A randomised prospective clinical trial into the effect of infant orthopaedics on maxillary arch dimensions in unilateral cleft lip and palate (Dutchcleft)

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial

BACKGROUND

Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment.

METHOD

The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site.

DISCUSSION

We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe.

TRIAL REGISTRATION

ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

Treatment Outcomes of Lip Taping in Patients with Non-syndromic Cleft Lip and/or Palate: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review of the data in peer-reviewed medical literature and evaluate the effectiveness of lip taping as a pre-surgical naso-alveolar molding (NAM) technique in infants with cleft lip and/or palate.

DESIGN

An electronic search of various databases for relevant studies, regardless of date, from inception to June 2023 was carried out and evaluated. After completing the electronic search and applying our inclusion/exclusion criteria, 6 studies-2 randomized control trials, 2 non-randomized studies, and 2 case series-were included. Data extraction of relevant articles was done independently by 2 authors. Quality assessment was done using the JBI prevalence critical appraisal tool and certainty of evidence was carried out by GRADE approach.

MAIN OUTCOME MEASURES

Nasolabial Aesthetics, Dentoalveolar Relationship.

RESULTS

A total of six studies were included in the current review. Meta-analysis was carried out, and forest plots were obtained for a single mean from the lip-taping group. 3 studies had a low risk of bias, while 3 studies displayed a serious risk of bias. Significant improvement in various outcome measures was noted with lip taping when compared with the control group although the certainty of evidence was very low.

CONCLUSION

When compared to no therapy, lip taping appears to ameliorate dentoalveolar measurements and nasolabial aesthetics. To increase our knowledge of lip taping, more research will be needed in the future, as there are not many studies to prove lip taping is better than other treatment approaches.

The impact of passive alveolar molding vs. nasoalveolar molding on cleft width and other parameters of maxillary growth in unilateral cleft lip palate

OBJECTIVE

Passive alveolar molding (PAM) and nasoalveolar molding (NAM) are established presurgical infant orthodontic (PSIO) therapies for cleft lip palate (CLP) patients. PAM guides maxillary growth with a modified Hotz appliance, while NAM also uses extraoral taping and includes nasal stents. The effects of these techniques on alveolar arch growth have rarely been compared.

MATERIAL AND METHODS

We retrospectively compared 3D-scanned maxillary models obtained before and after PSIO from infants with unilateral, non-syndromic CLP treated with PAM (n = 16) versus NAM (n = 13). Nine anatomical points were set digitally by four raters and transversal/sagittal distances and rotations of the maxilla were measured.

RESULTS

Both appliances reduced the anterior cleft, but NAM percentage wise more. NAM decreased the anterior and medial transversal width compared to PAM, which led to no change. With both appliances, the posterior width increased. The alveolar arch length of the great and small segments and the sagittal length of the maxilla increased with PAM but only partially with NAM. However, NAM induced a significant greater medial rotation of the larger and smaller segment compared to PAM with respect to the lateral angle.

CONCLUSIONS

NAM and PAM presented some significant differences regarding maxillary growth. While NAM reduced the anterior cleft and effectively rotated the segments medially, PAM allowed more transversal and sagittal growth.

CLINICAL RELEVANCE

The results of this study should be taken into consideration when to decide whether to use PAM or NAM, since they show a different outcome within the first few months. Further studies are necessary regarding long-term differences.

Evidencia de la efectividad del uso de aparatología ortopédica prequirúrgica en pacientes con labio y paladar hendido: revisión sistemática

This review article aimed to evaluate the evidence on the use of a presurgical orthopedic appliance (POP) in patients with cleft lip and palate. The search was conducted using Medline/PubMed, Scholar Google, Clinical Trails, ProQuest, Scopus, and Web of Science databases. During the search, 7,926 records were found, of which 105 full-text articles were analyzed, and 23 studies included analysis in patients with the use of POP, and their control groups without the use of POP prior to the same type of surgery. The devices most used for POP in the management of LPH were: the passive palate (Hotz palate), the nasolaveolar moulding (NAM), the McNeil device, and finally, the T-traction. The primary outcomes evaluated were: facial aesthetics and nasal appearance; the evaluation of cephalometric measurements, upper airways, nasal fissure width, as well as anatomical references such as inter-canine and inter-tuberosity distances. In addition, studies that evaluated occlusion and phonation were found. The evidence from this literature suggests that the use of active appliances had a better effect than passive appliances in terms of facial aesthetics and approximation of the maxillary seg-ments for the closure of the fissure. However, the heterogeneity, the risk of bias, and the low quality of the studies do not allow to state firm conclusions.

Effectiveness of pre-surgical orthopedics on patients with cleft lip and palate: A systematic review and meta-analysis

OBJECTIVE

Evaluate the effectiveness of pre-surgical orthopedics (PSO) in patients with cleft lip palate (CLP) in maxillary morphology (MM), facial growth and development (FGD), occlusal alterations (OA), parental satisfaction (PS), and side effects.

DESIGN

Systematic review and meta-analysis of randomized and controlled clinical trials. Searches was performed in CENTRAL, MEDLINE, and EMBASE.

RESULTS

From the eight studies included, three are randomized clinical trials, and five clinical trials are controlled. MM was evaluated by the intercanine width (Mean difference (MD) =1.44; CI95%= -0.30, 3.19; very low certainty), anteroposterior length (MD=1.32; CI95%= -0.59, 3.24; very low certainty) and intertuberocity width (MD=0.09; CI95%= -0.68, 0.49; certainty: very low). FGD was evaluated by SNA angle (MD: 1.29; P = 0.306; moderate certainty), SNB angle (MD: -0.79; P = 0.550; moderate certainty) and ANB angle (MD: 1; P = 0.362; moderate certainty). OA was evaluated by 5-years-old-index (MD= -0.09; P = 0.49; moderate certainty) and by Huddart score (MD=0.51; P = 0.736; moderate certainty). A valid questionnaire assessed PS only in one study (MD= -0.1; P = 0.199; moderate certainty). No studies reported side effects.

CONCLUSION

Due to the uncertainty of the effect of PSO on MM and the lack of clinically relevant effect on FGD, OA, or PS, it is not reasonable to include this intervention as a treatment until future studies clarify its effect.

The Perception and Experience of Parents of Children with Cleft Lip and Palate Concerning the Use Pre-Surgical Infant Orthopedics: A Questionnaire-Based Cross-Sectional Survey

Background: A transitory period prior to the surgical correction of cleft lip and palate (CLP) is associated with adverse impacts, which may require a medical intervention. Pre-surgical infant orthopedics (PSIO) is deemed to reduce the functional and psychological burden, offering a transition until the definite surgical intervention. Aim: To assess the attitude of Iraqi mothers concerning the application and management of pre-surgical orthopedic appliances in children with cleft lip and palate, taking consideration of the mothers’ occupational status. Methods: The cross-sectional study was conducted in the College of Dentistry at Baghdad University from 5 January 2020 to 4 December 2021. A questionnaire form was validated based on existing data related to the assessment of parents’ satisfaction concerning PSIO. Results: A concern related to the impression procedure was reported by a minority of the participants (6.8%) and it was associated mainly to the perceptions of housewives’ vs. working mothers (p < 0.05). The perceived infants’ discomfort during the impression procedure reported at 11.9% was significantly associated with housewives’ status (p < 0.05). In general, the vast majority of respondents considered the impression as being non-invasive (96.6%). Most mothers found no difficulties in following the instructions of the specialist regarding the insertion of the PSIO and/or taping the elastic bands (62.7%). Respondents believed that CLP infants routinely require PSIO treatment. Interestingly, only a minority of mothers performed an Internet search to look for information about PSIO (7%). The majority indicated the PSIO treatment as beneficial for their infant and a substantial proportion of respondents were satisfied with the outcomes of PSIO, encouraging other parents to consent the PSIO treatment. Conclusion: In general, mothers broadly acknowledged the primary concept of PSIO and accepted the proposed treatment, with a positive attitude towards pre-surgical CLP management, regardless their socio-economic status. They seemed to understand well the expected benefits of PSIO, including feeding improvement, normalization of speech, and optimization of future surgical outcomes.

Cleft lip, alveolus and palate: Defect or dislocation malformation? Importance of adopting a physiological concept for surgical repair in achieving optimal outcomes in LMICs. Part 1: Physiological processes in facial development

The conventional surgical procedures for the closure of cleft-lip and palate are based on proven plastic-surgical procedures from tumour surgery or traumatology. These flap surgeries take little account of the fact that the treatment of such malformations takes place during the time of a child's increased growth and is known to lead to pronounced scarring and skeletal growth disorders. It is therefore imperative to develop modified surgical procedures based on physiological growth processes. These physiological procedures must include the reconstruction of all facial structures such as orofacial, palatal and pharyngeal muscles, complete nose, upper jaw and palate. Transfer of this know how to low resource LMIC and training is essential if optimal outcomes are to be achieved.

Nasal molding prevents relapse of nasal deformity after primary rhinoplasty in patients with unilateral complete cleft lip: An outcomes-based comparative study of palatal plate alone versus nasoalveolar molding

Objectives

In recent years, many studies have reported that the presurgical nasoalveolar molding method improves the nose morphology; however, the reason for its effectiveness after surgery has never been understood. We evaluated the effect of nasoalveolar molding by comparing it with a passive orthopedic method without a nasal stent and focusing on the nostril morphology after primary cheiloplasty using various measurement methods. We then analyzed the essential factors.

Materials and methods

The patients involved were 31 infants with unilateral complete cleft lip and palate treated with primary cheiloplasty at the University of Tsukuba Hospital from 2004 to 2011. Of the 31 infants, 16 received nasoalveolar molding treatment and 15 received passive orthopedic treatment as controls. Photographic facial measurements were performed for all patients immediately and 7 months after primary cheiloplasty. The esthetics of the nostrils were assessed according to the left–right nostril symmetry, as measured by the Hausdorff distance, area ratio, perimeter ratio, and aspect a/u (the aspect ratio of the affected side)/(the aspect ratio of the unaffected side) ratio. In addition, the inclination of the nasal ridge was assessed using anthropometric measurements (Grc‐Grn∠midline and midline∠columellar axis).

Results

The area ratio, perimeter ratio, and Grc‐Grn∠midline were significantly greater in the nasoalveolar molding group immediately after surgery (p = 0.00062, 0.016, and 0.048, respectively) than in the control group. However, the Hausdorff distance and aspect a/u ratio were more favorable (p = 0.0018 and 0.0039, respectively) in the nasoalveolar molding group after 7 months.

Conclusions

The results of our study suggested that using nasoalveolar molding as a presurgical orthopedic treatment could improve the shape of the nasal cartilage with surgeon's corrections.

Comparative evaluation of nasal and alveolar changes in complete unilateral cleft lip and palate patients using intraoral and extraoral nasoalveolar molding techniques: randomized controlled trial

Objectives

Cleft lip and palate is a common congenital anomaly that impairs the aesthetics, speech, hearing, and psychological and social life of an individual. To achieve good aesthetic outcomes, presurgical nasoalveolar molding (NAM) has become important. Currently, the intraoral NAM technique is widely practiced. Numerous modifications have been made to intraoral NAM techniques, but the original problem of compliance leading to discontinuation of treatment remains unsolved. Therefore, the present study compared an extraoral NAM technique with the intraoral NAM technique.

Materials and Methods

Twenty infants with complete unilateral cleft lip and palate were included and divided into two equal groups. Group A received the intraoral NAM technique, and Group B received the extraoral NAM technique. Pre- and postoperative extraoral and intraoral measurements were recorded.

Results

Groups A and B did not differ significantly in any extraoral or intraoral parameter.

Conclusion

The extraoral NAM technique is as effective as the intraoral NAM technique in achieving significant nasal and alveolar changes in com-plete unilateral cleft lip and palate patients. Additionally, it reduces the need for frequent hospital visits for activation and the stress associated with the insertion and removal of the intraoral NAM plate, thereby improving compliance.

Continuous circular closure in unilateral cleft lip and plate repair in one surgery

The study aims at assessing wound healing and safety of single-stage two-layers continuous closure in patients with unilateral cleft lip and palate (UCLP). In this retrospective, descriptive cohort study, we assessed wound healing without fistula formation at 1, 3, and 6 months after a single-stage two-layer UCLP repair, in which the midline suture is continuously circular all along the oral and nasal sides. We examined lengths of hospital stay and the incidence of intra- and postoperative adverse events. Furthermore, we compared the cleft width at birth and on the day of surgery, after presurgical orthopaedics. Eleven UCLP patients underwent one cleft surgery between July 2016 and June 2018 at the age of 8-9 months. Full primary healing occurred in all patients without fistulas. Median length of post-operative hospital stay was 5 days (range = 4-9 days). No intra- or postoperative adverse events above Grade I (according to ClassIntra and Clavien-Dindo, respectively) occurred. Median and interquartile range (IQR) of the palatal cleft width decreased significantly from birth to surgery, i.e., from 12.0 mm (10.8-13.6 mm) to 5.0 mm (4.0-7.5 mm) anteriorly and from 14.0 mm (11.5-15.0 mm) to 7.3 mm (6.0-8.5 mm) posteriorly (p = 0.0033 in both cases). Given these preliminary results, the concept of single-stage continuous circular closure in UCLP has potential for further investigation. However, it remains to be proven that there are no relevant adverse effects such as inhibition of maxillary growth. Registered in clinicaltrials.gov:NCT04108416.

Systematic Review of the Long-Term Effects of Presurgical Orthopedic Devices on Patient Outcomes

Objective:

To perform a systematic review of the literature to identify the long-term effects of presurgical orthopedic (PSO) device use on patient outcomes.

Design:

A comprehensive literature review of Embase and Ovid databases was performed to identify all English-language publications related to unilateral cleft lip and palate, presurgical devices, and patient outcomes. Studies were excluded if they did not report patient outcomes beyond 2 years of age, did not describe the use of a PSO device, were case reports (n < 10), or were purely descriptive studies.

Main Outcome Measures:

Reported patient outcomes following the use of PSO devices.

Results:

Following a review of all articles by 2 independent reviews, 30 articles were selected for inclusion. Overall, there was no reported consensus as to the long-term effects of PSO devices. Furthermore, this study identified that only 10% of published research controlled for confounding factors that could influence the reported results. Confounding factors that were identified included different operating surgeon, different surgical protocols, and different rates of revision surgeries.

Conclusions:

Overall, this systematic review identified 2 important conclusions. Firstly, there is no consensus in the literature about the long-term effects of PSO devices on long-term patient outcomes. Secondly, research in this domain is limited by confounding factors that influence the applicability of the reported results.

Does Infant Orthopedics and Neonate Lip Surgery Influence the Occlusal Relationship in Patients With Unilateral Cleft Lip and Palate (UCLP)?

OBJECTIVE

To compare occlusal relationship in patients undergoing neonate versus conventional lip surgery (LS) with and without infant orthopedics (IO) by assessment of dental arch relationship in individuals with complete unilateral cleft lip and palate.

MATERIAL AND METHODS

Three groups treated by different protocols; Group I: neonate LS (1-15 days) + IO and palatoplasty (13-31 months); Group II: LS (3-12 months) + IO and palatoplasty (15-35 months); and Group III: LS (3-6 months) without IO and palatoplasty (12-18 months). The 112 intraoral photographs of individuals of all groups, obtained between 6 and 12 years of age, were assessed by the occlusal index for intraoral photograph rating. The groups were compared by the χ² test. The correlation between surgical timing and the scores was tested by the Spearman test (P < .05).

RESULTS

Group I presented the highest percentage of score 5, group II exhibited highest percentage of score 1, and group III presented the lowest percentage of score 5 according to the χ² test (P = .029). The Spearman correlation test revealed statistically significant difference between timing of LS and the occlusal index. The earlier the surgical timing, the higher the occlusal index (P = .019).

CONCLUSIONS

Infant orthopedics has demonstrated the possibility of postponing primary plastic surgeries. Patients submitted to late lip and palate repair had the best prognosis, while patients undergoing lip repair from 1 to 15 days of life, even operating the palate later, had the worst prognosis. Neonate LS negatively influenced the occlusal relationships.

A Three-Dimensional Study of the Nasolabial Soft Tissue Symmetry in Children With Unilateral Complete Cleft Lip and Palate Using Traditional and Split-Type Nasoalveolar Molding

BACKGROUND

Presurgical nasoalveolar molding (NAM) is the most common preoperative treatment for cleft lip and palate. However, NAM may have some limitations such as requiring high technical sensitivity and frequent visits. To simplify the device, some scholars have changed the traditional NAM into a split-NAM consisting of a alveolar molding plate and a nasal hook. This study compared the shaping effect of split NAM and traditional NAM on nasolabial soft tissue using three-dimensional (3D) measurement.

METHODS

A total of 39 patients with unilateral cleft lip and palate (UCLP) were enrolled and divided into 2 groups. 13 patients were treated with split-NAM while the other 26 patients were treated with traditional NAM. 3D images of all patients' craniofacial soft tissue before and after NAM treatment were recorded and measured by three-dimensional software. Statistical analysis of measurements in both groups was performed using SPSS software.

RESULTS

After treatment, nasal soft tissue symmetry in the split-NAM group was better improved than that in the NAM group in vertical and anterior-posterior direction, but was worse improved in transverse direction. There was no significant difference in labial soft tissue symmetry between two groups.

CONCLUSIONS

The split NAM can better elevate the alar and nostrils of the cleft side, and have a better forward effect on alar outer edge, nasal base, and nostrils. However, the traditional NAM can better reduce the width of nasal base.

The Surgical Nasoalveolar Molding: A Rational Treatment for Unilateral Cleft Lip Nose Deformity and Literature Review

The purposes of this study were to evaluate surgical outcomes after primary surgery to address unilateral cleft lip, nose, and palate deformities and to perform a review of the literature to evaluate the effects of nasoalveolar molding (NAM) plus primary surgical repair on nonsyndromic unilateral cleft lip and palate.

METHODS

A cohort study of 37 primary complete unilateral cleft lip nasal deformity repairs was performed by a single surgeon. The outcomes were anthropometric measurements of the repaired lip, nose, and alveolar cleft width at the age of 1 and 5 years. A review of the literature was performed for studies published until March 2020 to evaluate the effect of presurgical NAM on nasolabial aesthetics.

RESULTS

Statistically significant differences were observed between pre- and postoperative columellar angle and alveolar cleft width. A total of 308 studies were identified, and 8 were included in the final analysis of 684 patients. The overall study quality was low according to the Oxford Centre of Evidence-Based Medicine, and GRADE level of evidence was low.

CONCLUSIONS

Primary cheilorhinoplasty alone is a good approach to improve nose appearance and alveolar gap in patients with unilateral cleft lip nose and palate deformity. Definitive conclusions about the effectiveness of presurgical NAM cannot be drawn. Available scientific evidence is not sufficient to demonstrate that combined use of presurgical nasoalveolar molding and primary surgery provides better nasolabial aesthetic outcomes than does primary surgery alone.

The effect of lip closure on palatal growth in patients with unilateral clefts

Objectives

The objective of this study was to compare maxillary dimensions and growth in newborns with Complete Unilateral Cleft Lip and Palate (UCLP) to healthy newborns before and after cheiloplasty. Additionally, a palatal growth curve is constructed to give more information about the natural growth before surgical intervention.

Methods

Twenty-eight newborns with complete UCLP were enrolled in this study. Multiple plaster-casts of each child during their first year were collected and grouped in before and after cheiloplasty. A previous developed semi-automatic segmentation tool was used to assess the maxillary dimensions and were compared to a healthy control group. Z-scores were calculated to indicate differences between the two populations and if cheiloplasty had influence on maxillary growth. Furthermore, the prediction model created in a previous study was used to indicate differences between predictions and the outcome in UCLP measurements. The analysis was tested for inter- and intra-observer variability.

Results

Results show differences in alveolar and palatal shape in UCLP patients in comparison with healthy controls. Prior to cheiloplasty an increased width and alveolar length was observed while the palatal depth was decreased. After cheiloplasty the widths moved towards normal but were still significantly larger.

Conclusion

Infants with unilateral cleft lip and palate show a wider maxillary arch in comparison with the control population. Initial treatment has most influence on the width of the arch, which decreased towards normal.

Three-Dimensional Morphological Changes of the True Cleft under Passive Presurgical Orthopaedics in Unilateral Cleft Lip and Palate: A Retrospective Cohort Study

The aim of this cohort study was to quantify the morphological changes in the palatal cleft and true cleft areas with passive plate therapy using a new analysis method based on three-dimensional standardized reproducible landmarks. Forty-five casts of 15 consecutive patients with complete unilateral cleft lip and palate were laser scanned and investigated retrospectively. The landmarks and the coordinate system were defined, and the interrater and intrarater measurement errors were within 1.0 mm. The morphological changes of the cleft palate area after a period of 8 months of passive plate therapy without prior lip surgery are presented graphically. The median decrease in cleft width was 38.0% for the palatal cleft, whereas it was 44.5% for the true cleft. The width of the true and palatal cleft decreased significantly over a period of 8 months. The true cleft area decreased by 34.7% from a median of 185.4 mm² (interquartile range, IQR = 151.5-220.1) to 121.1 mm² (IQR = 100.2-144.6). The palatal cleft area decreased by 31.5% from a median of 334 mm² (IQR = 294.9-349.8) to 228.8 mm². The most important clinical considerations are the reproducibility and reliability of the anatomical points, as well as the associated morphological changes. We propose using the vomer edge to establish a validated measuring method for the width, area, and height of the true cleft.

Dentofacial Orthopedics for the Cleft Patient: The Latham Approach

Presurgical infant dentofacial orthopedic treatment (PSIOT) is a process by which cleft maxillary and soft tissue segments can be moved before surgical repair of lip. One of the PSIOT approaches used is the fixed PSIOT using Latham appliances. In this article, the authors provide an overview of this approach and the step-by-step process of placing these appliances intraorally. Prospective randomized clinical studies are necessary to definitively answer concerns surrounding the long-term effects of PSIOT.

Early Progressive Maxillary Changes with Nasoalveolar Molding: Randomized Controlled Clinical Trial

OBJECTIVES

Quantitative assessment of 3-dimensional progressive changes of the maxillary geometry in unilateral cleft lip palate (UCLP) with and without nasoalveolar molding (NAM).

METHODS

The study was designed as a prospective 2-arm randomized controlled clinical trial conducted in parallel. Forty infants with nonsyndromic UCLP were randomly assigned into a NAM-treated group (n = 20) and non-NAM treated group (n = 20). A total of 120 laser-scanned maxillary casts were collected and blindly analyzed via a modified algorithm at T0 (initial visit; baseline), T1 (after 3 wk; first interval), and T2 (after 6 wk; second interval). The main outcome measures were the amount and rate of cleft gap changes, the midline position, and the transverse, sagittal, and vertical growth through intervals.

RESULTS

More than 50% of the cleft gap (56.42%; P < 0.001) was reduced in the first 3 wk of alveolar molding (AM). The end point of the AM was obtained in 6 wk (86.25%; P < 0.001); then, the kinks of the greater segment were noticed. The AM effect decreased as far as posterior; the anterior arch width reduced slightly (1.23%; P < 0.001), while the middle and posterior arches increased slightly (P > 0.999 and P = 0.288, respectively). The posterior arch width was the least changing and was considered a baseline, while the anterior was the pivot of the segment rotation. Both groups showed different patterns of segment rotation and sagittal growth. The non-NAM treated group showed a slight increase in cleft gap length, arch width, and midline position.

CONCLUSION

Based on this study, it was concluded that the NAM treatment is effective in minimizing cleft severity and realigning maxillary segments without the deterioration of the transverse and vertical arch growth. Near follow-up visits are recommended to monitor the rapid gap reduction within the first 3 wk. Further trials are recommended to compare the outcomes regarding the sagittal growth to reference values (ClinicalTrials.gov NCT03029195).

KNOWLEDGE TRANSFER STATEMENT

The results of this study will help clinicians understand nasoalveolar molding biomechanics that may improve the treatment outcomes for patients with unilateral cleft lip and palate. The trial data can be a valuable guide to the qualitative and quantitative predictive virtual molding in computer aided design-simulated nasoalveolar molding therapy. The modified algorithm can be used by researchers to quantify the rate, the sequence, and the direction of the maxillary segments movement in unilateral cleft lip and palate.

Mean GOSLON Yardstick Scores After 3 Different Treatment Protocols—A Long-term Study of Patients With Unilateral Cleft Lip and Palate

Objectives:

(1) To evaluate dental arch relationships, with the Great Ormond Street, London and Oslo (GOSLON) Yardstick, of participants with Unilateral cleft lip and palate (UCLP) and treated with 1-stage palatal closure with 3 different surgical protocols (2) to compare the mean GOSLON ratings with other CLP centers.

Design:

Retrospective study of medical charts and dental models.

Setting:

Karolinska University Hospital, Stockholm, Sweden.

Participants:

Eighty-seven patients with UCLP operated with 1-stage palatal repair. Thirty-five were operated with Veau-Wardill-Kilner (VWK) technique 1975 to 1986, 31 with minimal incision technique (MIT) from 1987 to 1997, and 21 according to MIT with muscle reconstruction (MITmr) 1998 to 2004.

Interventions:

Dental casts at ages 5 (n = 87), 7 to 8 (n = 27), 10 (n = 81), 16 (n = 61), and 19 (n = 35) years were rated by 10 assessors with the GOSLON Yardstick. Information of other interventions was retrieved from patients’ charts.

Main outcome measures:

Mean GOSLON ratings.

Results:

A total of 82% of the participants were rated as having excellent to satisfactory outcome. Weighted κ statistics for the 10 assessors was good for inter-rater agreement and good/very good for intra-rater agreement.

Conclusions:

The mean GOSLON score in the Stockholm overall material at age 10 was 2.67. The VWK technique resulted in a greater need of orthognathic surgery than the MIT ( P < .01). The MITmr did not produce better dental arch relationships than MIT at age 5 ( P < .05). The best dental arch relationships were found in the MIT group at 10 years, mean 2.58, which is not significantly different from other centers with excellent outcome except Gothenburg and Vienna.

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

OBJECTIVE

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

DESIGN

A retrospective analysis of prospectively collected nonrandomized data.

INTERVENTIONS

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

SETTING

Participants were treated at 2 hospitals in the United Kingdom.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Influence of nasoalveolar molding on skeletal development in patients with unilateral cleft lip and palate at 5 years of age

INTRODUCTION

The aim of this retrospective study was to assess the influence of presurgical nasoalveolar molding (NAM) on skeletal development in patients with operated unilateral cleft lip and palate at 5 years of age.

MATERIALS

Lateral cephalometric radiographs of 26 unilateral cleft lip and palate patients who had undergone presurgical NAM (NAM group) and 20 unilateral cleft lip and palate patients who did not have any presurgical NAM (non-NAM group) were analyzed. The radiographs were digitally traced using Quick Ceph Studio software (version 3.5.1.r (1151); Quick Ceph Systems, San Diego, Calif). Independent samples t tests were performed for statistical analysis.

RESULTS

No significant differences were observed in sagittal and vertical skeletal measurements between the NAM and non-NAM groups.

CONCLUSIONS

NAM resulted in no significant difference in skeletal development in unilateral cleft lip and palate patients compared with those without NAM in early childhood.

The Effect of DynaCleft® on Cleft Width in Unilateral Cleft Lip and Palate Patients

OBJECTIVE

The specific aim of this retrospective cross-sectional study was to assess the efficacy of DynaCleft® as a method of presurgical orthopedics with infants with a unilateral cleft lip and cleft palate who used an oral obturator.

STUDY DESIGN

Data was collected from 25 infants all of comparable age diagnosed with a unilateral complete cleft lip and palate. Eight patients used DynaCleft ® and an obturator (Group Alpha) and seventeen patients only had an obturator (Group Beta). Maxillary impression casts were obtained from each patient at the initial clinic visit and at the time of cleft lip repair. Differences in alveolar cleft width were compared between the two groups. Casts were measured twice by one observer using a digital caliper.

RESULTS

Group Alpha began treatment on an average age of 24.25 days and Group Beta an average of 15.35 days of age. The average cleft width of Group Alpha was 8.13 mm and after treatment it was 4.59 mm. The average cleft width of Group Beta was 8.09 mm and 6.92 mm after treatment. Results of paired t-tests and two-sample t-test showed that cleft width changes between the two groups were significant (P = .03).

CONCLUSIONS

DynaCleft ® significantly decreased the size of the alveolar cleft width compared to infants who did not use it. Providers should consider using DynaCleft® for patients who may not have access to infant maxillary orthopedics.

Cost-Effectiveness of Infant Orthopedic Treatment regarding Speech in Patients with Complete Unilateral Cleft Lip and Palate: A Randomized Three-Center Trial in the Netherlands (Dutchcleft)

Objective

To investigate the cost-effectiveness of infant orthopedic treatment (IO), compared with no such treatment in children with complete unilateral cleft lip and palate (UCLP) focusing on the effects on speech development at age 2.5 years.

Design

In a three-center prospective, randomized clinical trial (Dutchcleft), two groups of children with complete UCLP were followed longitudinally: one group was treated with IO based on a modified Zurich approach in the first year of life (IO group) and the other group did not receive this treatment (non-IO group).

Patients

The participants had complete UCLP without soft tissue bands or other malformations. They were born at term and their parents were native Dutch speakers.

Outcome Measures

The effect of IO on speech development at age 2.5 years was measured blindly by five expert listeners judging the “total impression of speech quality” on a 10-point equal-appearing interval scale. Costs were measured from a societal viewpoint in Euro.

Results and Conclusion

The IO group (n = 10) obtained a statistically significant higher rating, compared with the non-IO group (n = 10). The effect size was large, indicating that the improvement may be considered a clinically important change. The cost for treatment by the orthodontist was higher in the IO group. For both groups, the mean cost was related to the mean rating for “total impression of speech quality.” The resulting cost-effectiveness for IO, compared to non-IO was €1041 for 1.34 point speech quality improvement. The financial investment that is necessary to obtain this improvement seems limited. Thus, from the perspective of speech development, the cost-effectiveness of IO over non-IO seems acceptable at this point in time.

Infant Orthopedics in UCLP: Effect on Feeding, Weight, and Length: A Randomized Clinical Trial (Dutchcleft)

Objective

To study the effects of infant orthopedics (IO) on feeding, weight, and length.

Design

Prospective two-arm randomized controlled trial in three academic Cleft Palate Centers. Treatment allocation was concealed and performed by means of a computerized balanced allocation method.

Setting

Cleft Palate Centers of Amsterdam, Nijmegen, and Rotterdam, the Netherlands.

Patients

Infants with complete unilateral cleft lip and palate (UCLP), no other malformations.

Interventions

One group (IO+) wore passive maxillary plates during the first year of life, but the other group (IO−) did not. All other interventions were the same for both groups.

Main Outcome Measures

Bottle feeding velocity (mL/min) at intake, 3, 6, 15, and 24 weeks (T0 to T24); weight-for-age, length-for-age, and weight-for-length using z scores; reference values from the Netherlands’ third nationwide survey on growth.

Results

Feeding velocity increased with time from 2.9 to 13.2 mL/min in the IO− group and from 2.6 to 13.8 mL/min in the IO+ group; no significant differences were found between groups. Weight-for-age, length-for-age, and weight-for-length (z scores) did not differ significantly between groups, but overall the infants with unilateral cleft lip and palate in both groups had significantly lower mean z scores for weight-for-age and height-for-age than the reference during the first 14 months, and had lower mean values for weight-for-length after soft palate closure.

Conclusion

Infant orthopedics with the aim of improving feeding and consequent nutritional status in infants with unilateral cleft lip and palate can be abandoned.

The Effect of Infant Orthopedics on the Occlusion of the Deciduous Dentition in Children with Complete Unilateral Cleft Lip and Palate (Dutchcleft)

Objective

Evaluation of the effect of infant orthopedics (IO) on the occlusion of the deciduous dentition in patients with unilateral cleft lip and palate (UCLP).

Design

Prospective, two-arm, randomized, controlled clinical trial with three participating cleft palate centers (Dutchcleft).

Setting

Cleft Palate Centers of the University Medical Center Nijmegen, Academic Center of Dentistry Amsterdam, and Dijkzigt University Hospital Rotterdam, The Netherlands.

Patients

Children with complete UCLP (n = 54) were included.

Interventions

In a concealed allocation procedure, half of the patients was randomized to wear a plate till surgical closure of the soft palate (IO+), and the other half (IO−) did not have a plate.

Mean Outcome Measures

Dental arch relationships were assessed at 4 and 6 years of age with the 5-year-old index; the Huddart-score; and measurements of overjet, overbite, and sagittal occlusion.

Results

There were no significant differences found between the IO+ and IO− groups for the 5-year-old index; the Huddart-score; and overjet, overbite, and sagittal occlusion.

Conclusions

IO had no observable effect on the occlusion in the deciduous dentition at 4 and 6 years of age. Considering the occlusion only, there is no need to perform IO in children with UCLP.

Infant Orthopedics Has No Effect on Maxillary Arch Dimensions in the Deciduous Dentition of Children with Complete Unilateral Cleft Lip and Palate (Dutchcleft)

Objective:

Evaluation of the effect of infant orthopedics on maxillary arch dimensions in the deciduous dentition in patients with unilateral cleft lip and palate.

Design:

Prospective two-arm randomized controlled clinical trial with three participating cleft palate centers.

Setting:

Cleft palate centers of the Radboud University Nijmegen Medical Center, Academic Center of Dentistry Amsterdam, and University Medical Center Rotterdam, the Netherlands.

Patients:

Children with complete unilateral cleft lip and palate (n = 54) were included.

Interventions:

Patients were randomly divided into two groups. Half of the patients (IO+) had a presurgical orthopedic plate until surgical closure of the soft palate at the age of 52 weeks; the other half (IO−) did not undergo presurgical orthopedics.

Mean outcome measures:

Maxillary arch dimensions were assessed on dental casts at 4 and 6 years of age with measurements for arch width, arch depth, arch length, arch form, and the vertical position of the lesser segment. Contact and collapse were assessed also.

Results:

There were no clinically significant differences found between IO+ and IO− for any of the variables.

Conclusions:

Infant orthopedics had no observable effect on the maxillary arch dimensions or on the contact and collapse scores in the deciduous dentition at the ages of 4 and 6 years. Considering the Dutchcleft results to date, there is no need to perform infant orthopedics for unilateral cleft lip and palate patients.

Infant Orthopedics and Facial Appearance: A Randomized Clinical Trial (Dutchcleft)

Objective:

To study the effect of infant orthopedics on facial appearance.

Design:

Prospective two-arm randomized controlled trial in parallel with three participating academic cleft palate centers. Treatment allocation was concealed and performed by means of a computerized balanced allocation method.

Setting:

Cleft Palate Centers of Amsterdam, Nijmegen, and Rotterdam, the Netherlands.

Patients:

Infants with complete unilateral cleft lip and palate, no other malformations.

Interventions:

One group (IO+) wore passive maxillary plates during the first year, the other group (IO−) did not.

Main Outcome Measure(s):

Two metrical response modalities were used (i.e., visual analog scales and reference scores) to score facial appearance. Full face and cropped photographs were compared with reference photographs and were judged. The photographs were judged by 45 judges, 24 laypeople, and 21 professionals. Transformation of the scores into z scores was applied to compare and to pool both response modalities. The validity of each individual judge was evaluated, as was the reliability of the scales. Differences between the treatment groups were evaluated by means of t tests.

Results:

Photographs were available of 41 subjects, 21 with and 20 without infant orthopedics. No significant differences were found between groups. Mean z-score values for the full-face photographs were: group IO+ = 0.10 (SD = 0.73) and group IO− = −0.03 (SD = 0.48); for the cropped photographs were: group IO+ = 0.12 (SD = 0.71) and group IO− = −0.06 (SD = 0.55).

Conclusions:

Infant orthopedics have no effect on facial appearance.

Use of a Perceptual Evaluation Instrument to Assess the Effects of Infant Orthopedics on the Speech of Toddlers with Cleft Lip and Palate

Objective

To investigate the effects of infant orthopedics (IO) administered in the first year of life on the speech characteristics of 2.5-year-old children with complete unilateral cleft lip and palate (UCLP) using a perceptual evaluation instrument with equal-appearing interval (EAI) scales.

Design

In a prospective randomized clinical trial (Dutchcleft), two groups of children with complete UCLP were followed longitudinally. One group received IO based on a modified Zurich approach (IO group), and the other group did not (non-IO group). The appliance was used until soft palate closure at age 12 months. Hard palate closure is delayed until 9 years of age.

Participants

Three groups of 2.5-year-old toddlers participated in this investigation: 10 IO, 10 non-IO, and 8 noncleft controls matched for age and socioeconomic status.

Method

Five trained listeners assessed the children's speech in a blinded perceptual rating procedure. They judged 13 specific speech characteristics and indicated their total impression of speech on EAI scales.

Results

The reliability and consistency of 11 of the rating scales was good. The intelligibility rating scale was the single speech characteristic that distinguished the IO group from the non-IO group; the IO group was judged to be superior. The cleft groups differed from the noncleft group on 9 of the 11 scales.

Conclusions

Evaluation of speech by means of the present newly developed perceptual rating instrument showed that the IO group obtained significantly higher ratings for intelligibility than the non-IO group. The groups did not differ regarding any of the other speech aspects.

Treatment outcomes of pre-surgical infant orthopedics in patients with non-syndromic cleft lip and/or palate: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Non-syndromic clefts lip and/or palate (CL/P) defects may have manifold significant and detrimental consequences for the affected individuals and their family environment. Although the use of pre-surgical infant orthopedics (PSIO) was introduced as a means to improve management and treatment outcomes, there still remains a controversy.

OBJECTIVE

To investigate the effectiveness of PSIO in patients with non-syndromic CL/P and evaluate the quality of the available evidence.

SEARCH METHODS

Search without restrictions, together with hand searching, until May 2016.

SELECTION CRITERIA

Randomized clinical trials investigating the effects of pre-surgical infant orthopedic appliances.

DATA COLLECTION AND ANALYSIS

Following study retrieval and selection, data extraction and individual study risk of bias assessment using the Cochrane Risk of Bias Tool took place. The overall quality of the available evidence was assessed with the Grades of Recommendation, Assessment, Development and Evaluation approach.

RESULTS

Finally 20 papers (3 unique trials) were identified, involving a total of 118 patients with unilateral complete CL/P and 16 with cleft of the soft and at least two thirds of the hard palate. Eight publications were considered as being of low, four of unclear and eight of high risk of bias. In general, the investigated appliances did not present significant effects when compared to each other or to no treatment in terms of feeding and general body growth, facial esthetics, cephalometric variables, maxillary dentoalveolar variables and dental arch relationships, speech and language evaluation, caregiver-reported outcomes, economic evaluation, as well as, adverse effects and problems. Overall, the quality of the available evidence was considered low.

CONCLUSIONS

The aforementioned findings could provide initial guidance in the clinical setting. However, given the multitude of parameters, which may have affected the results, good practice would suggest further research, in order to reach more robust relevant recommendations for management decisions in individual cases.

Presurgical cleft lip and palate orthopedics: an overview

Patients with cleft lip and/or palate go through a lifelong journey of multidisciplinary care, starting from before birth and extending until adulthood. Presurgical orthopedic (PSO) treatment is one of the earliest stages of this care plan. In this paper we provide a review of the PSO treatment. This review should help general and specialist dentists to better understand the cleft patient care path and to be able to answer patient queries more efficiently. The objectives of this paper were to review the basic principles of PSO treatment, the various types of techniques used in this therapy, and the protocol followed, and to critically evaluate the advantages and disadvantages of some of these techniques. In conclusion, we believe that PSO treatment, specifically nasoalveolar molding, does help to approximate the segments of the cleft maxilla and does reduce the intersegment space in readiness for the surgical closure of cleft sites. However, what we remain unable to prove equivocally at this point is whether the reduction in the dimensions of the cleft presurgically and the manipulation of the nasal complex benefit our patients in the long term.

Three-dimensional digital evaluation of dental arches in infants with cleft lip and/or palate

The aim of this study was to measure and compare the dimensions of the dental arches on three-dimensional digital study models in children with and without cleft lip and palate before the primary surgery. The sample consisted of 223 digital models of children aged 3-9 months, divided into 5 groups: without craniofacial deformities, unilateral and bilateral incomplete cleft lip and alveolus, unilateral and bilateral complete cleft lip and alveolus, unilateral cleft lip and palate, and bilateral cleft lip and palate. Dental casts of the maxillary dental arches of the children were used. The dental casts underwent a process of scanning through 3D scanner and the measurements used for the correlation among groups were made on the scanned images. Statistical analysis was performed by t test and ANOVA followed by Tukey test. The results showed that the intercanine distance and anterior cleft width was wider in children with unilateral cleft lip and palate. The intertuberosity distances and posterior cleft width was wider in children with bilateral cleft lip and palate among the groups. Children with cleft lip and palate before the primary surgery had wider maxillary arch dimensions than the children without cleft lip and palate.

Initial Nutritional Assessment of Infants With Cleft Lip and/or Palate: Interventions and Return to Birth Weight

OBJECTIVE

To assess and quantify cleft team practices with regard to nutritional support in the neonatal period Design :  Retrospective review.

SETTING

Tertiary pediatric hospital.

PATIENTS

One hundred consecutive newborn patients with a diagnosis of cleft lip and/or cleft palate between 2009 and 2012.

MAIN OUTCOME MEASURES

Birth weight, cleft type, initial cleft team weight measurements, initial feeding practices, recommended nutritional interventions, and follow-up nutritional assessments.

RESULTS

All patients in the study were evaluated by a registered dietitian and an occupational feeding therapist. Average birth weight and average age at the first cleft team visit were similar for each cleft type: cleft lip (CL), cleft lip and palate (CLP), and cleft palate (CP). The calculated age (in days) for return to birth weight was significantly different between cleft types: CL = 13.58 days, CLP = 15.88 days, and CP = 21.93 days. Exclusive use of breast milk was 50% for patients with CL, 30.3% for patients with CLP, and 21.4% for patients with CP. Detailed nutritional interventions were made for 31 patients at the first visit: two with CL, 14 with CLP, and 15 with CP.

CONCLUSIONS

Distinct differences were seen in neonatal weight gain between cleft types. There was significantly greater total weight gain for patients with CL at their first visit and significantly slower return to birth weight for patients with isolated CP. Patients with CL required far fewer interventions at the initial assessment and were more likely to be provided breast milk exclusively or in combination with formula. Infants with CP were far less likely to receive any breast milk. Patients with CLP and CP required frequent nutritional interventions.

Presurgical nasoalveolar molding therapy in cleft lip and palate individuals: Case series and review

The nasoalveolar molding (NAM) therapy is advocated to reduce the severity of alveolar cleft and nasal deformity. NAM therapy has demonstrated to be an effective method for reducing cleft and improve nose anatomy. This paper presents a case report of three cleft lip and palate individuals treated with NAM therapy. Furthermore, the paper highlights the advantages of NAM therapy along with an enumeration of literature suggesting in favor of NAM therapy and otherwise. Regardless of controversies and divergent views involved with NAM therapy, the immediate success of NAM therapy facilitating primary lip repair surgery cannot be under-emphasized.

[Implant-borne prosthetic rehabilitation in patients with cleft lip and palate: A retrospective study on 43 patients]

INTRODUCTION

Implant-borne rehabilitation in cleft lip and palate patient are aimed to allow for good orofacial functions, stable occlusion, and adequate support for the naso-labial region. The goal of our study was to evaluate the functional and esthetic results of the implant-born dental rehabilitation of the cleft lip and palate patients in our department.

MATERIAL AND METHODS

Our retrospective study concerned patients operated between 1995 and 2010 in our department. All included patients suffered from a cleft alveolus and lip, with or without cleft palate. Dental implants were placed in the bone-grafted alveolus and the end of growth and at distance from the bone graft procedure. Criteria of implant survival and implant-borne rehabilitation success were defined.

RESULTS

A total of 78 implants were placed in 43 patients between 1995 and 2010. Two implants were lost (implant survival rate: 97.4%). Despite this loss, all the patients could be rehabilitated with good functional and esthetic results.

DISCUSSION

Implant-borne rehabilitation is a reliable solution for prosthetic rehabilitation in patients with cleft lip and palate. This solution allows for avoiding removable prosthesis and dental mutilation.

Operative and Immediate Postoperative Outcomes of Using a Latham-Type Dentomaxillary Appliance in Patients with Unilateral Complete Cleft Lip and Palate

Objective

The objective of this study is to examine the operative and immediate postoperative effects of the use of a dentomaxillary appliance (DMA).

Design

Retrospective chart review of 40 treated patients with unilateral complete cleft lip and palate who had a comprehensive set of pre-, peri-, and postoperative records.

Setting

Boston Children's Hospital.

Patients

Forty treated patients with unilateral complete cleft lip and palate.

Interventions

Use of DMA.

Main Outcome Measures

Outcome variables of interest included cleft lip width reduction following use of DMA and odds of having primary gingivoperiostetoplasty (GPP).

Results

The study sample included 40 subjects (31 boys and 9 girls). The average age at the time of DMA insertion was 11 weeks. The average width of the alveolar cleft prior to DMA insertion was 10.77 mm. The mean cleft width reduction was 8.66 mm. Each 1-mm increase in pre-DMA cleft width was associated with a 0.631-mm reduction in cleft width ( P < .001). Thirty-three patients (82.5%) had a GPP procedure. Each 1-mm increase in post-DMA width was associated with a lower odds of having a GPP (odds ratio = 0.32, 95% confidence interval = 0.14–0.77, P = .01).

Conclusions

Post-DMA width was the significant factor associated with the performance of GPP. The use of DMA is associated with a significant reduction in the width of the cleft, and outcomes are predictable without any major adverse events or complications.

Health economic evaluations in orthodontics: a systematic review

BACKGROUND

Economic evaluation is assuming increasing importance as an integral component of health services research.

AIM

To conduct a systematic review of the literature and assess the evidence from studies presenting orthodontic treatment outcomes and the related costs.

MATERIALS/METHODS

The literature review was conducted in four steps, according to Goodman's model, in order to identify all studies evaluating economic aspects of orthodontic interventions. The search covered the databases Medline, Cinahl, Cochrane, Embase, Google Scholar, National Health Service Economic Evaluation Database, and SCOPUS, for the period from 1966 to September 2014. The inclusion criteria were as follows: randomized controlled trials or controlled clinical trials comparing at least two different orthodontic interventions, evaluation of both economic and orthodontic outcomes, and study populations of all ages. The quality of each included study was assessed as limited, moderate, or high. The overall evidence was assessed according to the GRADE system (The Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

The applied terms for searches yielded 1838 studies, of which 989 were excluded as duplicates. Application of the inclusion and exclusion criteria identified 26 eligible studies for which the full-text versions were retrieved and scrutinized. At the final analysis, eight studies remained. Three studies were based on cost-effectiveness analyses and the other five on cost-minimization analysis. Two of the cost-minimization studies included a societal perspective, i.e. the sum of direct and indirect costs. The aims of most of the studies varied widely and of studies comparing equivalent treatment methods, few were of sufficiently high study quality. Thus, the literature to date provides an inadequate evidence base for economic aspects of orthodontic treatment.

CONCLUSION

This systematic review disclosed that few orthodontic studies have presented both economic and clinical outcomes. There is currently insufficient evidence available about the health economics of orthodontic interventions. Further investigation is warranted.

Transverse dental arch relationship at 9 and 12 years in children with unilateral cleft lip and palate treated with infant orthopedics: a randomized clinical trial (DUTCHCLEFT)

Objective

A long-term evaluation to assess the transverse dental arch relationships at 9 and 12 years of age in unilateral cleft lip and palate treated with or without infant orthopedics (IO). The hypothesis is that IO has no effect on the transverse dental arch relationship.

Material and methods

A prospective two-arm randomized controlled trial (DUTCHCLEFT) in three academic cleft palate centers (Amsterdam, Nijmegen and Rotterdam, the Netherlands). Fifty-four children with complete unilateral cleft lip and palate and no other malformations were enrolled in this evaluation. One group wore passive maxillary plates (IO+) during the first year of life, and the other group did not (IO−). Until the age of 1.5, all other interventions were the same. Hard palate was closed simultaneously with bone grafting according to protocol of all teams. Orthodontic treatment was performed when indicated. The transverse dental arch relationship was assessed on dental casts using the modified Huddart/Bodenham score to measure the maxillary arch constriction at 9 and 12 years of age.

Results

No significant differences were found between the IO+ and IO− groups. Differences between the centers increased from 9 to 12 years of age.

Conclusions

Transverse dental arch relationships at 9 and 12 years of age do not differ between children with UCLP treated with or without IO.

Clinical relevance

There is no orthodontic need to perform IO as applied in this study in children with UCLP.

Assessment of morbidity following insertion of fixed preoperative orthopedic appliance in infants with complete cleft lip and palate

OBJECTIVE

To examine physiologic and behavioral indicators of pain within the first 24 hours following insertion of the fixed presurgical orthopedic appliance (FPOA) under general anesthesia in infants with unilateral and bilateral complete cleft lip and palate.

METHODS

The study sample included 109 infants who had either a dentomaxillary appliance (DMA) or an elastomeric chain premaxillary retraction (ECPR) appliance. Vital signs and FLACC (Face, Legs, Activity, Cry, Consolability) scores were used to measure the outcomes.

RESULTS

There was an initial postoperative increase in the median heart rate. Heart rate returned to the median baseline level by 8 hours. The median systolic blood pressure increased postoperatively and remained elevated throughout the time of evaluation. The median respiratory rate remained below that at baseline throughout the study period. The highest mean change in FLACC measurements was observed approximately 2 hours postoperatively. By 3 hours postoperatively, the scores decreased.

CONCLUSIONS

Although there was a large individual variability, the FLACC scores became reduced after 3 hours following surgical insertion of the DMA and the ECPR appliance.