Three-dimensional assessment of early surgical outcome in repaired unilateral cleft lip and palate: Part 1. Nasal changes

Three-dimensional nasal asymmetry analysis between adolescence and adulthood in postoperative patients with unilateral cleft lip and palate using computed tomography

AIM

To investigate the differences of the nasal soft and hard tissue asymmetry in postoperative patients with unilateral cleft lip and palate (UCLP) between adolescence and adulthood, and to explore the correlation of nasal soft and hard tissue asymmetry.

METHODS

CT data from 47 repaired UCLP patients were included and divided into two groups:1. adolescent group: 23 patients (15 males, 8 females; age: 10-12 years old). 2. adult group: 24 patients (16 males, 8 females; age:18-32 years old). The three-dimensional asymmetry in nasal soft and hard tissues was analyzed. Additionally, the correlation between nasal soft and hard tissue asymmetry was also analyzed.

RESULTS

Both the adolescent group and adult group showed asymmetries in nasal soft and hard tissues. Compared to the adolescent group, the adult group had a significantly increased horizontal asymmetry of nasal soft tissues Sbal (P < 0.05). Furthermore, the sagittal asymmetry of soft tissue Glat (P < 0.05), Sbal (P < 0.001), Sni (P < 0.001) and hard tissue LPA (P < 0.05) also increased significantly. In the adult group, there were more landmarks with a correlation between the asymmetry of nasal hard tissue and soft tissue compared to the adolescent group. There were moderate to strong correlations between nasal hard and soft tissue symmetries in the horizontal and sagittal directions (0.444 < r < 764), but no correlation in the vertical direction in the adult group (P > 0.05).

CONCLUSIONS

The asymmetry of nasal soft and hard tissues in patients with repaired UCLP becomes more apparent in the horizontal and sagittal dimensions from adolescence to adulthood. The correlation between the asymmetry of nasal hard tissue and soft tissue becomes stronger in the horizontal and sagittal dimensions. These factors should be taken into account when performing treatment for repaired UCLP patients in adolescence and adulthood.

Volumetric assessment of the nose after primary unilateral cleft rhinoplasty using Laberge's technique

BACKGROUND

There is a lack of standardized surgery for cleft rhinoplasty. We felt that the technique described by Dr Louise Caouette Laberge is an ideal way to approach this problem, thus we tried to quantify the outcome of surgery by volumetric assessment.

MATERIAL AND METHOD

We recorded 3D images using an Artec scanner and performed volume calculations of the cleft side and noncleft side of the nose. These readings were taken once in the preoperative and then 2 weeks postoperative. Another scan of the face was performed 2 years after the surgery to compare the volumes of the cleft and noncleft side nostril.

RESULTS

Of the 31 patients with unilateral cleft lip operated on (mean age 3-8 months), we found a significant increase in the cleft side volume at 3 weeks postoperative from 3.95 mm3 to 5.65 mm3 (p < 0.001 on paired t-test). A repeat scan done on the study population at 2 years postoperative found that the mean volume of the cleft side was 30.43 mm3 (standard deviation [SD], 2.49) and that of the normal side was 30.82 mm3 (SD, 2.51). An independent t-test found that there was no significant difference between the two volumes (p > 0.05) CONCLUSION: The use of volumetric data in the evaluation of postoperative outcomes provides an objective criterion for assessing the aesthetics as well as the growth. Our study concludes that the Laberge technique provides a good aesthetic outcome with minimal scarring for the management of cleft nose and lip with the anterior palate.

Growth patterns of the nasolabial region following unilateral cleft lip primary repair

Surgical correction is the optimal way of repairing a congenital cleft lip. Patients with this condition often undergo initial surgical treatment at an early age and achieve an acceptable outcome. However, their levels of satisfaction will decrease in later stages of life as facial growth and development will inevitably cause changes in long-term outcomes, especially in the nasolabial region. Therefore, it is important for surgeons to understand nasolabial development after primary treatment and tailor their surgical techniques appropriately. This review focuses on the growth patterns of the nasolabial region after primary repair, so as to provide references for operative strategy.

Morphological Correlations in Nasolabial Formation After Primary Lip Repair for Unilateral Cleft Lip

PURPOSE

We aim to reveal postoperative morphological correlations between the nasolabial components in patients with unilateral cleft lip (UCL). The hypothetical correlations are first, a correlation between the vertical height of the cleft-side alar base and the length of the cleft-side red lip, and second, a correlation between the length of the cleft-side red lip and the vertical position of the cleft-side oral commissure. We explain how these morphological balances are controlled by surgery.

METHODS

Three-dimensional bilateral measurements of the length of the red lip, vertical height of the nasal alar base, and vertical height of the oral commissure were conducted retrospectively on 31 patients with UCL and palate (complete UCL: 26; incomplete UCL: 5) who underwent primary lip plasty at Osaka Women's and Children's Hospital from 2017 to 2019.

RESULTS

We found a statistically significant correlation between the vertical height of the cleft-side alar base and cleft-side red lip length (P = .012, r = 0.45); thus, the longer the red lip, the lower was the nasal alar base. The correlation between the cleft-side red lip length and the vertical height of the cleft-side oral commissure also showed a statistical significance (P = .00074, r = 0.57); thus, the shorter the red lip, the higher was the oral commissure.

CONCLUSIONS

The present results provided objective evidence showing basic morphological relationships between the postoperative nasolabial features of patients with UCL. The results lead to a reasonable approach to define the proposed peak of the Cupid's bow, an unsettled major controversy in cleft lip surgery.

Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty

BACKGROUND

Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to "upright the nose," without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse.

METHODS

Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison.

RESULTS

Significant changes in anthropometric and morphometric measurements occurred following surgery. Postoperative form was similar to controls immediately after surgery and at 5 years. Nasal corrections were satisfactory, and only two patients have elected to undergo revision. When subjects were grouped according to cleft type, we found the same trends. When comparing different methods of nasal sidewall reconstruction or septoplasty, we found no differences. Alveolar cleft width was a significant predictor of worse preoperative and postoperative form.

CONCLUSIONS

Significant nasal correction can be achieved by means of reconstruction of nasal foundation, without nasal tip dissection. Preservation of tissue planes may allow for easier secondary revision, if necessary.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Craniofacial Anthropometry: Normative Data for Caucasian Infants

PURPOSE

Craniofacial anthropometry is a valuable tool for characterization of facial dysmorphology and evaluation of treatment outcomes. Databases of normal anthropometric ranges are limited for infants. The aim of this study is to establish normative data for craniofacial anthropometric measurements in Caucasian infants.

METHODS

This is a prospective cross-sectional study including Caucasian infants (≤12 months old) that were recruited from a pediatric medicine practice and Boston Children's Hospital. Infants with craniofacial deformities, trauma or operations were excluded. The sample was stratified by age (in months) into 4 groups: 0 to 3, 3.1 to 6, 6.1 to 9, and 9.1 to 12. Three dimensional (3D) photographs were obtained for all subjects. Forty-five standard anthropometric points were plotted, and 37 measurements were made on the 3D photographs. Two evaluators independently performed all measurements. One examiner repeated the measurements on 25% of the subjects. Intraclass correlation coefficients (ICC) were calculated to assess inter-rater and intra-rater agreement.

RESULTS

Thirty-three subjects were enrolled in the study. The mean age for the entire sample was 6.3 ± 3.0 months, and 17 subjects (52%) were female. The mean ages (months) for each group were: 1.9 ± 0.7 for group 1 (n = 6); 4.4 ± 0.7 for group 2 (n = 8); 7.5 ± 1.1 for group 3 (n = 11); and 9.9 ± 1.0 for group 4 (n = 8). Descriptive statistics are presented for each group. Inter- and intra-rater agreements were acceptable (ICC >0.6) for 21 anthropometric measurements.

CONCLUSIONS

This study generated normative craniofacial anthropometric measurements for Caucasian infants. These data can be used in the interpretation of measurements for research studies evaluating craniofacial anomalies in this population.

Longitudinal Follow-up of Individuals With Cleft Lip Using Three-Dimensional Stereophotogrammetry

The usefulness of three-dimensional (3D) stereophotogrammetry for treating cleft lip (CL) has been well documented. However, there are only a few reliable anthropometric analyses in infants with CL because at this age they cannot assume a resting facial position. Since 2014, we have used a handheld 3D imaging system in the operating room to obtain optimal images of infants with CL and palate under general anesthesia. Currently, 168 infants with a unilateral cleft, 50 infants with bilateral clefts, and 47 infants with an isolated cleft palate are being followed up in this way for a maximum of 30 months. Most patients ≥3 years of age are cooperative and allow staff to obtain 3D images without sedation. We plan to follow them until adulthood, obtaining 3D images at every intervention. Each year, >150 infants can be added to this ongoing longitudinal study. Using an archive of these digital images, various retrospective studies can be attempted in the future, which include comparisons of the long-term outcomes of various surgical techniques and interventions at different time intervals. This is the first 2-year preliminary report of a 20-year longitudinal study.

Objective Assessment of the Unilateral Cleft Lip Nasal Deformity Using Three-Dimensional Stereophotogrammetry: Severity and Outcome

BACKGROUND

Optimization of care to correct the unilateral cleft lip nasal deformity is hampered by lack of objective measures to quantify preoperative severity and outcome. The purpose of this study was to develop a consensus standard of nasal appearance using three-dimensional stereophotogrammetry; determine whether anthropometric measurements could be used to quantify severity and outcome; and determine whether preoperative severity predicts postoperative outcome.

METHODS

The authors collected facial three-dimensional images of 100 subjects in three groups: 45 infants before cleft lip repair; the same 45 infants after cleft lip repair; and 45 children aged 8 to 10 years with previous repairs. Five additional age-matched unaffected control subjects were included in each group. Seven expert surgeons ranked images in each group according to nasal appearance. The rank sum score was used as consensus standard. Anthropometric analysis was performed on each image and compared to the rank sum score. Preoperative rank and anthropometric measurements were compared to postoperative rank.

RESULTS

Interrater and intrarater reliability was excellent (intraclass correlation coefficient, >0.76; Pearson correlation, >0.75) on each of the three image sets. Columellar angle, nostril width ratio, and lateral lip height ratio were highly correlated with preoperative severity and moderately correlated with postoperative nasal appearance. Postoperative outcome was associated with preoperative severity (rank and anthropometric measurement).

CONCLUSIONS

Consensus ranking of preoperative severity and postoperative outcome can be achieved on three-dimensional images. Preoperative severity predicts postoperative outcomes. Columellar angle, nostril width ratio, and lateral lip height ratio are objective measures that correlate with consensus ratings by surgeons at multiple ages.

Using three-dimensional average facial meshes to determine nasolabial soft tissue deformity in adult UCLP patients

BACKGROUND AND PURPOSE

There is limited literature discussing the residual nasolabial deformity of adult patients prior to undergoing orthognathic surgery. The purpose of this study is to determine the site and severity of the residual nasolabial soft tissue deformity between adult unilateral cleft lip and palate (UCLP) patients and a non-cleft reference group, prior to orthognathic surgery.

MATERIAL AND METHODS

Sixteen adult male UCLP patients, who all received primary lip and palate surgery according to a standardised Hong Kong protocol were recruited for this study. Facial images of each individual were captured using three-dimensional (3D) stereophotogrammetry and compared to a previous published Hong Kong non-cleft reference group of 48 male adults. Using two-sample t-tests differences in linear and angular measurements and asymmetry scores were evaluated between the two groups. In addition a "conformed" average UCLP facial template was superimposed and compared to conformed average non-cleft reference group facial template. Reproducibility of the measurements were assessed using Students paired t-tests and coefficients of reliability.

MAIN FINDINGS

Significant differences in linear and angular measurements and asymmetry scores were observed between the two groups (p < 0.05). Adult UCLP patients showed significantly narrower nostril floor widths, longer columella length on the unaffected side, a wider nose, shorter cutaneous lip height, shorter upper lip length and shorter philtrum length. Prior to orthognathic surgery adult UCLP patients showed significantly more facial asymmetry. Superimposition of the average facial meshes clearly showed the site and severity of the deficiency in the x, y and z-directions.

CONCLUSIONS

Many of the nasolabial characteristics reported to be present in children following primary UCLP repair continue into adulthood. The detrimental soft tissue effects of orthognathic surgery for UCLP patients may be different to non-cleft individuals; and as such the site and severity of the residual deformity should be assessed prior to surgery.

3D Assessment of Nasolabial Appearance in Patients With Complete Unilateral Cleft Lip and Palate

OBJECTIVE

Rhinoplasty in patients with complete unilateral cleft lip and palate (UCLP) is challenging, and the surgical outcome of the nose is complicated to evaluate. The aim of this study was to assess the nasolabial appearance of patients with UCLP compared with a control group.

DESIGN

Cross-sectional study.

SETTING

Riga Cleft Lip and Palate Centre, Latvia.

PARTICIPANTS

All consecutive 35 patients born between 1994 and 2004 with nonsyndromic complete UCLP were included. Of 35 patients, 29 came for checkup; the mean age was 14.7 years (range 10-18). In the control group, 35 noncleft participants at 10 years of age were included.

INTERVENTIONS

Nasolabial appearance was evaluated from 3-dimensional images using a 3-dimensional stereo-photogrammetric camera setup (3dMDface System), the results being analysed statistically.

RESULTS

In UCLP group, a statistically significant difference between cleft and noncleft side was found only in alar wing length ( P < .05). The difference of nasolabial anthropometric distances in the control group between the left and right side was not significant. The difference between the UCLP group and the control group was significant in all anthropometric distances except the lateral lip length to cupid's bow.

CONCLUSIONS

The nasolabial appearance with acceptable symmetry after cleft lip and reconstructive surgery of the nose was achieved. Symmetry of the nasolabial appearance in patients with UCLP differed from those in the control group. The 3D photographs with a proposed set of anthropometric landmarks for evaluation of nasolabial appearance seems to be a convenient, accurate, and noninvasive way to follow and evaluate patients after surgery.

A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 1: General concept and validation

PURPOSE

The need for a widely accepted method suitable for a multicentre quantitative evaluation of facial aesthetics after surgical treatment of cleft lip and palate (CLP) has been emphasized for years. The aim of this study was to validate a novel computer system 'Analyse It Doc' (A.I.D.) as a tool for objective anthropometric analysis of the nasolabial region.

MATERIALS AND METHODS

An indirect anthropometric analysis of facial photographs was conducted with the A.I.D. system and Adobe Photoshop/ImageJ software. Intra-rater and inter-rater reliability and the time required for the analysis were estimated separately for each method and compared.

RESULTS

Analysis with A.I.D. system was nearly 10-fold faster than that with the reference evaluation method. The A.I.D. system provided strong inter-rater and intra-rater correlations for linear, angular and area measurements of the nasolabial region, as well as a significantly higher accuracy and reproducibility of angular measurements in submental view. No statistically significant inter-method differences were found for other measurements.

CONCLUSIONS

The hereby presented novel computer system is suitable for simple, time-efficient and reliable multicenter photogrammetric analyses of the nasolabial region in CLP patients and healthy subjects.

A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 2: Comparative anthropometric analysis of patients with repaired unilateral complete cleft lip and palate and healthy individuals

PURPOSE

The aim of this study was to use a novel system, 'Analyse It Doc' (A.I.D.) for a complex anthropometric analysis of the nasolabial region in patients with repaired unilateral complete cleft lip and palate and in healthy individuals.

MATERIALS AND METHODS

A set of standardized facial photographs in frontal, lateral and submental view have been taken in 50 non-cleft controls (mean age 20.6 years) and 42 patients with repaired unilateral complete cleft and palate (mean age 19.57 years). Then, based on linear, angular and area measurements taken from the digital photographs with the aid of the A.I.D. system, a photogrammetric analysis of intergroup differences in nasolabial morphology and symmetry was conducted.

RESULTS

Patients with cleft lip and palate differed from the controls in terms of more than half of analysed angular measurements and proportion indices derived from linear and area measurements of the nasolabial region.

CONCLUSIONS

The findings presented herein imply that despite primary surgical repair, patients with unilateral complete cleft lip and palate still show some degree of nasolabial dysmorphology. Furthermore, the study demonstrated that the novel computer system is suitable for a reliable, simple and time-efficient anthropometric analysis in a clinical setting.

Three-dimensional evaluation of facial morphology in pre-school cleft patients following neonatal cheiloplasty

PURPOSE

To evaluate the facial morphology of pre-school patients with various types of orofacial cleft after neonatal cheiloplasty in pre-school aged children; and to compare facial variability and mean shape with age-corresponding healthy controls.

MATERIALS AND METHODS

The sample included 40 patients with unilateral cleft lip (CL), 22 patients with unilateral cleft lip and palate (UCLP), and 10 patients with bilateral cleft lip and palate (BCLP). Patients were divided into two age categories, with a mean age of 3 years and 4.5 years, respectively. The group of healthy age-matched controls contained 60 individuals. Three-dimensional virtual facial models were evaluated using geometric morphometry and multivariate statistics methods.

RESULTS

Statistically significant differences were found between each of the cleft groups and the controls. Color-coded maps showed facial shape deviations, which were located mainly in the nasal area and philtrum in all groups examined, and also in the buccal region and the chin in patients with UCLP or BCLP. These differences became more apparent, but not significantly so, in the older age category.

CONCLUSION

Facial deviations typical of patients with clefts were observed in all of the patient groups examined. Although the analysis showed statistically significant differences in overall facial shape between patients and controls among all groups tested, the facial morphology in patients who have undergone only neonatal cheiloplasty (CL) is influenced to a small extent and may be considered satisfactory. More severe cleft types (UCLP, BCLP) together with palatoplasty, are reflected in more marked impairments in facial shape.

Comparison of Oxygen Saturation During Impression Taking Before and After Presurgical Orthopedic Therapy in Babies With Cleft Lip and Palate

AIM

The objective of this study was to (1) evaluate the oxygen saturation (SpO₂) levels during intraoral and extraoral impression taking and (2) compare the SpO₂ levels during impression taking before and after presurgical orthopedic therapy (POT) of infants with cleft lip and palate (CLP).

PATIENTS AND METHODS

In our study, 31 babies with CLP before (mean age 7.6 ± 3.2 days) and after (mean age 108.3 ± 24.2 days) POT were monitored, and SpO₂ levels were measured under operating conditions before any intervention (T1), after oxygenation (T2), during taking intraoral (T3), and extraoral (T4) impressions with oxygen support and immediately before the discharge from the operating room (T5).

RESULTS

In both groups, statistically significant differences in SpO₂ measurements at T1, T2, T3, T4, and T5 stages were found (P < .01). For the pre-POT measurements, increases in SpO₂ levels from T1 to T2 and T4 to T5 (P < .05) and decreases from T2 to T3 and T3 to T4 (P < .01) were noted. Similarly, SpO₂ levels decreased significantly from the intraoral (T3) to extraoral (T4) post-POT impression periods (P < .01). Comparisons of pre- and post-POT measurements revealed that the SpO₂ level of each time period was higher at the post-POT impression taking except for stages T2 and T5 (P < .01).

CONCLUSION

The SpO₂ values were low at the onset of POT in infants with CLP before any intervention. Oxygen saturation levels may decrease particularly during extraoral impression taking in infants with CLP despite the supplemental oxygen. SpO₂ measurements were higher during post-POT intraoral and extraoral impression taking when compared with pre-POT measurements.

Measuring Symmetry in Children With Cleft Lip. Part 2: Quantification of Nasolabial Symmetry Before and After Cleft Lip Repair

OBJECTIVE

The first part of this study validated an automated computer-based method of identifying the three-dimensional midfacial plane in children with unrepaired cleft lip. The purpose of this second part is to develop computer-based methods to quantify symmetry and to determine the correlation of these measures to clinical expectations.

PARTICIPANTS

A total of 35 infants with unrepaired unilateral cleft lip and 14 infant controls.

INTERVENTIONS

Six computer-based methods of quantifying symmetry were developed and applied to the three-dimensional images of infants with unilateral cleft lip before and after cleft lip repair and to those of controls.

MAIN OUTCOME MEASURE

Symmetry scores for cleft type, changes with surgery, and individual subjects ranked according to cleft severity were assessed.

RESULTS

Significant differences in symmetry scores were found between cleft types and found before and after surgery. Symmetry scores for infants with unilateral cleft lip approached those of controls after surgery, and there was a strong correlation with ranked cleft severity.

CONCLUSIONS

Our computer-based three-dimensional analysis of nasolabial symmetry correlated with clinical expectations. Automated processing made measurement convenient. Use of these measures may help to objectively measure cleft severity and treatment outcome.

Reliability of nasolabial anthropometric measures using three-dimensional stereophotogrammetry in infants with unrepaired unilateral cleft lip

BACKGROUND

Surgical and orthodontic treatment of unilateral cleft lip +/- palate can produce dramatic changes in nasolabial form; however, the lack of ideal methods with which to objectively document three-dimensional form limits the ability to assess treatment outcomes. The purpose of this study was to determine the reliability of three-dimensional stereophotogrammetry for anthropometric assessment of the unilateral cleft lip +/- palate deformity in infants before cleft lip repair.

METHODS

Preoperative three-dimensional images were acquired from 26 consecutive patients with unrepaired unilateral cleft lip +/- palate. Three raters performed indirect anthropometry on each image on two separate occasions, with at least 1 week between rating sessions. One rater performed direct measurements on participants before surgery while in the operating room. Twenty-six linear and angular measurements were considered, and intrarater, interrater, and intermethod reliability were assessed.

RESULTS

Regarding intrarater and interrater reliability, most measurements had Pearson coefficients greater than 0.75, mean differences less than 0.8 mm, and mean proportional differences less than 0.1. For measurements involving vermilion height, nostril remnants, or Cupid's bow width, Pearson coefficients ranged from 0.3 to 0.75, mean differences ranged from 0.4 to 0.9 mm, and mean proportional differences ranged from 0.1 to 0.3. Regarding intermethod reliability, correlation coefficients ranged from 0.4 to 0.75 for most measurements. The mean differences for nose and lip measurements were less than 1 mm and between 0.8 and 1.3 mm, respectively.

CONCLUSION

Three-dimensional stereophotogrammetry provides a reliable method for many anthropometric measurements of nasolabial form in infants with unrepaired unilateral cleft lip +/- palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Three-dimensional imaging methods for quantitative analysis of facial soft tissues and skeletal morphology in patients with orofacial clefts: a systematic review

Background

Current guidelines for evaluating cleft palate treatments are mostly based on two-dimensional (2D) evaluation, but three-dimensional (3D) imaging methods to assess treatment outcome are steadily rising.

Objective

To identify 3D imaging methods for quantitative assessment of soft tissue and skeletal morphology in patients with cleft lip and palate.

Data sources

Literature was searched using PubMed (1948–2012), EMBASE (1980–2012), Scopus (2004–2012), Web of Science (1945–2012), and the Cochrane Library. The last search was performed September 30, 2012. Reference lists were hand searched for potentially eligible studies. There was no language restriction.

Study selection

We included publications using 3D imaging techniques to assess facial soft tissue or skeletal morphology in patients older than 5 years with a cleft lip with/or without cleft palate. We reviewed studies involving the facial region when at least 10 subjects in the sample size had at least one cleft type. Only primary publications were included.

Data extraction

Independent extraction of data and quality assessments were performed by two observers.

Results

Five hundred full text publications were retrieved, 144 met the inclusion criteria, with 63 high quality studies. There were differences in study designs, topics studied, patient characteristics, and success measurements; therefore, only a systematic review could be conducted. Main 3D-techniques that are used in cleft lip and palate patients are CT, CBCT, MRI, stereophotogrammetry, and laser surface scanning. These techniques are mainly used for soft tissue analysis, evaluation of bone grafting, and changes in the craniofacial skeleton. Digital dental casts are used to evaluate treatment and changes over time.

Conclusion

Available evidence implies that 3D imaging methods can be used for documentation of CLP patients. No data are available yet showing that 3D methods are more informative than conventional 2D methods. Further research is warranted to elucidate it.

Systematic review registration

International Prospective Register of Systematic Reviews, PROSPERO CRD42012002041

Scoring systems of cleft-related facial deformities: a review of literature

Objective :  There is a need for an internationally agreed objective method of assessing cleft-related deformities in order to compare the results of individual surgeons and different surgical techniques or to determine the optimal timing for primary lip closure. To assess the current methods, an overview of the recent developments in postoperative scoring systems of cleft-related deformities was made. Methods :  A Medline search from June 2003 through July 2011 was conducted, and references in the selected articles were checked. This search yielded 428 articles, and after application of the inclusion and exclusion criteria, 40 articles were included in this review. Results :  Twenty-five studies used two-dimensional (2D) photographs for the assessment of cleft-related deformities. Fourteen of these studies used a subjective method for the assessment and 11 performed anthropometric measurements. Good reliability has been found for subjective assessments and measurements from 2D photographs. Fifteen studies assessed three-dimensional (3D) imaging. Conclusions :  Although there is a wide variety in study design, 3D imaging seems most reliable in assessing cleft-related facial deformities. However, scoring on 2D photographs is easier to perform and more applicable in daily practice because all cleft patients are photographed through the course of their treatment.