Quantitative 3D maxillary arch evaluation of two different infant managements for unilateral cleft lip and palate

Presurgical Reduction of the Cleft Palate: Serendipitous Benefit of the Stanford Orthodontic Airway Plate Treatment (SOAP) for Infants with Robin Sequence

OBJECTIVE

Narrowing of the palatal cleft is often observed in infants with Robin sequence (RS) treated with the Stanford Orthodontic Airway Plate treatment (SOAP) even though SOAP is utilized primarily to establish airway patency. The current study quantified dimensional changes of the cleft palate (CP) in infants with RS treated with SOAP.

DESIGN

A retrospective chart review.

PATIENTS

Infants with RS and CP who completed SOAP and had maxillary arch models at both pre- and post-treatment time points at a single tertiary referral hospital between September 2019 and July 2023.

SETTING AND OUTCOME MEASURE

Maxillary arch models were measured and analyzed using Bivariate statistical analysis.

RESULTS

Seventeen infants were included in the study. The median age (min, max) was 6.7 weeks (1.1, 21.9) at pre-treatment and 26.6 weeks (18.7, 37.0) at post-treatment. The median Obstructive Apnea Hypopnea Index was 36.2 events/hour (8.1, 103.1) at pre-treatment and 4.1 events/hour (1.9, 8.6) at post-treatment. The pre-treatment width of CP decreased by an average (± standard diviation) of 6.37 mm (± 3.55, p < 0.001) at post-treatment. The ratio of the posterior cleft width to the total maxillary arch width decreased from 40% (± 9.1) at pre-treatment to 22% (± 11) at post-treatment (p < 0.001).

CONCLUSION

The dimensions of CP reduced significantly during SOAP in infants with RS and CP treated for their severe upper airway obstruction. The findings highlight a potential benefit of SOAP that may contribute favorably to the palate repair surgery.

Comparative study on cleft palate morphology after passive presurgical plate therapy in unilateral cleft lip and palate

BACKGROUND

Presurgical plate therapy has been widely accepted as a treatment prior to palatal cleft closure. The effects of passive presurgical plate therapy on cleft morphology prior to single-stage unilateral cleft lip and palate (UCLP) repair were quantified.

PATIENTS AND METHODS

We compared the dimensions of cleft width and cleft area (true cleft and palatal cleft) measured preoperatively at 2 European cleft centers. Center A performed single-stage UCLP repair in 8-month-old infants without any presurgical orthopedic treatment. Center B initiated passive presurgical plate therapy immediately after the birth of the neonates, followed by single-stage UCLP repair at 8 months of age.

RESULTS

We included 28 patients with complete UCLP from Center A and 12 patients from Center B. The average anterior width of the true cleft before surgery was significantly smaller in infants at Center B than that in Center A (p = 0.001) with 95% confidence interval of (1.8, 5.7) mm, but the average posterior width was similar in the 2 groups. The mean presurgical true cleft area amounted to 106.8 mm2 (SD = 42.4 mm2) at Center A and 71.9 mm2 (SD = 32.2 mm2) at Center B, with a confidence interval for the difference being (9.8, 60.1) mm2. This corresponded to a 32.7% reduction of the true cleft area when passive presurgical plate therapy was used for the first 8 months of the infants' life.

CONCLUSION

Passive presurgical plate therapy in UCLP significantly reduced the cleft area. Implications for the subsequent surgical outcome might depend on the surgical technique used.

Three-dimensional Analysis of Maxillary Morphology in Infants with Unilateral Cleft Lip and Palate

OBJECTIVE

To three-dimensionally (3D) analyze the maxillary morphology of infants with unilateral cleft lip and palate (UCLP) and preliminarily classify the alveolar arch to assist in personalization of sequence therapy.

DESIGN

Retrospective study.

SETTING

Patients with UCLP referred to outpatients' clinic.

PARTICIPANTS

84 nonsyndromic infants with complete UCLP were recruited (58 boys, 26 girls, mean age 29.48 days).

MAIN OUTCOME MEASURE

Morphometric analysis was conducted on 3D maxillary models. Principal component analysis (PCA) and cluster analysis were combined to classify maxillary phenotypes preliminarily. The Wilcoxon Signed Rank test and the Kruskal-Wallis test were used to compare differences between variables. A P value less than .05 was considered statistically significant.

RESULTS

The maxilla was divided into three types: narrow, homogenous and broad, accounting for 9.52%, 23.81% and 66.67% respectively. The alveolar cleft site (median value) was located in 61% of the total length of the alveolar arch. In the comparison of anterior and total alveolar lengths, the non-cleft side had longer alveolar bone than the affected side, a difference of approximately 2 mm. Pairwise comparisons of variables describing alveolar symmetry revealed significant differences in all subjects; whereas type C had poorer arch symmetry than types A and B, mainly in terms of anterior and overall symmetry.

CONCLUSIONS

In infants with UCLP, the maxillary alveolar arch was inherently asymmetrical with partially bone missing (about 2 mm). Significant differences in alveolar bone morphology and symmetry exist between different types of infants, with individuals with broad clefts (type C, the largest proportion) having the worst maxillary development.

Histologic Aspect of the Curved Vomerine Mucosa in Cleft Lip and Palate

Background:

Common surgical techniques aim to turn the entire vomerine mucosa with vomer flaps either to the oral side or to the nasal side. The latter approach is widely performed due to the similarity in color to the nasal mucosa. However, we lack a histologic description of the curved vomerine mucosa in cleft lip and palate malformations.

Methods:

We histologically examined an excess of curved vomerine mucosa in 8 patients using hematoxylin–eosin, periodic acid–Schiff, Elastin van Gieson, and Alcian blue stains. Tissue samples were obtained during surgery at 8 months of age.

Results:

Our histological analysis of the mucoperiosteum overlying the curved vomer revealed characteristics consistent with those of an oral mucosa or a squamous metaplasia of the nasal mucosa, as exhibited by a stratified squamous epithelium containing numerous seromucous glands. Some areas showed a palisaded arrangement of the basal cells compatible with metaplasia of respiratory epithelium, but no goblet cells or respiratory cilia were identified. Abundant fibrosis and rich vascularity were present.

Conclusion:

The vomer mucosa showed no specific signs of nasal mucosa. These findings should be considered in presurgical cleft orthopedics and palatal surgery for further refinement. Shifting the vomer mucosa according to a fixed physiologic belief should not overrule other important aspects of cleft repair such as primary healing and establishing optimal form and function of palatal roof and nasal floor.

The Effect of Cleft Size in Infants with Unilateral Cleft Lip and Palate on Mixed Dentition Dental Arch Relationship

Objective

To determine the relationship between infant cleft size and dental arch relationship in the mixed dentition in patients with complete unilateral cleft lip and palate.

Design

Retrospective analysis of mixed longitudinal records.

Patients

A total of 29 consecutively enrolled patients with unilateral cleft lip and palate participated in a longitudinal study that included dental casts prior to lip surgery (T1: age 1 month), prior to palate surgery (T2: age 10 months), and in mixed dentition (T3: age 9 years).

Interventions

All infants were managed with lip repair (2.5 months), hard palate repair (12 months), and soft palate repair (16 months) but without any presurgical orthopedic treatment and no orthodontic intervention prior to mixed dentition records.

Main Outcome Measures

The outcome measures included determination of an infant cleft severity ratio, defined as the ratio of palatal cleft area to palatal surface area, at both T1 and T2, and the 9-year-old (T3) dental arch relationship as determined using the GOSLON Yardstick. The correlation between the infant cleft severity ratio at T1 and T2 and the later GOSLON Yardstick score at T3 was determined using Pearson r. The intrarater reliability of the infant cleft severity ratio was assessed with Pearson r and the interrater reliability of the GOSLON Yardstick ratings, by weighted kappa.

Results

Reliability for the infant cleft severity ratio method was r = .92 to .95, and for GOSLON ratings κ = .81 to .91. There was no significant correlation between 1-month infant cleft severity ratio and GOSLON ( r = .3) and 10-month infant cleft severity ratio and GOSLON ( r = .1).

Conclusions

Cleft size versus the amount of palatal tissue available for repair and concern over more scarring with a greater infant cleft severity ratio were not factors in affecting the eventual dental arch relationship.

Management of Prominent Premaxilla in Bilateral Cleft Lip and Alveolus

Our aim was to describe the early management protocol of the prominent premaxilla in bilateral cleft lip and alveolus and its rationale, as used in the Cleft Centre at the 1st Department of Pediatrics and at the Department of Pedodontics and Orthodontics at the Semmelweis University Budapest. The non-surgical and surgical procedures included lip taping, nasoalveolar molding, lip adhesion and definitive one-stage lip closure. With this treatment sequence, arch management was satisfactory and at the time of the definitive lip closure the position of the premaxilla did not interfere with adequate surgical repair.

Long-Term Effects of Presurgical Infant Orthopedics in Patients with Cleft Lip and Palate: A Systematic Review

Objective

This study aimed to assess the scientific evidence on the efficiency of presurgical infant orthopedic appliances in patients with cleft lip and palate to shed light on a specific, contemporary discussion of whether the appliances have long-term advantages with respect to treatment outcomes.

Design

A systematic review.

Method

Two literature surveys from the five electronic databases were performed with a 1-month interval. Randomized controlled trials and controlled clinical trials (controls had no presurgical infant orthopedics) that had follow-up periods of a minimum of 6 years were included in the study. The exceptions to the follow-up limit were studies related to feeding and parent satisfaction.

Results

Of the 319 articles retrieved in the literature surveys, 12 were qualified for the final analysis. The level of evidence of these articles ranged from 1b to 4. Eight randomized controlled trials and four controlled clinical trials were available on eight treatment outcomes. The longest follow-up period of the randomized controlled trials was 6 years. No randomized controlled trials were found on active presurgical infant orthopedic appliances and on nasoalveolar molding appliances.

Conclusions

Based on the results, presurgical infant orthopedic appliances have no long-term positive effects on seven of the eight studied treatment outcomes in patients with cleft lip and palate. More randomized controlled trials need to be done to have evidence regarding the effects of presurgical infant orthopedics in different surgical protocols. Also, the encouraging results about the effect of nasolaveolar molding appliances on nasal symmetry have to be supported by future randomized controlled trials.

Lip adhesion revisited: A technical note with review of literature

CONTEXT (BACKGROUND): Lip adhesion is a direct edge approximation without changing lip landmarks or disturbing tissue required for definitive closure. This converts a complete cleft into an incomplete cleft, facilitating and enhancing subsequent definitive lip and nose repair.

AIM

The study aims to describe our technique of lip adhesion and its morbidity, and discuss the rationale for its use.

SETTINGS AND DESIGN

Retrospective follow-up study of complete clefts operated upon in the Bruges Cleft and Craniofacial Centre, at the supra regional teaching hospital AZ St. Jan, Bruges, between June 1, 1991 and May 1, 2009.

METHODS AND MATERIAL

The group comprised 33 unilateral and 24 bilateral lip adhesion procedures. The medical files were reviewed for changes in surgical technique, morbidity, and complications and their treatment.

RESULTS

The lip adhesion procedure was performed at the age of two to eight weeks postnatal, and definitive lip closure, at the age of four to six months. In all cases, segment repositioning was further controlled by a palatal guidance plate. Wound dehiscence occurred in eight patients (14.0%), and three patients (5.3%) required reoperation.

CONCLUSIONS

Although complications occurred, the beneficial effects of lip adhesion in combination with a guidance plate outweighed the risks for anatomical reconstruction of a platform for definitive lip and nose repair. Modifications are suggested to reduce these complications.

Comparative osseous and soft tissue morphology following cleft lip repair

OBJECTIVE

To quantify comparative improvement between osseous and soft tissue asymmetry following primary lip repair.

DESIGN

Retrospective analysis of preoperative and postoperative computed tomography scans of infants with unilateral cleft lip and palate. Sixteen soft tissue landmarks were placed using an exploratory two-/three-dimensional image processing system and compared for asymmetry.

PATIENTS

Computed tomography scans were obtained on 26 patients (13 boys, 13 girls) of Chinese ethnicity (mean age = 0.25 years) prior to Millard lip repair. Nineteen of these contributed to follow-up comparative studies prior to palatoplasty at a mean age of 0.92 years. There were 18 left-sided and eight right-sided clefts.

MAIN OUTCOME MEASURE

Euclidean distance matrix asymmetry analysis was used to determine the amount of soft tissue asymmetry pre- and postlip repair. Similar analyses of the same scans were performed for 41 osseous landmarks.

RESULTS

Soft tissue landmarks had 36/39 (92%) preoperative and 13/39 (33%) postoperative asymmetric pairs. Osseous distances demonstrated 77/125 (61%) asymmetric pairs preoperatively and 60/125 (48%) postoperatively. Soft tissue and osseous distances of the lip region demonstrated 32% and 39% postoperative asymmetry, respectively. Soft tissue and osseous distances of the nasal region demonstrated 52% and 72% postoperative asymmetry, respectively. Soft tissue and osseous distances of the facial landmarks demonstrated 24% and 34% postoperative asymmetry, respectively.

CONCLUSIONS

Primary lip repair appears to effect gains in symmetry in soft tissue and provides sufficient molding forces to cause correlating symmetry changes in underlying osseous structures.

Three-dimensional facial morphology following surgical repair of unilateral cleft lip and palate in patients after nasoalveolar molding

OBJECTIVE

To evaluate three-dimensional (3D) facial morphology in patients surgically corrected for unilateral cleft lip and palate (UCLP) following pre-surgical nasoalveolar molding (NAM).

DESIGN

Prospective, longitudinal study. Digital stereophotogrammetry was used to capture 3D facial images, and x, y, and z coordinates of five landmarks were digitized to compute mean morphologies. The sample comprised 15 patients with left UCLP and 10 matched control subjects. Facial form differences at age 37 weeks, using principal components analysis and finite-element scaling analysis (FESA) were assessed.

RESULTS

Using the first two principal components, which accounted for 63% of the total shape-change, UCLP and control groups showed similar distributions in the modal space (p > 0.05). For the UCLP group, the mean 3D facial form was smaller and less protrusive when superimposed on the non-cleft mean. Using FESA, reductions in facial volume were found in the UCLP group, involving the columella (29%), labial tubercle (51%), lower lip (29%) and lateral aspects of the face (19%). The UCLP group also showed increases in size above the tip of the nose (25%) and laterally to the columella directly below the nares (29%).

CONCLUSIONS

Following surgical repair of UCLP in patients previously treated with NAM, 3D facial morphology was virtually indistinguishable from the non-cleft mean. Clinically, the apparent improvement in the facial soft tissues may mask dysmorphic skeletal growth, and further studies are required to characterize the underlying bony changes associated with the soft tissue changes reported here.

Influence of early hard palate closure in unilateral and bilateral cleft lip and palate on maxillary transverse growth during the first four years of age

OBJECTIVE

To evaluate and compare the effects of early primary closure of the hard palate on the anterior and posterior width of the maxillary arch in children with bilateral (BCLP) and unilateral (UCLP) cleft lip and palate during the first 4 years of life.

DESIGN

A retrospective, mixed-longitudinal study.

SETTING

Cleft Palate Center of the University of Erlangen-Nuremberg.

SUBJECTS AND METHODS

The present investigation analyzes longitudinally 42 children with UCLP and 8 children with BCLP between 1996 and 2000 with early simultaneous primary closure of lip and hard palate (4 to 5 months). Palatal arch width was measured on dental casts with a computer-controlled three-dimensional digitizing system, and their growth velocities were calculated from consecutive periods (mean follow-up 39 months). Differences in growth velocities were compared with those of 25 children with UCLP and 15 children with BCLP with delayed closure of hard palate (12 to 14 months).

RESULTS AND CONCLUSIONS

There was no significant difference in terms of anterior and posterior maxillary width between early and delayed closure of hard palate within the first 4 years of life.