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Tse RW, Ettinger RE, Sitzman TJ, Mercan E. Revisiting the unrepaired unilateral cleft lip and nasal deformity using 3D surface image analysis: A data-driven model and its implications. J Plast Reconstr Aesthet Surg 2021; 74:2694-2704. [PMID: 33941472 DOI: 10.1016/j.bjps.2021.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/04/2021] [Accepted: 03/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current descriptions of the unilateral cleft lip and nasal deformity (uCLND) are based upon limited sample sets and subjective observations. While those descriptions are inconsistent and contradictory, theoretical models, including Hogan's "tilted tripod" and Fisher's "nasal arch forms", have never been tested. Given that favorable outcomes of treatment remain elusive, detailed study of the deformity is critical in devising better treatments. The purpose of this study was to develop a data-driven three-dimensional (3D) model of uCLND that spans the spectrum of presentation and involves a pervasive underlying mechanism. METHODS We studied 3D images of 100 infants with unrepaired cleft lip at 6 months of age. Objective assessment included the landmark positions, anthropometric dimensions, and shape-based measures. Cleft severity was stratified by the lateral displacement of subnasale, so that a model could be developed using linear regression. RESULTS With progressive deviation of subnasale, the non-cleft alar base moved lateral, the cleft alar base was left posterior, and the nasal dorsum followed the caudal septum (deviating towards the non-cleft side). The "twist" resulted in opposing cleft alar dome collapse, non-cleft alar ring constriction (the non-cleft nasal sill narrowed, lateral genu rose, and alar-cheek junction became more acute), and displacement of the philtrum from midline. CONCLUSIONS Our study not only supports theoretical models of uCLND but also clarifies vectors of change and reveals significant non-cleft side alterations. On the basis of our findings, the objectives of treatment should involve centralization of the columella and philtrum and rebalancing the nose by untwisting the orthogonal displacement of the alar bases.
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Affiliation(s)
- Raymond W Tse
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, Seattle, WA, USA; Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA.
| | - Russell E Ettinger
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, Seattle, WA, USA; Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Thomas J Sitzman
- Division of Plastic Surgery, Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Ezgi Mercan
- Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital, Seattle, WA, USA
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Esenlik E, Gibson T, Kassam S, Sato Y, Garfinkle J, Figueroa AA, AlQatami F, Runyan C, Alperovich M, Golinko MS, Lee C, Chatzigianni A, Zafeiriadis AA, Santiago P, Hosseinian B, Kaygısız EU, Üçüncü N, Aslan BI, Uzuner FD, Gülşen A, Akkurt A, Arslan SG, Sabás M, Muñoz-Mendoza MA, Masis D, Holguin L, Granados A, Rojas NE, Campo B, Keskin K, Akçam MO, Lowe KM, Morselli PG, Pannuto L, Yarza IN, Martinez AT, Coşkun EY, Nissan S. NAM Therapy-Evidence-Based Results. Cleft Palate Craniofac J 2020; 57:529-531. [PMID: 31960709 DOI: 10.1177/1055665619899752] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Many orthodontists working on patients with cleft lip and palate (CLP) have shown great enthusiasm for presurgical infant orthopedics (PSIO) to improve surgical outcomes with minimal intervention. Even though every clinician aims to use the best treatment modality for their patients, PSIO effects can be confounded by surgical type and timing of the primary repair, as is discussed in many studies. In such cases, one should be cautious when evaluating the particular outcomes for patients with CLP since it is difficult to differentiate the sole effect of an individual surgical or orthodontic intervention. As with any treatment methodology, nasoalveolar molding (NAM) has both benefits and limitations. Commonly cited concerns with NAM, and PSIO in general, include increased cost, increased burden of care, and a negative impact on maxillary growth. However, NAM cannot be deemed as having apparent long-term negative or positive effects on skeletal or soft tissue facial growth, based on previous studies. A review of the literature suggests that NAM does not alter skeletal facial growth when compared with the samples that did not receive PSIO. Nevertheless, the published studies on NAM show evidence of benefits to the patient, caregivers, the surgeon, and society. These benefits include documented reduction in severity of the cleft deformity prior to surgery and as a consequence improved surgical outcomes, reduced burden of care on the care givers, reduction in the need for revision surgery, and consequent reduced overall cost of care to the patient and society.
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Affiliation(s)
- Elçin Esenlik
- Department of Orthodontics, Faculty of Dentistry, Akdeniz University, Antalya, Turkey
| | - Travis Gibson
- BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Serena Kassam
- Department of Pediatric Dentistry, Faculty of Dentistry, New York University, NY, USA.,Division of Pediatric Dentistry, Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Pediatric Dentistry, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Yuki Sato
- Japan Orthodontic Centre, Tokyo, Japan
| | | | | | | | - Christopher Runyan
- Department of Plastic Surgery, Wake Forest Baptist Health Hospital, Winston-Salem, NC, USA
| | - Michael Alperovich
- Department of Plastic Surgery, Yale University Faculty of Medicine, New Haven, CT, USA
| | - Michael S Golinko
- Department of Plastic Surgery, University of Vanderbilt, Nashville, TN, USA
| | - Catherine Lee
- Plastic Surgery Department (Cleft-Craniofacial), Singapore General Hospital, Singapore.,Department of Surgery, National University Hospital of Singapore, Singapore
| | - Athina Chatzigianni
- Department of Orthodontics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios A Zafeiriadis
- Department of Orthodontics, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Private Practice, Thessaloniki, Greece
| | - Pedro Santiago
- Duke University, Durham, NC, USA.,Department of Orthodontics, University of North Carolina, Chapel Hill, USA
| | | | - Emine Uluğ Kaygısız
- Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey
| | - Neslihan Üçüncü
- Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey
| | - Belma Işık Aslan
- Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey
| | - Fatma Deniz Uzuner
- Department of Orthodontics, Faculty of Dentistry, Gazi University, Ankara, Turkey
| | - Ayşe Gülşen
- Department of Plastic and Reconstructive Surgery, Medical Faculty, Gazi University, Ankara, Turkey
| | - Atılım Akkurt
- Department of Orthodontics, Faculty of Dentistry, Dicle University, Diyarbakır, Turkey
| | - Seher Gündüz Arslan
- Department of Orthodontics, Faculty of Dentistry, Dicle University, Diyarbakır, Turkey
| | - Mariana Sabás
- Hospital of Pediatrics S.A.M.I.C. Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | | | | | - Lizbeth Holguin
- Craniofacial Department, El Paso Children's Hospital, TX, USA
| | | | - Nancy Edith Rojas
- Odontology Research Center of Columbia College-CICO, Heroes, Bogotá, Colombia
| | - Beatrice Campo
- IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy
| | - Kamile Keskin
- Department of Orthodontics, Faculty of Dentistry, Dicle University, Diyarbakır, Turkey
| | - M Okan Akçam
- Department of Orthodontics, Faculty of Dentistry, Ankara University, Ankara, Turkey
| | - Kristen M Lowe
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado, CO, USA.,Craniofacial Orthodontics Program, Children's Hospital Colorado, CO, USA
| | - Paolo G Morselli
- Plastic Surgery Department, Alma Mater University of Bologna, Bologna, Italy
| | - Lucia Pannuto
- Plastic Surgery Department, Alma Mater University of Bologna, Bologna, Italy
| | - Ignacio Nacho Yarza
- Oral Surgery, Clinica Yarza, Carrer de Joaquim Botia, Palma De Mallorca, Spain
| | | | | | - Sagit Nissan
- Maxillofacial and Dental Health-Center, Tel-Aviv, Israel
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Rubin MS, Clouston S, Ahmed MM, M Lowe K, Shetye PR, Broder HL, Warren SM, Grayson BH. Assessment of presurgical clefts and predicted surgical outcome in patients treated with and without nasoalveolar molding. J Craniofac Surg 2015; 26:71-5. [PMID: 25534051 DOI: 10.1097/scs.0000000000001233] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Obtaining an esthetic and functional primary surgical repair in patients with complete cleft lip and palate (CLP) can be challenging because of tissue deficiencies and alveolar ridge displacement. This study aimed to describe surgeons' assessments of presurgical deformity and predicted surgical outcomes in patients with complete unilateral and bilateral CLP (UCLP and BCLP, respectively) treated with and without nasoalveolar molding (NAM). Cleft surgeon members of the American Cleft Palate-Craniofacial Association completed online surveys to evaluate 20 presurgical photograph sets (frontal and basal views) of patients with UCLP (n = 10) and BCLP (n = 10) for severity of cleft deformity, quality of predicted surgical outcome, and likelihood of early surgical revision. Five patients in each group (UCLP and BCLP) received NAM, and 5 patients did not receive NAM. Surgeons were masked to patient group. Twenty-four percent (176/731) of surgeons with valid e-mail addresses responded to the survey. For patients with UCLP, surgeons reported that, for NAM-prepared patients, 53.3% had minimum severity clefts, 58.9% were anticipated to be among their best surgical outcomes, and 82.9% were unlikely to need revision surgery. For patients with BCLP, these percentages were 29.8%, 38.6%, and 59.9%, respectively. Comparing NAM-prepared with non-NAM-prepared patients showed statistically significant differences (P < 0.001), favoring NAM-prepared patients. This study suggests that cleft surgeons assess NAM-prepared patients as more likely to have less severe clefts, to be among the best of their surgical outcomes, and to be less likely to need revision surgery when compared with patients not prepared with NAM.
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Affiliation(s)
- Marcie S Rubin
- From the *Department of Plastic Surgery, New York University Langone Medical Center, New York, NY; †Program in Public Health and Department of Preventive Medicine, Stony Brook University, Stony Brook, NY; ‡Cariology and Comprehensive Care, New York University College of Dentistry, New York, NY
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Huang AH, Patel KB, Maschhoff CW, Huebener DV, Skolnick GB, Naidoo SD, Woo AS. Occlusal Classification in Relation to Original Cleft Width in Patients With Unilateral Cleft Lip and Palate. Cleft Palate Craniofac J 2014; 52:574-8. [PMID: 25058122 DOI: 10.1597/13-263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine a correlation between the width of the cleft palate measured at the time of lip adhesion, definitive lip repair, and palatoplasty and the subsequent occlusal classification of patients born with unilateral cleft lip and palate. DESIGN Retrospective, observational study. SETTING Referral, urban, children's hospital Participants : Dental models and records of 270 patients were analyzed. INTERVENTIONS None. MAIN OUTCOME MEASURE Angle occlusion classification. RESULTS The mean age at which occlusal classification was determined was 11 ± 0.3 years. Of the children studies, 84 were diagnosed with Class I or II occlusion, 67 were diagnosed with Class III occlusion, and 119 were lost to follow up or transferred care. Mean cleft widths were significantly larger in subjects with Class III occlusion for all measures at time of lip adhesion and definitive lip repair (P < .02). At time of palatoplasty, cleft widths were significantly greater at the alveolus (P = .025) but not at the midportion of the hard palate (P = .35) or posterior hard palate (P = .10). CONCLUSION Cleft widths from the lip through to the posterior hard palate are generally greater in children who are diagnosed with Class III occlusion later in life. Notably, the alveolar cleft width is significantly greater at each time point for patients who went on to develop Class III occlusion. There were no significant differences in cleft widths between patients diagnosed later with Class I and Class II occlusions.
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