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

An Innovative Technique of Presurgical Lip, Alveolus, and Nose Approximation (PLANA) for Infants with Clefts

The innovative technique of "presurgical lip, alveolus, and nose approximation" (PLANA) offers a new approach within the domain of presurgical infant orthopedics for infants born with cleft lip and palate. Presurgical lip, alveolus, and nose approximation introduces the utilization of the NoseAlign device in conjunction with medical adhesive tapes, designed to approximate and support displaced soft tissue nasolabial structures in patients with cleft, without an intraoral plate. The NoseAlign device, constructed from medical-grade silicone, consists of 2 tubular portions that fit into the nostrils, connected by a columella band. Notably, it also features a wave-shaped and curved horizontal lip band, resting on the upper lip, with elastic clasps for secure attachment to the face with medical adhesive tapes. Presurgical lip, alveolus, and nose approximation therapy employs the NoseAlign device to support the collapsed nasal alar rim and cartilage, the displaced columella, the deviated nasal septum, and the displaced nasal alar base. This innovative approach minimizes the need for frequent office visits, making it particularly suitable for patients residing at a distance from specialized cleft centers. The prefabricated NoseAlign device offers effective support to nasal structures, making it suitable for unilateral and bilateral clefts. Importantly, the absence of an intraoral plate ensures it does not interfere with feeding. Presurgical lip, alveolus, and nose approximation therapy, initiated as early as 1 to 2 weeks, leverages the plasticity of nasal soft tissue and cartilage to achieve the desired nasal form before primary surgery. Although presurgical lip, alveolus, and nose approximation therapy does have some limitations, particularly in cases of medially collapsed alveolar segments, its simplicity, universal applicability, and patient-friendliness make it a promising technique in the presurgical infant orthopedics field.

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.

The orthodontic management of patients with cleft lip and palate: from birth to the late mixed dentition

This is the first of two papers outlining the orthodontic management of patients with cleft lip and palate. This paper will review orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. It will emphasise the importance of timing in alveolar bone grafting, the role of the general dental practitioner and the impact of timing on definitive orthodontic outcome.

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.

A Preliminary Study of Interdisciplinary Approach with a Single-Stage Surgery in Children with Cleft Lip and Palate

A two-stage surgical procedure involving labioplasty and palatoplasty is a common surgical modality performed in children with cleft lip and palate. Additionally, an alveolar cleft bone graft is performed prior to the eruption of the canine teeth. These three surgeries impose the burden of general anesthesia separately for each procedure, and the formation of scar tissue from the procedure inhibits maxillary growth. We adopted a single-stage surgical procedure to overcome these drawbacks. To date, there have been no reports comparing the treatment outcomes of alveolar morphology and maxillary growth and development in children who underwent single-stage surgery with those who underwent two-stage surgery using plaster casts and cephalograms. Twenty children aged 5–7 years were equally divided into two groups based on whether they had undergone a two- or single-stage procedure. Cephalometric analysis and analysis of dentition models were conducted. The results showed that the single-stage surgery exhibited significant differences in the sella-nasion angle, point A to McNamara line, maxillary length, mandibular body length, and posterior arch width and length compared with the two-stage surgery. Therefore, it was suggested that the single-stage surgery had a favorable effect on maxillary growth compared with the two-stage surgery.

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.

Three-dimensional Analysis of Factors Related to the Effective Alveolar Molding in Presurgical Infant Orthopedics: Findings From a Pilot Study

OBJECTIVE

Presurgical infant orthopedics (PIO) reduces the severity of the original cleft and burden on patients and their parents, provides better esthetics and function, and enables surgeons to achieve better surgical repair. To reduce the alveolar cleft width and to predict treatment difficulty using PIO, various measures were examined in pretreatment cast models.

DESIGN

Retrospective case-control pilot study.

PATIENTS

The patients were 22 infants with non-syndromic unilateral cleft lip and palate (UCLP), and cast models of these infants were used.

METHODS

After PIO using passive plates, infants with UCLP were divided into two groups: contact group (12 cases with close proximity of the greater and lesser segments) and non-contact group (10 cases without proximity of segments). The two groups were compared, and variables related to the proximity between alveolar clefts were examined.

RESULTS

There was no significant difference in age at PIO initiation between the two groups. However, the treatment duration was significantly longer in the non-contact group than in the contact group. Among the 13 variables, the initial lateral deviation of the nasal septum was significantly larger in the contact group than in the non-contact group. A significant positive correlation was observed between the initial lateral deviation of the nasal septum and reduction of the alveolar cleft width by PIO.

CONCLUSION

Initial lateral deviation of the nasal septum is a predictive factor for the proximity between alveolar segments in infants with UCLP at the PIO.

A modified presurgical alveolar molding technique for treatment of cleft in Down syndrome

Craniofacial clefts are extremely rare deformities. Tessier’s classification is a widely accepted system that is based on clinical, radiographical, and surgical observations. The Tessier No. 0 cleft most commonly affects the upper lip, nose, and palate. This case presentation aims to report the outcome of a modified presurgical alveolar molding (PAM) appliance used in the treatment of an infant with Tessier No. 0 cleft as an alternate approach to mold such defects before surgery. The modified PAM appliance consisted of reciprocal parts connected by a helix. The segments were approximated by stripping the appliance at the midline in a V-shaped manner and the force was exerted by the extraoral elastics. The procedure gave results in 8 weeks, which may be regarded as a reasonable duration. The anterior cleft gap, which was 13 mm before the treatment, was reduced to 3 mm after the treatment by using modified PAM appliance. On a 21-month follow-up period, oral reshaping was regarded successful due to stability of the improved oral mold.

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.

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.

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.

Marked Variation Exists Among Surgeons and Hospitals in the Use of Secondary Cleft Lip Surgery

OBJECTIVE

To identify child-, surgeon-, and hospital-specific factors at the time of primary cleft lip repair that are associated with the use of secondary cleft lip surgery.

DESIGN

Retrospective cohort study.

SETTING

Forty-nine pediatric hospitals.

PARTICIPANTS

Children who underwent cleft lip repair between 1999 and 2015.

MAIN OUTCOME MEASURE

Time from primary cleft lip repair to secondary lip surgery.

RESULTS

By 5 years after primary lip repair, 24.0% of children had undergone a secondary lip surgery. In multivariable analysis, primary lip repair before 3 months had a 1.22-fold increased hazard of secondary surgery (95% confidence interval [CI]: 1.02-1.46) compared to repair at 7 to 12 months of age, and children with multiple congenital anomalies had a 0.77-fold decreased hazard of secondary surgery (95% CI: 0.68-0.87). After adjusting for cleft type, age at repair, presence of multiple congenital anomalies, and procedure volume, there remained substantial variation in secondary surgery use among surgeons and hospitals (P < .01). For children with unilateral cleft lip repaired at 3 to 6 months of age, the predicted proportion of children undergoing secondary surgery within 5 years of primary repair ranged from 4.9% to 21.8% across surgeons and from 4.5% to 24.7% across hospitals.

CONCLUSIONS

There are substantial differences among surgeons and hospitals in the rates of secondary lip surgery. Further work is needed to identify causes for this variation among providers.

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.

The Effects of Presurgical Nasoalveolar Molding on the Midface Symmetry of Children with Unilateral Cleft Lip and Palate: A Long-term Follow-up Study

Background:

Midface symmetry is an important indicator of success of complete unilateral cleft lip and palate (CUCLP) treatment. There is little literature on the long-term effects of presurgical nasoalveolar molding (PNAM) on midface symmetry in children treated for CUCLP. This study aimed to compare children with CUCLP who underwent PNAM before surgical interventions, children who did not receive PNAM, and age- and sex-matched controls in terms of midface symmetry.

Methods:

We evaluated 39 frontal facial photographs of 13 patients with CUCLP who underwent PNAM as part of the treatment (group 1: PNAM), 13 patient with CUCLP who did not undergo PNAM (group 2: no nasoalveolar molding), and 13 age- and sex-matched controls. The children were evaluated in their fifth year of life. Three midline and 3 bilateral orthopometric midface landmarks were programmed using a custom software (OnyxCeph3, Image Instruments GmbH, Germany), and corresponding linear measurements from the midline were obtained and compared between the groups using 1-way analysis of variance and Scheffe’s post hoc test.

Results:

Significant differences were observed between the control and CUCLP groups for the measurements of the proanasale, subnasale, and zygion. However, there were no significant differences between the PNAM and no nasoalveolar molding groups for the 6 midface landmarks.

Conclusions:

PNAM does not seem to significantly impact the long-term midface symmetry in children with CUCLP.

Presurgical Preparation of Infants With Unilateral Cleft Lip and Palate: The SAC-PP-MR Innovative Technique

In this article, we demonstrate an effective, cheap, and fast way to shape the nasal alar cartilage in patients with unilateral cleft lip and palate. This technique straightens the vomer and brings the philtrum, columella, premaxilla, and the maxillary frenum to the midsagittal plane, while the alveolar ridges are shaped and positioned. This reduces the lip and palatal cleft to zero even in a 4-week period.

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.

Treatment Outcome of Bangladeshi UCLP Patients Based on Both Phenotype and Postnatal Treatment Factors using Modified Huddart Bodenham (mHB) Index

OBJECTIVE

To evaluate the dental arch relationship (DAR) of nonsyndromic unilateral cleft lip and palate (UCLP) and to explore the various phenotype and postnatal treatment factors that are responsible for poor DAR.

DESIGN

Retrospective study.

SETTING

School of Dental Science, Universiti Sains Malaysia.

SUBJECTS

Eighty-four Bangladeshi children with nonsyndromic UCLP who received cheiloplasty and palatoplasty.

MAIN OUTCOME MEASURES

Dental models were taken at 5 to 12 years of age (man: 7.69), and dental arch relationships were assessed using modified Huddart/Bodenham index (mHB) by two raters. Kappa statistics was used to evaluate the intra- and interexaminer agreements, chi-square was used to assess the associations, and logistic regression analysis was used to explore the responsible factors that affect DAR.

RESULTS

The total mHB score (mean [SD]) was -8.261 (7.115). Intra- and interagreement was very good. Using crude and stepwise backward regression analysis, significant association was found between positive history of class III (P = .025, P = .030, respectively) and unfavorable DAR. Complete UCLP (P = .003) was also significantly correlated with unfavorable DAR.

CONCLUSION

This multivariate study suggested complete type of UCLP and positive history of class III had a significantly unfavorable effect on the DAR.

An Intercenter Comparison of Dental Arch Relationships and Craniofacial Form Including a Center Using Nasoalveolar Molding

Objective:

To compare dental arch relationship and craniofacial morphology of patients with CUCLP in pre-adolescence from five cleft centers including a center using NAM.

Design:

Retrospective cohort study.

Setting:

Five cleft centers in North America.

Patients:

One hundred eighty-two subjects with repaired CUCLP from the five cleft centers participated in the craniofacial form study. One hundred forty-eight subjects from four of the five centers participated in the dental arch relationship study.

Methods:

Digital dental models were assessed using the GOSLON Yardstick. Eighteen cephalometric measurements were performed. Measurement means, by center, were compared. Analysis of variance and Tukey-Kramer analysis were used to compare GOSLON scores and cephalometric measurements.

Results:

The center that performed neither PSOT (including NAM) nor primary bone grafting exhibited the most favorable mean GOSLON score. The same center also showed the highest mean SNA, ANB, and ANS-N-Pg angles. However, the mean ANB and ANS-N-Pg angles were not significantly different from those of the center using NAM. No statistically significant differences were seen for mandibular prominence, vertical dimensions, or dental inclinations. The center with NAM also showed a significantly smaller nasoform angle than two of the four other centers.

Conclusion:

The centers that used NAM and other forms of PSOT did not have better dental arch relationships or craniofacial morphology compared with the centers that performed only primary lip repair. However, this study was not designed to investigate the cause-and-effect relationship between specific outcomes and particular features of those protocols.

A Comparative Evaluation of Efficacy and Efficiency of Grayson's Presurgical Nasoalveolar Molding Technique in Patients with Complete Unilateral Cleft Lip and Palate with Those Treated with Figueroa's Modified Technique

Background

Presurgical nasoalveolar molding (PNAM) has been used for aligning and not only for approximating the maxillary alveolar segments preoperatively but also for improving the nasal symmetry and therefore facilitates primary surgical repairs in cleft patients.

Aim

This study was conducted to compare the efficacy and efficiency of Grayson's technique with Figueroa's modified presurgical nasoalveolar technique in complete unilateral cleft lip and palate (UCLP) infants.

Materials and Methods

Twenty-two infants aged 10-15 days were randomly divided into two equal groups: Group I treated with Grayson's PNAM technique and Group II with Figueroa's PNAM technique.

Results

When we compared nasal asymmetry values preoperatively and postoperatively of Group I and Group II, it was found that the nostril height increased significantly on the cleft side and nostril width decreased significantly postoperatively on the cleft side. When we compared nasal asymmetry values postoperatively of Group I with Group II, all the values were nonsignificant. When we compared the digital maxillary cast analysis outcomes preoperatively and postoperatively in Group I and Group II, it was found that there was a significant reduction in the alveolar gap and there is a significant increase in the arch width. When we compared the efficiency of Group I with Group II, it was found that Group II was more efficient than Group II.

Conclusion

This study showed a morphological improvement in nasal symmetry and maxillary alveoli of infants with UCLP treated with both Grayson's PNAM technique and Figueroa's PNAM technique with Grayson's PNAM technique being more efficient.

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.

Correlation between Nasoalveolar Molding and Surgical, Aesthetic, Functional and Socioeconomic Outcomes Following Primary Repair Surgery: a Systematic Review

OBJECTIVES

The authors performed a systematic review to evaluate the potential beneficial effects of the nasoalveolar molding appliance on nonsyndromic unilateral clefts of the lip and/or palate prior to primary lip repair.

MATERIAL AND METHODS

A literature search was performed using three electronic databases (PubMed, Embase, Web of Science) and three journals ("Cleft Palate-Craniofacial Journal", "Plastic and Reconstructive Surgery Journal" and "American Journal of Orthodontics and Dentofacial Orthopaedic") from January 1980 to April 2017. Data extraction was performed with tables treating different subjects: surgical, aesthetical, functional, socio-economical effects of nasoalveolar molding (NAM) appliances and the evolution of NAM appliances, especially three-dimensional technology.

RESULTS

Of the 145 articles retrieved in the literature surveys, 28 were qualified for the final analysis and 20 studies were excluded because of their small sample size (less than 10 patients) and/or too long follow-up (exceeded 18 months). Four randomized controlled trials were available. Although literature allowed discussing the short-term benefits of NAM appliance and the three-dimensional technology, scientific evidence is lacking.

CONCLUSIONS

Based on the results, nasoalveolar molding appliances have positive surgical, aesthetical, functional and socio-economical effects on unilateral clefts of the lip and/or palate treatment before the primary repair surgeries. Three-dimensional technology results in a more efficient and predictable nasoalveolar molding appliance treatment. However, nasoalveolar molding appliance effect in a short term remains unclear with the available literature. Further studies that integrate three-dimensional technology in a large scale are still needed.

The effect of various factors on the dental arch relationship in non-syndromic unilateral cleft lip and palate children assessed by new approach: a retrospective study

Background

Cleft lip and palate (CLP) is one of the most common birth defects. Multiple factors are believed to be responsible for an unfavorable dental arch relationship in CLP. Facial growth (maxillary) retardation, which results in class III malocclusion, is the primary challenge that CLP patients face. Phenotype factors and postnatal treatment factors influence treatment outcomes in unilateral cleft lip and palate (UCLP) children, which has led to a great diversity in protocols and surgical techniques by various cleft groups worldwide. The aim of this study was to illustrate the dental arch relationship (DAR) and palatal morphology (PM) of UCLP in Bangladeshi children and to explore the various factors that are responsible for poor DAR and PM.

Methods

Dental models of 84 subjects were taken before orthodontic treatment and alveolar bone grafting. The mean age was 7.69 (SD 2.46) years. The DAR and PM were assessed blindly by five raters using the EUROCRAN index (EI). Kappa statistics was used to evaluate the intra- and inter-examiner agreement, chi square was used to assess the associations, and logistic regression analysis was used to explore the responsible factors that affect DAR and PM.

Results

The mean EUROCRAN scores were 2.44 and 1.93 for DAR and PM, respectively. Intra- and inter-examiner agreement was moderate to very good. Using crude and stepwise backward regression analyses, significant associations were found between the modified Millard technique (P = 0.047, P = 0.034 respectively) of cheiloplasty and unfavorable DAR. Complete UCLP (P = 0.017) was also significantly correlated with unfavorable DAR. The PM showed a significant association with the type of cleft, type of cheiloplasty and type of palatoplasty.

Conclusion

This multivariate study determined that the complete type of UCLP and the modified Millard technique of cheiloplasty had significantly unfavorable effects on both the DAR and PM.

Long-term effect of presurgical nasoalveolar molding on growth of maxillary arch in unilateral cleft lip and palate: randomized controlled trial

The objective of this study was to investigate the long-term effect of presurgical nasoalveolar molding (PNAM) on growth of the maxillary arch through early childhood until 6 years of age in complete unilateral cleft lip and palate (UCLP) patients presenting for PNAM at different ages. Complete UCLP patients who were treated at our centre were divided into two groups. The study group underwent PNAM and was further subdivided into three subgroups (PNAM initiated within 1 month, between 1 and 6 months, and between 6 and 12 months of age in subgroup I, II, and III, respectively). The control group did not undergo PNAM and was further subdivided into three subgroups. Patients were evaluated at T1 (first visit), T2 (before cheiloplasty), and T3 (at 6 years). Between T1and T2, the intersegment distance (ISD) reduced significantly in the study group but increased in the control group, whereas the intercanine width (ICW) in both the study and control groups did not show significant change. Between T2 and T3, ISD and ICW were reduced significantly in the control group due to arch collapse, whereas in the study group, ISD reduced slightly with ICW remaining almost similar to noncleft norms. We conclude that reduced ISD following PNAM improves arch symmetry and stability, and thus may prevent arch collapse in the long term.

Reporting of Randomized Controlled Trials in Cleft Lip and Palate: A 10-Year Review

Objectives

Reviews of the quality of reporting of randomized controlled trials (RCTs) have recently been conducted in different surgical specialties. In this review of RCTs relating to cleft lip, cleft palate, and cleft lip and palate (CL/P), we investigate the quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist.

Design

A systematic review of CL/P RCTs published from 2004 to 2013, with the included articles scored against the CONSORT checklist.

Patients, Participants

The literature search identified 174 articles. Studies were selected for participants with CL/P who were involved in an RCT with prospective data collection and reported in a full journal article. A total of 6352 participants were included from 65 CUP RCTs during the study period.

Main Outcome Measures

The methodological quality of RCTs was assessed using the CONSORT checklist and Jadad scale.

Results

The mean CONSORT score was 15.8, and the mean Jadad score was 3.3. There was a significant positive correlation between the CONSORT and Jadad score ( P < .0001, ρ = .47). The only significant correlation showed that with an increasing number of authors, both the CONSORT and the Jadad score increased.

Conclusion

This analysis has shown that that there are deficiencies in the transparent reporting of factors such as randomization implementation, blinding, and participant flow. Interventions, outcomes, and the interpretation of results are well presented. We would recommend that RCTs are conceived and undertaken using the CONSORT checklist and reported in a clear and reproducible manner.

[Three-dimensional analysis of alveolar changes of complete unilateral cleft lip patients after presurgical nasoalveolar molding treatment]

OBJECTIVE

This study analyzed the alveolar changes of complete unilateral cleft lip (UCCL) patients after pre-surgical nasoalveolar molding (PNAM) treatment using a three-dimensional method.

METHODS

Palate impressions of thirty UCCL patients who underwent PNAM treatment in the Affiliated Stomatology Hospital of Guangxi Medical University were taken pre- and post-PNAM. The plaster impressions were scanned using cone beam computed tomography (CBCT). The DICOM files were exported and 3D models reconstructed in Mimics 15.0. The following parameters were analyzed in SPSS 17.0: cleft alveolar gap width, alveolar arch end width, upper lip frenulum-median plane distance, alveolar shift distance, and length of alveolar section.

RESULTS

After PNAM treatment, the cleft alveolar gap width and upper lip frenulum-median plane distance decreased significantly (P<0.05). No statistically significant change was observed in the alveolar arch end width (P>0.05). Alveolar shift distances for both sides increased significantly (P<0.05), and the shift distance of major alveolar sec-tion had a more significant increase than the minor alveolar section. The lengths of the alveolar section of both sides increased significantly (P<0.05) with the length of the major alveolar section increasing more significantly than the minor alveolar section.

CONCLUSIONS

The impression-CBCT method supply accurate three-dimensional data of the alveolar process. The PNAM treatment can significantly correct alveolar deformity and improve appearance.

The Burden of Care for Children with Unilateral Cleft Lip: A Systematic Review of Revision Surgery

Objective

To identify the average rate of revision surgery following cleft lip repair.

Design

PubMed, CINAHL, and SCOPUS were searched from database inception through March 2013 using the search terms cleft lip and surgery. Two investigators independently screened all abstracts and determined eligibility from review of full manuscripts using prespecified inclusion and exclusion criteria. Strengths and limitation of the studies were assessed, followed by qualitative synthesis. The I2 test of homogeneity was performed to determine if meta-analysis was appropriate.

Results

The search identified 3034 articles. Of those, 45 met the inclusion criteria. Studies were primarily case series and retrospective cohort studies, with only one randomized controlled trial. One-third of studies (n = 15) did not describe how the study sample was selected. Follow-up duration was not reported in one-fourth of studies (n = 11). Nasolabial aesthetics were reported in 44% of studies (n = 20). The incidence of revision surgery ranged from 0% to 100%. Meta-analysis was precluded because of study heterogeneity (I2 = 97%).

Conclusions

The average incidence of cleft lip revision surgery cannot be estimated from the published literature, due to significant heterogeneity among existing reports and limited study quality. To provide valid information about the burden of care for unilateral cleft lip, a population-based or multicenter longitudinal cohort study is necessary; this study should measure the number of surgical procedures and the patient's aesthetic outcomes.

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.

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.

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.

Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review

Rehabilitation of cleft lip and palate (CLP) patients is a challenge for all the concerned members of the cleft team, and various treatment modalities have been attempted to obtain aesthetic results. Presurgical infant orthopaedics (PSIO) was introduced to reshape alveolar and nasal segments prior to surgical repair of cleft lip. However, literature reports lot of controversy regarding the use of PSIO in patients with CLP. Evaluation of long-term results of PSIO can provide scientific evidence on the efficacy and usefulness of PSIO in CLP patients. The aim was to assess the scientific evidence on the efficiency of PSIO appliances in patients with CLP and to critically analyse the current status of PSIO. A PubMed search was performed using the terms PSIO, presurgical nasoalveolar moulding and its long-term results and related articles were selected for the review. The documented studies report no beneficial effect of PSIO on maxillary arch dimensions, facial aesthetics and in the subsequent development of dentition and occlusion in CLP patients. Nasal moulding seems to be more beneficial and effective in unilateral cleft lip and palate patients with better long-term results.

Effect of lip closure on early maxillary growth in patients with cleft lip and palate

IMPORTANCE

Debate continues about the cause of midfacial growth disturbance in patients with facial clefts.

OBJECTIVE

To evaluate the functional effect of surgical closure of the lip before palatal closure according to the technique by Delaire on early maxillary growth in patients with complete unilateral cleft lip and palate.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-two patients with unilateral cleft lip and palate were studied using plaster casts obtained at the time of cheilorhinoplasty and 6 months later before palatal closure. The interrupted lateral muscles were anatomically repositioned using the surgical technique by Delaire. No patients had received preoperative orthodontic treatment or a passive palatal plate. Cast analyses were performed using a digital caliper.

MAIN OUTCOMES AND MEASURES

Landmark positioning was performed 3 times by 2 different examiners to define intraobserver and interobserver differences. The final maxilla dimensions were recorded as the distances between the mean landmark positions. Using the t test, dimensions obtained before palatal closure were compared with dimensions obtained before lip closure.

RESULTS

The method allowed good reproducibility. Functional closure of the lip significantly narrowed the transverse anterior cleft areas by -2.36 mm (P < .05). Sagittal variables were increased by 1.68 mm on the nonaffected side and by 1.48 mm on the affected side (P < .05 for both).

CONCLUSIONS AND RELEVANCE

Functional closure according to the technique by Delaire narrows the transverse dimensions of the maxilla, while simultaneously preserving initial sagittal growth.

LEVEL OF EVIDENCE

4.

Apriori feasibility testing of randomized clinical trial design in patients with cleft deformities and Class III malocclusion

OBJECTIVES

To assess the feasibility of randomizing treatment (surgical vs. non-surgical) for correction of a Class III malocclusion (underbite) resulting from an earlier repair of cleft lip and palate.

MATERIALS AND METHODS

Surveys about willingness to accept randomized treatment during adolescence were mailed to the parents of cleft lip and palate patients under the care of Children's Hospital Los Angeles between 2005 and 2010. The inclusion criteria were patients with cleft lip and palate, Class III malocclusion due to maxillary deficiency, and absence of medical and cognitive contraindications to treatment.

RESULTS

Out of 287 surveys, 82 (28%) were completed and returned; 47% of the subjects held a strong treatment preference (95% CI, 35-58%), while 30% were willing to accept randomization (95% CI, 20-41%). Seventy-eight percent would drop out of a randomized trial if dissatisfied with the assigned treatment (95% CI, 67-86%). The three most commonly cited reasons for being unwilling to accept random treatment assignment were 1) the desire for doctors to choose the best treatment, 2) the desire for parents to have input on treatment, and 3) the desire to correct the underbite as early as possible.

CONCLUSION

Based on this study, parents and patients would be unwilling to accept a randomly assigned treatment and would not remain in an assigned group if treatment did not meet expectations. This highlight the limitations associated with randomization trials involving surgical modalities and provide justification for other research models (e.g., cohort studies) to compare two treatment options when randomization is not feasible.

Unilateral cleft lip: principles and practice of surgical management

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

Short-term molding effects on the upper alveolar arch following unilateral cleft lip repair with/without nasal vestibular expansion

Objective : To elucidate the various effects on maxillary growth following different procedures for vestibular expansion at the time of primary lip repair for unilateral cleft lip and palate (UCLP). Participants : Thirty patients with complete UCLP who underwent primary lip repair using a triangular-flap technique with nasal vestibular expansion (NVE; the NVE group) and 30 patients who underwent the same lip repair with closure of the nasal floor (non-NVE group) were enrolled in this study. Interventions : Serial dental casts on lip and palatal repair were scanned with a laser scanner. The three-dimensional coordinates of seven anatomical landmarks and their growth changes, the curvature radius rate between major/minor segments, and the collapse rates were compared between the two groups. Results : At the time of lip repair, the incisal point was located slightly anteriorly in the non-NVE group. At the time of palatal repair, the cleft edge of the alveolar process in the minor segment was located significantly anteriorly and laterally in the NVE group, showing the significantly forward change of the minor segment. The minor segment collapsed in the non-NVE group. The collapse rate of the NVE group (3.3%) was significantly lower than that of the non-NVE group (40.0%). Conclusions : NVE following simultaneous advancement of nasolabial components on the affected side at the time of primary lip repair for UCLP facilitates the forward molding of the maxilla, resulting in a more symmetrical alveolar arch form.

Simplifying cleft surgery by presurgical nasoalveolar molding (PNAM) for infant born with unilateral cleft lip, alveolus, and palate: a clinical report

PATIENT

A 2-day-old female infant with complete unilateral cleft lip, alveolus, and palate (left side) was presented to the Department of Prosthodontics, Government Dental College and Hospital, Nagpur for evaluation and treatment with presurgical nasoalveolar molding (PNAM) prior to surgical intervention.

DISCUSSION

The alignment of the alveolar segments creates the foundation upon which excellent results of primary lip and nasal surgery are dependent in the repair of the cleft lip, alveolus, and palate patient. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. One of the problems that the traditional approach failed to address was the deformity of the nasal cartilages and the deficiency of columella tissue in infants with unilateral and bilateral cleft lip and palate. The purpose of this article is to illustrate the step-by-step fabrication process of the PNAM prosthesis used to direct growth of the alveolar segments, lips, and nose in the presurgical treatment of cleft lip and palate.

CONCLUSION

As a result, the primary surgical repair of the lip and nose heals under minimal tension, thereby reducing scar formation and improving the esthetic result. Frequent surgical intervention to achieve the desired esthetic results can be avoided by PNAM.