The Facial Growth Pattern and the Amount of Palatal Bone Deficiency Relative to Cleft Size Should Be Considered in Treatment Planning

Harnessing the Power of Artificial Intelligence in Cleft Lip and Palate: An In-Depth Analysis from Diagnosis to Treatment, a Comprehensive Review

Cleft lip and palate (CLP) is the most common craniofacial malformation, with a range of physical, psychological, and aesthetic consequences. In this comprehensive review, our main objective is to thoroughly examine the relationship between CLP anomalies and the use of artificial intelligence (AI) in children. Additionally, we aim to explore how the integration of AI technology can bring about significant advancements in the fields of diagnosis, treatment methods, and predictive outcomes. By analyzing the existing evidence, we will highlight state-of-the-art algorithms and predictive AI models that play a crucial role in achieving precise diagnosis, susceptibility assessment, and treatment planning for children with CLP anomalies. Our focus will specifically be on the efficacy of alveolar bone graft and orthodontic interventions. The findings of this review showed that deep learning (DL) models revolutionize the diagnostic process, predict susceptibility to CLP, and enhance alveolar bone grafts and orthodontic treatment. DL models surpass human capabilities in terms of precision, and AI algorithms applied to large datasets can uncover the intricate genetic and environmental factors contributing to CLP. Additionally, Machine learning aids in preoperative planning for alveolar bone grafts and provides personalized treatment plans in orthodontic treatment. In conclusion, these advancements inspire optimism for a future where AI seamlessly integrates with CLP management, augmenting its analytical capabilities.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity

BACKGROUND

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP).

METHODS

A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP.

RESULTS

Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery.

CONCLUSION

Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Tooth Agenesis in Patients with Complete Bilateral Cleft Lip and Palate

Aim

The aim of this study was to compare the number of teeth in the premaxilla (cleft area) and to assess the presence of tooth agenesis with the ultimate goal of finding whether differences existed in the two suggested subtypes of nonsyndromic bilateral cleft lip and palate (BCLP) patients.

Settings and Design

A retrospective comparative study was conducted, where cone- beam computed tomography (CBCT) images of 22 BCLP patients (10 males and 12 females, with age range 8 to 14, mean age 9.6 years) obtained from archive of Cleft Clinic, affiliated to the Oral and Maxillofacial Surgery department, Ain-Shams University, Cairo, Egypt were assessed.

Subjects and Methods

CBCT images were divided into two subtypes: Group (P) - this represents BCLP characterized by well-developed (P) prominent premaxilla and SNA >80 ± 2 and Group (R) - this represents BCLP characterized by ill-developed (R) rudimentary premaxilla and SNA <80 ± 2. The number of teeth in the premaxilla was evaluated, and the presence of agenesis in the premaxilla and posterior segments was documented.

Statistical Analysis Used

Unpaired-Student's t-test was used to compare the number of teeth among the two groups and to test significance at P < 0.05. Intraobserver agreement was assessed using alpha (Cronbach) reliability analysis. A descriptive analysis using percentages was performed to characterize tooth agenesis.

Results

A significant difference was found in the number of teeth in the premaxilla among Group R and Group P. Maxillary lateral incisor showed the highest percentage of agenesis in the two groups followed by the maxillary second premolar.

Conclusions

The number of teeth might be useful in differentiating different subtypes of nonsyndromic BCLP.

Management of the protuberant premaxilla: where does it fit in?

PURPOSE OF REVIEW

To discuss multidisciplinary treatment options for the protuberant premaxilla associated with bilateral cleft lip and palate. Lessons have been learned throughout the years regarding the effect of growth restriction after early and aggressive therapy. Multiple surgical and orthodontic interventions are discussed. Recent literature will be highlighted and discussed.

RECENT FINDINGS

A paucity of long-term studies was noted. Recent literature revealed numerous studies introducing innovative presurgical orthopedic devices as less expensive and easier to use alternatives to nasoalveolar molding. Multiple approaches to premaxillary setback were presented, offering multiple approaches to improve success rates and minimize burden to the patient. Novel orthodontic and advanced microvascular procedures were discussed as additional tools for treatment of the malpositioned premaxilla once skeletal maturity is reached.

SUMMARY

Multidisciplinary team management of the protuberant premaxilla and bilateral cleft lip and palate is becoming increasingly embraced worldwide. Numerous surgical procedures and orthodontic treatments are required to optimally reposition the premaxilla; however, these interventions can inhibit growth, resulting in maxillary retrusion. Long-term follow-up studies are needed to determine what protocol is best. Studies should also include ways to overcome barriers to treatment success, such as late intervention, resource disparity, and limited access to care.

The absolute and relative effects of presurgical nasoalveolar moulding in bilateral cleft lip and palate patients compared with nasal growth in healthy newborns

BACKGROUND

This study investigated the efficiency of nasoalveolar moulding (NAM) in patients presenting with bilateral cleft lip and palate (BCLP). It focused explicitly on nasal outcome and therefore made comparisons with healthy age-matched infants with normal nasal development.

METHODS

Nasal impressions from 19 BCLP patients were analysed at the beginning and at the end of NAM treatment. In addition, nasal impressions from 32 healthy newborns were taken monthly for 4 months. The casts were digitalized and analysed, using defined anatomic landmarks, by two independent observers. Initial values were compared with outcome parameters at the end of NAM therapy and with the healthy cohort.

RESULTS

NAM significantly elongated the columella in BCLP patients, with an increase of 106.5% versus 14.5% in healthy newborns. Nostril height showed significant expansion from 4.2 mm to 5.6 mm on the right side, and from 4.3 mm to 6.2 mm on the left side.

CONCLUSION

NAM significantly elongated columella length and increased nostril height. The comparison with healthy newborns showed the effectiveness of early cartilage moulding. Detailed knowledge about absolute and relative early nasal growth was gained. However, despite highly effective NAM treatment in BCLP, nasal dimensions will not reach healthy proportions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Comparative Cephalometric Study of Nasoalveolar Molding- and Non-Nasoalveolar Molding-Treated Bilateral Cleft Patients at Early Mixed Dentition Period

OBJECTIVE

To evaluate and compare early maxillary growth in 2 groups of patients with repaired bilateral cleft lip and palate (BCLP) who had and had not received nasoalveolar molding (NAM) therapy in infancy.

HYPOTHESIS

Nasoalveolar molding does not have any effect on maxillomandibular growth at the early mixed dentition period.

DESIGN

Retrospective study.

PATIENTS

The study group consisted of forty-two 7-year-old patients with BCLP-20 in the NAM group and 22 in the no-NAM group. The control group consisted of nineteen 7-year-old noncleft, normal patients.

INTERVENTIONS

Nasoalveolar molding was carried out prior to surgeries in those children who were brought in within 8 weeks of birth. Children brought in later were treated without a presurgical intervention. All patients were treated with a single-stage modified Millard cheiloplasty without gingivoperiosteoplasty. Palatoplasty was done by single-stage Bardach palatoplasty with muscle repositioning.

MEAN OUTCOME MEASURES

Hard tissue and dental cephalometric values measured on lateral cephalograms, recorded at 7 years of age.

RESULTS

A comparison of the mean sagittal values showed a statistically significant maxillomandibular retrusion and incisor retroclination of both BCLP groups in comparison to the control group. None of the cephalometric parameters varied statistically between NAM and no-NAM groups. The maxillomandibular relation, lower face height ratio, mandibular plane, and mandibular axis angles did not show statistically significant difference between all 3 groups.

CONCLUSIONS

On the basis of this study, NAM does not have any effect on maxillomandibular growth at the early mixed dentition period.

Stress Distribution Patterns within Viscero- and Neurocranium during Nasoalveolar Molding: a Finite Element Analysis

Background

The purpose of this study was to evaluate the stress distribution patterns within the viscero- and neurocranium of neonates during nasoalveolar molding.

Methods

Finite element models of 3 different healthy neonates at different times of life (date of birth, 4 weeks, and 3.5 months) were generated on the basis of computed tomography scans. A validated workflow, including segmentation, meshing, setting of boundary conditions, and implementation of a bone density-dependent material model, was carried out for each model. A small and a large unilateral alveolar and hard palatal cleft were virtually cut in each model. The stress distribution pattern in each model was then analyzed by using Ansys APDL.

Results

Convergence analysis validated the results. The virtual experiments at the date of birth showed a stress pattern above a previously defined threshold value of 30,000 Pa in the ipsilateral naso-orbital-complex, frontal sinus, and the anterior fossa of the base of the skull, with von Mises values > 35,000 Pa. Stress patterns at the age of 4 weeks and 3.5 months showed reduced von Mises values at < 15,000 Pa.

Conclusions

Nasoalveolar molding therapy is a safe presurgical treatment modality without significant influence on the viscero- and neurocranium of neonates. Treatment, considering the stress distribution at the naso-orbital-complex and anterior fossa of the base of the skull, should begin in the second week of life, and treatment initiation of preterm infants should be adapted respectively.

Effects of Nasoalveolar Molding Therapy on Alveolar and Palatal Cleft Deformities in Unilateral and Bilateral Cleft Lip and Palate

OBJECTIVE

The purpose of this study was to evaluate and compare the efficacy of nasoalveolar molding (NAM) therapy in the improvement of alveolar and palatal cleft deformity on unilateral (UCLP) versus bilateral (BCLP) cleft lip and palate.

MATERIALS AND METHODS

A total of 19 UCLP (14 boys and 5 girls) and 8 BCLP (7 boys and 1 girl) infants completed NAM therapy were included in this study. Standardized parameters of cleft width of alveol and palate were measured on photocopies taken from the pre- and post-treatment plaster casts. To assess the intragroup differences, paired-samples test in UCLP and Wilcoxon test in BCLP groups were used. Mann-Whitney U test was used to evaluate the differences between the groups.

RESULTS

Significant decreases in alveolar and palatal cleft gaps were achieved in an average period of 3.3 ± 1.9 and 3.7 ± 1.6 months in UCLP and BCLP patients, respectively. The alveolar cleft decreased 7.85 ± 4.59 mm in UCLP and 4.25 ± 3.13 and 3.81 ± 3.50 mm in right and left alveolar cleft sides in BCLP, respectively. The palatal clefts were decreased 4.63 ± 2.44 mm in medial and 3.72 ± 2.62 mm in posterior parts in UCLP. The decrements in BCLP were 3.00 ± 2.75 mm in medial and 2.88 ± 2.75 mm in posterior palatal cleft distances. No significant differences were determined in the amount of alveolar or palatal cleft closure between UCLP and BCLP groups. The only decrease in arch width was 1.39 mm in medial part of palate in UCLP.

CONCLUSION

The NAM device provides significant decreases in both alveolar and palatal cleft deformities in UCLP and BCLP infants, as compared with their birth status.

Establishment of a finite element model of a neonate's skull to evaluate the stress pattern distribution resulting during nasoalveolar molding therapy of cleft lip and palate patients

Nasoalveolar Molding (NAM) is associated with ambivalent acceptance regarding effectiveness and unknown long-term results. Our purpose was to analyze the stress distribution patterns within the viscero- and neurocranium of neonates during the first phase of NAM therapy. A finite element (FE) model of a healthy four-week-old neonate was generated, derived from a computed tomography scan allowing the implementation of a bone-density-dependent material model. The influence of dental germs with variable material properties, the cleft width and area of expected force application were analyzed in a worst-case scenario. The resulting stress distribution patterns for each situation were analyzed using the software Ansys APDL. The established FE model was verified with a convergence analysis. Overall, stress patterns at the age of four weeks showed von Mises stress values below 60.000 Pa in the viscero- and neurocranium. The influences of the allocation of material properties for the dental germs, the area of force application, and the cleft width were negligible. A workflow to simulate the stress distribution and deformation in neonates attributable to various areas of force application has been established. Further analyses of the skulls of younger and older neonates are needed to describe the stress distribution patterns during NAM therapy.