regard to the FACE-Q nostrils scale than the normal age-, gender-, and ethnicity-matched subjects (n = 107), without any significant difference in FACE-Q nose scale. The cleft cohort had significantly (p < 0.001) smaller nasal length, nasal tip projection, and columellar angle and greater nasal protrusion, alar width, and columellar-labial angle values than the dentofacial and normal cohorts; however, there were no significant differences between the dentofacial versus normal cohorts. The FACE-Q nose and nostrils scales were significantly (p < 0.001; r = -0.26-0.27) correlated to the results of the 3D morphometric analysis, with regard to nasal length, alar width, columella angle, and columellar-labial angle parameters. This study revealed differences in satisfaction with the appearance of the nose according to the type of underlying deformity, and demonstrated a significant correlation (low correlation coefficients) between the patient-reports and 3D image-based outcome measure tools, which has implications for multidisciplinary-centered research, auditing, and clinical care.

Modern Surgery-First Approach Concept in Cleft-Orthognathic Surgery: A Comparative Cohort Study with 3D Quantitative Analysis of Surgical-Occlusion Setup

Despite the evident benefits of the modern surgery-first orthognathic surgery approach (reduced treatment time, efficient tooth decompensation, and early improvement in facial esthetics), the challenge of the surgical-occlusion setup acts as a hindering factor for the widespread and global adoption of this therapeutic modality, especially for the management of cleft-skeletofacial deformity. This is the first study to assess three-dimensional (3D) quantitative data of the surgical-occlusion setup in surgery-first cleft-orthognathic surgery. This comparative retrospective study was performed on 3D image datasets from consecutive patients with skeletal Class III deformity who had a unilateral cleft lip/palate (cleft cohort, n = 44) or a noncleft dentofacial deformity (noncleft cohort, n = 22) and underwent 3D computer-assisted single-splint two-jaw surgery by a single multidisciplinary team between 2014 and 2018. They received conventional orthodontics-first or surgery-first approaches. 3D quantitative characterization (linear, angular, and positional measurements) of the final surgical-occlusion setup was performed and adopted for comparative analyses. In the cleft cohort, the occlusion setup in the surgery-first approach had a significantly (all p < 0.05) smaller number of anterior teeth contacts and larger incisor overjet compared to the conventional approach. Considering the surgery-first approach, the cleft cohort presented significantly (all p < 0.05) larger (canine lateral overjet parameter) and smaller (incisor overjet, maxillary intercanine distance, maxillary intermolar distance, ratio of intercanine distance, and ratio of intermolar distance parameters) values than the noncleft cohort. This study contributes to the literature by providing 3D quantitative data of the surgical-occlusion setup in surgery-first cleft-orthognathic surgery, and delivers information that may assist multidisciplinary teams to adopt the surgery-first concept to optimize cleft care.