Orthodontic Retainers and the Stability of the Maxillary Arch in Unilateral Cleft lip and Palate Patients: A Systematic Review

OBJECTIVE

The aim of this systematic review was to elucidate the role of orthodontic retainers on the stability of compensatory orthodontic treatment in patients with unilateral cleft lip and palate.

METHODS

Five electronic databases (PubMed, Scopus, Web of Science, LILACS, and LIVIVO) and the grey literature (OpenGrey and Google Scholar) were investigated, according to the population, exposure, comparator, outcomes and Study design eligibility criterion. The risk of bias assessment was determined based on the Risk of Bias In Nonrandomized Studies of Exposure (ROBINS-E) and the level of evidence with the GRADE tool.

RESULTS

Three studies were included: two presented moderate risk of bias and one high. A moderate level of evidence revealed a mean value of 0.6 mm of intercanine relapse distance, and great variability between the data, regardless of the use or type of retention or rehabilitation. Relapse in the posterior region showed clinical significance, from -1 to -1.7 mm, especially in individuals who did not use retention, except in patients with symmetrical arches with Hawley retainer, where this value varies from -0.2 ± 0.63 mm.

CONCLUSIONS

Orthodontic retainers do not seem essential to prevent relapse at anterior maxillary dimensions after compensatory orthodontic treatment in patients with unilateral cleft lip and palate. Relapse in the posterior region can achieve greater clinical significance, which highlights the need for prolonged use of Hawley retainers and periodic evaluation of the stability of treatment results. Prospective studies with a longer follow-up can improve the certainty of the evidence.

Prognostic Factors for Orthognathic Surgery in Children With Cleft Lip and/or Palate: Dentition and Palatal Morphology

To determine dental and palatal morphology in children with cleft lip and/or palate (CL/P) and identify morphological prognostic factors for orthognathic surgery (OGS).

Retrospective cohort study.

Orthodontic department of a university dental hospital.

This study included 80 patients with bilateral and unilateral CL/P who had lateral cephalograms at the ages of 7 (T1), 15 (T2) years, and a dental plaster model at T1.

Plaster models at T1 were scanned with a three-dimensional (3D) scanner. Morphological features were extracted from 3D models with geometric morphometrics software as principal components (PCs). The combinations of the PCs and other predictive factors (ie, the No. of clefts in the lip and alveolus, the palatal repair method, sex, cephalometric variables at T1, and the No. of missing teeth) were examined by logistic regression to determine the predictability for OGS. The need for OGS and skeletal and dental discrepancies at T2 were examined as outcomes.

Shrinkage of the palate, including vertical shallowing and transverse narrowing of the posterior maxilla and cleft-side asymmetry of the anterior maxilla at T1, as well as the No. of clefts in the lip and alveolus, the palatal repair method, male sex, several cephalometric variables for the sagittal and vertical dimensions, and the No. of missing teeth, were found to be predictive factors for OGS.

Morphological prognostic factors for OGS in children with CL/P were determined.

Prevalence and Risk Factors for Obstructive Sleep Apnea Syndrome Among Children and Adolescents with Cleft lip and Palate: A Survey Study in Hong Kong

OBJECTIVE

To investigate the prevalence of obstructive sleep apnea syndrome (OSAS) risk and related risk factors among children and adolescents of Hong Kong with cleft lip and/or palate (CL/P).

DESIGN

Retrospective survey study adopting three questionnaires, obstructive sleep apnea-18 (OSA-18), pediatric sleep questionnaire-22 (PSQ-22), and modified Epworth Sleepiness Scale (ESS).

SETTINGS

Multicenter study in two public hospitals.

PATIENTS

A total of 351 Chinese children and adolescents with non-syndromic CL/P (6-18-year-old, 57% males) visited between September 2017 and November 2019, with primary palatal repair surgery done before 3-year-old.

MAIN OUTCOME MEASURE

Positive OSAS risk was determined based on cut-off ≥60 for OSA-18, ≥8 for PSQ-22, and >8 for ESS. Age, sex, overweight presence, cleft type, embryonic secondary palate involvement, palatal repair surgery, palatal revision surgery, and orthodontic treatment were analyzed as possible risk factors.

RESULTS

A total of 9.5% of patients had positive OSAS risk based on OSA-18, 13.6% based on PSQ-22, and 13.2% according to ESS. A higher prevalence of patients with positive OSAS risk was of younger age (OSA-18, p = .034), had cleft involving embryonic secondary palate (PSQ-22, p = .009), and history of fixed orthodontic treatment (ESS, p = .002). The regression model identified only involvement of embryonic secondary palate as a risk factor (PSQ-22, odds ratio = 3.7, p = .015).

CONCLUSIONS

OSAS risk among children and adolescents of Hong Kong with CL/P was 9.5% to 13.6%. Patients at higher risk were those with cleft involving embryonic secondary palate. OSAS risk assessment may be influenced by different aspects of the disease spectrum, and a multimodal approach should be considered for such assessment.

Correction of a prominent premaxilla in a juvenile with a bilateral cleft lip and palate using a novel, hybrid function regulator, the FR-BCPPm, followed by preadjusted fixed appliances: A 20-year follow-up

A seven-year-old boy with a repaired bilateral cleft lip and palate, presented with a severe skeletal II base and an extremely prominent premaxilla. He had grossly incompetent lips with lower lip trapping, an 18.5-mm overjet, a deep overbite, markedly retroclined lower incisors, bilateral crossbites and 12-mm-wide alveolar gaps together with 6-mm vertical steps between the extruded premaxillary incisors and the posterior teeth. Before the eruption of the permanent canines, there was an urgency to approximate the opposing cleft alveolar margins and to level the split maxillary occlusal plane, in order to facilitate the successful insertion and subsequent consolidation of secondary alveolar bone grafts.A new functional appliance was therefore designed to achieve this objective, which drew components from Fränkel's FR I and FR III function regulators. Together with a couple of novel components, it created a hybrid appliance, namely the function regulator for juveniles with a bilateral cleft and a prominent premaxilla: the FR-BCPPm.The patient was treated with this appliance and a nocturnal headgear at 7-13 years, together with a concomitant quad helix appliance followed by a transpalatal arch and bilateral bone grafts. He was then treated non-extraction up to the age of 17 years with preadjusted fixed appliances to correct his residual, crowded Class II malocclusion.The marked improvement in his occlusion, dentofacial appearance and his perioral function after a decade of treatment was then followed up over 20 years, during which time mild relapse of the incisor overjet and moderate recurrence of the lower anterior misalignment was noted two years after treatment.While no further relapse was observed at the four-year post-treatment review, by 20 years after treatment, a little further misalignment of the lower anterior teeth was noted, half of which was deemed to be attributable to age-related maturation.

The Effect of Multiple Surgeries on Psychosocial Outcomes in Pediatric Patients: A Scoping Review

BACKGROUND

Birth defects affect 3% of all babies born in the United States each year. Unlike reconstruction for many acquired deformities, one hallmark of reconstruction for complex congenital conditions is the requirement of multiple surgeries, procedures, and therapies from birth to maturity. These interventions often result in significant medical burden on children during development with potential long-term psychosocial consequences. The aim of this study was therefore to better define the psychosocial impact of repetitive operations on the pediatric patient.

METHODS

A scoping review was performed under the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Review guidelines. We searched the PubMed, Cochrane Library, Science Direct, and Web of Science databases using key words "number of surgeries," "psychosocial," "pediatric," and related terms. Primary articles published in English describing psychosocial outcomes in pediatric patients who underwent more than one procedure or surgery were included (n = 25). The Newcastle-Ottawa Scale was used to assess the quality of each study.

RESULTS

We included 25 articles published between 1995 and 2019, which included 6520 patients. The most common diagnosis across all studies was congenital heart disease (CHD) (n = 4169, 63.9%), followed by cleft lip and palate (n = 1196, 18.3%). The average number of operations and procedures was 3.4 (range = 1-18) and 32.1 (range = 6-89), respectively. The association between repetitive surgeries and poorer psychosocial outcomes was demonstrated in children with early-onset scoliosis, CHD, hydrocephalus, bladder exstrophy, posterior urethral rupture, anorectal anomalies, and conditions requiring numerous nonsurgical procedures. There were also a few CHD, cleft lip and/or palate, and hydrocephalus studies that did not find a significant correlation.

CONCLUSIONS

The studies here suggest that certain pediatric patient populations are at risk for impaired psychosocial functioning as a result of repetitive procedures. However, it is important to differentiate whether the association with poorer psychosocial outcomes is from the number of surgical procedures or whether the number if just a surrogate for increased disease complexity. Standardized psychosocial outcomes measures and future prospective, long-term, randomized clinical trials are also warranted.

Factors Influencing Timely Preparation of Alveolar Bone Grafting: A Survey of the ACPA

OBJECTIVE

To identify factors that are commonly felt to impact a team's ability to ensure patients are orthodontically and dentally prepared for alveolar bone grafting at the appropriate time.

DESIGN

Cross-sectional survey.

SETTING

American Cleft Palate-Craniofacial Association (ACPA)-approved multidisciplinary cleft teams.

PARTICIPANTS

Cleft team coordinators.

INTERVENTIONS

Cleft team coordinators were asked to complete the survey.

RESULTS

Fifty-three team coordinators from the 167 ACPA-certified cleft teams completed the survey (response rate = 32%). The majority (83.02%) of cleft teams feel having a case manager increases or would increase the rate of timely bone graft preparation. Orthodontic and dental coverage varied greatly between teams with university/hospital employed dentists and volunteer private practice orthodontists representing the most frequent models. The reported percentage of patients seeking regular dental and orthodontic care with providers affiliated with the team did not correlate with the likelihood of timely bone graft preparation (P = .17; P = .43). Great variability was noted in the manner and frequency of team communication with families during orthodontic bone graft preparation. The presence of a designated case manager on the team was not significantly associated with the percentage of patients who were reported to be orthodontically prepared for bone graft surgery (P = .25).

CONCLUSION

Within our survey data, there is great variability noted in factors that may potentially impact orthodontic bone graft preparation. The majority of teams felt that a case manager did or would help with this process, however, our study does not support this fact. Significant recall bias concerning the success of bone graft preparation may affect these results.

What Is the Burden of Care of Nasoalveolar Molding?

OBJECTIVE

This systematic review aims to evaluate nasoalveolar molding (NAM) in the context of burden of care defined as physical, psychosocial, or financial burden on caregivers.

SEARCH METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 5 databases were searched from inception through December 24, 2019, for keywords and subject headings pertaining to cleft lip and/or palate and NAM.

ELIGIBILITY CRITERIA

Clinical studies on NAM with reference to physical (access to care, number of visits, distance traveled), psychosocial (caregiver perceptions, family interactions, breast milk feeding), and financial (direct and indirect costs) burden were included.

DATA COLLECTION AND ANALYSIS

Study selection was performed by 2 independent reviewers.

RESULTS

The search identified 1107 articles and 114 articles remained for qualitative synthesis. Burden of care domains were discussed but not measured in 43% of articles and only 25% assessed burden of care through a primary outcome. Of these, 20 articles reported on physical, 8 articles on psychosocial, and 12 articles on financial burden. Quality of evidence is limited by study design and risk of bias.

CONCLUSION

Nasoalveolar molding has been indiscriminately associated with burden of care in the literature. Although NAM may not be the ideal treatment option for all patients and families, the physical considerations are limited when accounting for the observed psychosocial advantages. Financial burden appears to be offset, but further research is required. Teams should directly assess the impact of this early intervention on the well-being of caregivers and advance strategies that improve access to care.

Comparison of Pain Perception in Patients Affected by Cleft and Cranio Facial Anomalies Treated With Traditional Fixed Appliances or Invisalign

Introduction:

The objective of this prospective study was to compare the difference in pain perception between treatment with aligners (AL) and fixed appliances (FA) in patients affected by cleft and craniofacial anomalies (CFA).

Methods:

The sample consisted of 100 syndromic caucasian patients affected by various CFA from 2 different hospitals. Fifty patients treated with AL were matched for sex, age, and CFA with a control sample of 50 patients treated with FA. A modification of the Mc Gill Pain Questionnaire was adapted to our needs.

Results:

Statistical differences were found. Aligners induced more tightness and tension than FA, while FA induced more pain descriptors and patients reported a higher intake of painkillers.

Conclusions:

The results of this study documented a higher pain perception with FA than with AL in patients affected by CFA. The higher sensitivity to pain in cleft and craniofacial patients with fixed treatment could be related to their higher prior sensitization, given the past surgeries and orthodontic treatments. Thus, this study might suggest that Invisalign treatment might be a further interesting treatment option for patients with cleft in order to reduce their burden of orthodontic pain.

CONSTRUCTION OF AN EDUCATIONAL VIDEO ON POSTOPERATIVE CARE FOR CHEILOPLASTY AND PALATOPLASTY

ABSTRACT Objective: to describe the process for building up an educational video on the postoperative cares for primary cheiloplasty and palatoplasty surgeries. Method: a five-step technology elaborated development study (analysis and planning, modeling, implementation, evaluation and distribution) conducted in a public institution specialized in treating cleft lip and palate. Results: the evaluation was carried out by six judges regarding content criticism and criteria of familiarity, plausibility and linguistic clarity. Concordance percentage was 98%, which obtained approval and consent from most of the judges participating in the study. The feature adopted after the judges’ analysis was qualified as a facilitator of the information needed to train caregivers' skills in the specific postoperative condition, and an additional in procedures related to basic health care in the hospital system. The video was completed with 11 minutes and 50 seconds. Conclusion: the educational video proved to be efficient in its constitution and applicability for preparing parents and other children caregivers who live with the need to learn about the postoperative care of cheiloplasty and palatoplasty surgeries.

Use of an esthetic overdenture as an alternative treatment in a patient with bilateral cleft lip and palate

Stable occlusion and a pleasing esthetic appearance are often difficult to achieve in patients with congenital defects and severe midfacial deficiencies. Conventional therapy, such as orthodontic treatment followed by orthognathic surgery, is often not sufficient to fully correct the dental and esthetic problems. An interdisciplinary approach for these patients should include prosthodontic treatment that will assist in establishing a harmonious occlusion and improve facial appearance. This clinical report describes the interdisciplinary approach for a young patient with a history of bilateral cleft lip and palate, spina bifida, hydrocephalus, and ventriculoperitoneal shunt. The patient was treated with conventional orthodontic treatment and orthognathic surgery that failed to fully correct the malocclusion. A removable overlay prosthesis made of crystallized acetyl resin was used to reestablish esthetics and create a stable occlusion.