A randomized prospective clinical trial of the effect of infant orthopedics in unilateral cleft lip and palate: prevention of collapse of the alveolar segments (Dutchcleft)

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial

BACKGROUND

Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment.

METHOD

The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site.

DISCUSSION

We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe.

TRIAL REGISTRATION

ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

A Cross-Sectional Study of the Dental Arch Relationship and Palatal Morphology after Cleft Surgery in Italian Children with Unilateral Cleft and Lip Palate

Dental arch relationships (DARs) and palatal morphology (PM) were evaluated in in non-syndromic complete unilateral cleft lip and palate (UCLP) Italian patients after surgery. Pre- and postnatal factors affecting the results were investigated. Sixty-six children with UCLP (40 boys and 26 girls, with a mean age of 10.1 ± 2.9 years), predominantly Caucasian (77%), were consecutively enrolled in this cross-sectional study. Twenty children had received a one-stage protocol consisting of an early periosteal palate surgical repair and lip closure and forty-six were submitted to a staged surgical protocol with delayed palate repair (DPR). A single clinician collected data on their medical history and carried out a dental examination. The DAR and PM were graded on dental casts according to the Eurocran index and dichotomised as favourable and unfavourable based on the treatment outcome. Multiple logistic regression analyses demonstrated that female sex (OR = 6.08, 95% CI: 1.47-25.23, p = 0.013), DPR (OR = 4.77, 95% CI: 1.14-19.93, p = 0.032) and the use of a neonatal plate (OR = 4.68, 95% CI: 1.27-17.16, p = 0.020) increased the odds of having favourable DAR, while only DPR (OR = 9.76, 95% CI: 2.40-39.71, p = 0.001) was significantly associated with a favourable PM. Based on these findings, only DPR had a significantly favourable effect on both DAR and DM in Italian children with complete UCLP.

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.

The Perception and Experience of Parents of Children with Cleft Lip and Palate Concerning the Use Pre-Surgical Infant Orthopedics: A Questionnaire-Based Cross-Sectional Survey

Background: A transitory period prior to the surgical correction of cleft lip and palate (CLP) is associated with adverse impacts, which may require a medical intervention. Pre-surgical infant orthopedics (PSIO) is deemed to reduce the functional and psychological burden, offering a transition until the definite surgical intervention. Aim: To assess the attitude of Iraqi mothers concerning the application and management of pre-surgical orthopedic appliances in children with cleft lip and palate, taking consideration of the mothers’ occupational status. Methods: The cross-sectional study was conducted in the College of Dentistry at Baghdad University from 5 January 2020 to 4 December 2021. A questionnaire form was validated based on existing data related to the assessment of parents’ satisfaction concerning PSIO. Results: A concern related to the impression procedure was reported by a minority of the participants (6.8%) and it was associated mainly to the perceptions of housewives’ vs. working mothers (p < 0.05). The perceived infants’ discomfort during the impression procedure reported at 11.9% was significantly associated with housewives’ status (p < 0.05). In general, the vast majority of respondents considered the impression as being non-invasive (96.6%). Most mothers found no difficulties in following the instructions of the specialist regarding the insertion of the PSIO and/or taping the elastic bands (62.7%). Respondents believed that CLP infants routinely require PSIO treatment. Interestingly, only a minority of mothers performed an Internet search to look for information about PSIO (7%). The majority indicated the PSIO treatment as beneficial for their infant and a substantial proportion of respondents were satisfied with the outcomes of PSIO, encouraging other parents to consent the PSIO treatment. Conclusion: In general, mothers broadly acknowledged the primary concept of PSIO and accepted the proposed treatment, with a positive attitude towards pre-surgical CLP management, regardless their socio-economic status. They seemed to understand well the expected benefits of PSIO, including feeding improvement, normalization of speech, and optimization of future surgical outcomes.

Gingivosupraperiosteoplasty following Presurgical Maxillary Orthopedics Is Associated with Normal Midface Growth in Complete Unilateral and Bilateral Cleft Patients at Mixed Dentition

BACKGROUND

Passive orthodontic appliances and gingivosupraperiosteoplasty are adjuncts that can be used by surgeons at the time of primary cleft lip repair. These treatments, along with the surgical technique of cleft lip and palate repair, may impact midface growth. The objective of this study was to describe the authors' protocol for unilateral and bilateral cleft lip repair and to evaluate midfacial growth in a cohort of patients at mixed dentition who had undergone presurgical passive orthodontic appliance therapy and gingivosupraperiosteoplasty at the time of unilateral and bilateral cleft lip repair.

METHODS

Fifteen complete unilateral and 15 complete bilateral cleft lip and palate patients underwent passive orthodontic appliance treatment and primary lip repair with gingivosupraperiosteoplasty. Lateral cephalograms were analyzed by three blinded reviewers. Mean cephalometric measurements at mixed dentition were compared to cephalometric values for noncleft patients, unilateral cleft lip and palate patients who did not undergo gingivoperiosteoplasty or presurgical treatment, and unilateral cleft lip and palate patients who underwent gingivoperiosteoplasty/nasoalveolar molding with independent samples t tests.

RESULTS

Mean cephalometric values were within age-specific normal values for sella-nasion-A point, sella-nasion-B point, A point-nasion-B point, and facial axis. Eighty-seven (13/15) percent of unilateral cleft lip and palate patients and 93 percent (14/15) of bilateral cleft lip and palate patients did not exhibit skeletal class III malocclusion. There was no significant difference between cephalometric values for our patients and patients who did not receive gingivosupraperiosteoplasty or presurgical treatment or who underwent the gingivoperiosteoplasty/nasoalveolar molding protocol.

CONCLUSIONS

Presurgical passive orthodontic appliances, combined with gingivosupraperiosteoplasty at the time of lip repair, leads to normal maxillary development in most patients at mixed dentition. Assessment of midface growth at skeletal maturity is required.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns

BACKGROUND

The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons.

METHODS

An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care.

RESULTS

Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time.

CONCLUSIONS

Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

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.

Three-dimensional evaluation of alveolar changes induced by nasoalveolar molding in infants with unilateral cleft lip and palate: A case-control study

OBJECTIVE

The objectives of this study were to evaluate linear and volumetric alveolar changes induced by nasoalveolar molding (NAM) in infants with complete unilateral cleft lip and palate (UCLP) and compare the maxillary dimensions after NAM with the normal dimensions in infants without clefts.

METHODS

A total of 26 infants with UCLP treated by NAM (mean age before and after NAM: 14.20 ± 8.09 days and 118.16 ± 10.06 days, respectively) comprised the treatment group, while 26 infants without clefts (mean age: 115.81 ± 8.71 days) comprised the control group. Changes in the maxillary dimensions following NAM were measured on three-dimensional models using Mimics software, version 17.0.

RESULTS

During NAM, there was a decrease in the cleft widths, maxillary arch depths, and rotation of the greater segment. While the anterior alveolar arch width exhibited a significant decrease, the posterior arch width was mostly maintained. There were no changes in the anterior vertical deviations of the alveolar segments. The alveolar crest lengths, arch circumference, and bilateral posterior volumetric measures exhibited an increase. After NAM, the anterior arch width was comparable between the treatment and control groups, whereas the posterior arch width and anterior vertical deviations were greater in the treatment group than in the control group. The maxillary arch depths, alveolar crest lengths, and maxillary volumes were smaller in the NAM group than in the control group.

CONCLUSIONS

During NAM in infants with UCLP, the cleft width and anteroposterior and transverse alveolar dimensions exhibited a decrease while the vertical dimensions were maintained. Compared with infants without clefts, those with UCLP treated by NAM exhibited sagittal and vertical alveolar growth deficiencies and tissue insufficiency.

Clinical Outcomes Utilizing a "Modified Latham" Appliance for Presurgical Infant Orthopedics in Patients With Unilateral Complete Cleft Lip and Palate

Presurgical infant orthopedic manipulation is utilized prior to cleft lip/nasal repair to facilitate a gingivoperiosteoplasty (GPP) and primary nasolabial repairs. The Latham dentomaxillary advancement appliance uses a screw that must be tightened daily to approximate the cleft segments in unilateral complete clefts. Our cleft center has been utilizing a "modified Latham" appliance since 1987, including an orthodontic elastic power chain to close the gap in a shorter amount of time. We performed a retrospective chart review of all patients undergoing treatment at Johns Hopkins All Children's Hospital (JHACH) with a unilateral complete cleft lip and palate between 1987 and 2017. Patients were identified by the International Classification of Diseases, Ninth Revision code (749.21). The majority of the patients represent the experience of the senior authors (E.R. and R.F.). Two hundred and eighty-one patients with unilateral complete cleft lip/palate were identified. Seventy-five patients were treated with a "modified Latham" appliance prior to their lip repair. The "modified Latham" appliance remained in place on average 20.6 days (range: 4-82), and average hospital stay after placement was 1.18 days. Nearly 96% of patients underwent a successful GPP at the time of nasolabial repair. Modification of the Latham appliance by utilizing an elastic power chain and eliminating the screw allows rapid closure of the alveolar cleft with limited need for adjustments and outpatient visits. Direct approximation of the palatal segments allows successful completion of a GPP in 95.9% of patients with limited dissection.

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.

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.

Active Presurgical Infant Orthopedics for Unilateral Cleft Lip and Palate: Intercenter Outcome Comparison of Latham, Modified McNeil, and Nasoalveolar Molding

OBJECTIVE

To compare dental arch relationship, craniofacial form, and nasolabial aesthetic outcomes among cleft centers using distinct methods of presurgical infant orthopedics (PSIO).

DESIGN

Retrospective cohort study.

SETTING

Four cleft centers in North America.

PATIENTS

One hundred ninety-one children with repaired complete unilateral cleft lip and palate (CUCLP).

MAIN OUTCOME MEASURES

Dental arch relationship was assessed using the GOSLON Yardstick. Craniofacial form was assessed by 12 cephalometric measurements. Nasolabial aesthetics were assessed using the Asher-McDade system. Assessments were performed between 6 and 12 years of age.

RESULTS

The center that used no PSIO achieved the most favorable dental arch relationship and maxillomandibular relationship, with a median GOSLON score of 2.3 ( P < .01) and an ANB angle of 5.1° ( P < .05). The proportion of children assigned a GOSLON score of 4 or 5, predictive of the need for orthognathic surgery in adolescence, was 16% at the center that used no PSIO and no secondary surgery, compared to 76% at the centers that used the Latham appliance and early secondary lip and nose surgery ( P < .01). The center that used no PSIO and no secondary surgery achieved significantly less favorable nasolabial aesthetic outcomes than the centers using Latham appliance or nasoalveolar molding (NAM) ( P < .01).

CONCLUSIONS

Effects of active PSIO are multifaceted and intertwined with use of revision surgery. In our study, centers using either the Latham appliance combined with early revision surgery or the NAM appliance without revision surgery achieved better nasolabial aesthetic outcomes but worse maxillary growth, compared to a center using no PSIO and secondary surgery.

Long-Term Follow-Up of UCLP Patients: Surgical and Orthodontic Burden of Care during Growth and Final Orthognathic Surgery Need

Objective

The goal of this study was to evaluate the craniofacial morphology at 5 and 10 years of age and at the completion of growth, the need for final orthognathic surgery, and the orthodontic burden in a sample of patients with unilateral cleft lip and palate consecutively treated by the same surgeon with the same two-step protocol.

Design

A sample of 62 adult patients with unilateral cleft lip and palate was retrospectively collected (mean age, 17.5 years). Lateral cephalograms at three time points were traced. The need for orthognathic surgery was assessed, subdividing the sample into an orthognathic surgery group and nonorthognathic surgery group. Time and modality of orthodontic treatment were recorded.

Results

Cephalometric values related to maxillary growth (SNA, SNAns) and maxillomandibular relation (ANB, NAPg) were significantly different between the two groups already at 5 and 10 years of age. All patients presenting an ANB smaller than 2° at 5 years needed a Le Fort I osteotomy. Mandibular protrusion (SNB, SNPg) was not different at 5 and 10 years, but was different at the completion of growth. Patients with the same initial maxillomandibular relation did not show better growth when subjected to earlier or longer orthodontic treatment.

Conclusion

Patients needing final jaw surgery had a more severe skeletal discrepancy during early childhood. The ANB angle at 5 years allowed doctors to identify 45% of the need for orthognathic surgery. The final craniofacial pattern does not seem to change significantly with early or prolonged orthodontic treatment.

The Effect of Infant Orthopedics on the Occlusion of the Deciduous Dentition in Children with Complete Unilateral Cleft Lip and Palate (Dutchcleft)

Objective

Evaluation of the effect of infant orthopedics (IO) on the occlusion of the deciduous dentition in patients with unilateral cleft lip and palate (UCLP).

Design

Prospective, two-arm, randomized, controlled clinical trial with three participating cleft palate centers (Dutchcleft).

Setting

Cleft Palate Centers of the University Medical Center Nijmegen, Academic Center of Dentistry Amsterdam, and Dijkzigt University Hospital Rotterdam, The Netherlands.

Patients

Children with complete UCLP (n = 54) were included.

Interventions

In a concealed allocation procedure, half of the patients was randomized to wear a plate till surgical closure of the soft palate (IO+), and the other half (IO−) did not have a plate.

Mean Outcome Measures

Dental arch relationships were assessed at 4 and 6 years of age with the 5-year-old index; the Huddart-score; and measurements of overjet, overbite, and sagittal occlusion.

Results

There were no significant differences found between the IO+ and IO− groups for the 5-year-old index; the Huddart-score; and overjet, overbite, and sagittal occlusion.

Conclusions

IO had no observable effect on the occlusion in the deciduous dentition at 4 and 6 years of age. Considering the occlusion only, there is no need to perform IO in children with UCLP.

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

Objective:

Evaluation of the effect of infant orthopedics on maxillary arch dimensions in the deciduous dentition in patients with unilateral cleft lip and palate.

Design:

Prospective two-arm randomized controlled clinical trial with three participating cleft palate centers.

Setting:

Cleft palate centers of the Radboud University Nijmegen Medical Center, Academic Center of Dentistry Amsterdam, and University Medical Center Rotterdam, the Netherlands.

Patients:

Children with complete unilateral cleft lip and palate (n = 54) were included.

Interventions:

Patients were randomly divided into two groups. Half of the patients (IO+) had a presurgical orthopedic plate until surgical closure of the soft palate at the age of 52 weeks; the other half (IO−) did not undergo presurgical orthopedics.

Mean outcome measures:

Maxillary arch dimensions were assessed on dental casts at 4 and 6 years of age with measurements for arch width, arch depth, arch length, arch form, and the vertical position of the lesser segment. Contact and collapse were assessed also.

Results:

There were no clinically significant differences found between IO+ and IO− for any of the variables.

Conclusions:

Infant orthopedics had no observable effect on the maxillary arch dimensions or on the contact and collapse scores in the deciduous dentition at the ages of 4 and 6 years. Considering the Dutchcleft results to date, there is no need to perform infant orthopedics for unilateral cleft lip and palate patients.

Infant Orthopedics and Facial Appearance: A Randomized Clinical Trial (Dutchcleft)

Objective:

To study the effect of infant orthopedics on facial appearance.

Design:

Prospective two-arm randomized controlled trial in parallel with three participating academic cleft palate centers. Treatment allocation was concealed and performed by means of a computerized balanced allocation method.

Setting:

Cleft Palate Centers of Amsterdam, Nijmegen, and Rotterdam, the Netherlands.

Patients:

Infants with complete unilateral cleft lip and palate, no other malformations.

Interventions:

One group (IO+) wore passive maxillary plates during the first year, the other group (IO−) did not.

Main Outcome Measure(s):

Two metrical response modalities were used (i.e., visual analog scales and reference scores) to score facial appearance. Full face and cropped photographs were compared with reference photographs and were judged. The photographs were judged by 45 judges, 24 laypeople, and 21 professionals. Transformation of the scores into z scores was applied to compare and to pool both response modalities. The validity of each individual judge was evaluated, as was the reliability of the scales. Differences between the treatment groups were evaluated by means of t tests.

Results:

Photographs were available of 41 subjects, 21 with and 20 without infant orthopedics. No significant differences were found between groups. Mean z-score values for the full-face photographs were: group IO+ = 0.10 (SD = 0.73) and group IO− = −0.03 (SD = 0.48); for the cropped photographs were: group IO+ = 0.12 (SD = 0.71) and group IO− = −0.06 (SD = 0.55).

Conclusions:

Infant orthopedics have no effect on facial appearance.

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.

Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

Objective

In the treatment of bilateral cleft lip and palate (BCLP) patients, there is discussion about the management of the position of the premaxilla. This literature analysis summarises the literature on managing this condition.

Materials and methods

A PubMed, Embase and Cochrane Library search was conducted resulting in 4465 articles which were screened on title and abstract.

Results

Seventy-one articles were available in full text, 16 of which were included in this literature analysis. We searched on keywords timing and technique, complications, growth of the maxilla and results after bone grafting the alveolar process. This literature analysis has shown that there are various ways to correct the position of the premaxilla. These can be divided into primary, early, late secondary and tertiary intervention before the age of 8 years, between the ages of 8 and 12 years and older than 12 years. Correction is done with surgery, orthodontics or a combination, with or without bone grafting.

Conclusions

An osteotomy of the premaxilla in combination with secondary alveolar bone grafting appears to be the most successful technique. Combining early secondary alveolar bone grafting with osteotomy creates more room to ensure a watertight closure of the nasal mucosa resulting in fewer postoperative complications. Before surgery, the orthodontist should try to optimise the position of the premaxilla for its surgical correction prior to bone grafting.

Clinical relevance

The treatment of BCLP patients is still based on experience and expert opinions. This literature analysis tries to give a summery on how to handle the protruded and displaced premaxilla.

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.

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.

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.

Long-Term, Longitudinal Follow-Up of Individuals with UCLP after the Gothenburg Primary Early Veloplasty and Delayed Hard Palate Closure Protocol: Maxillofacial Growth Outcome

Objective

To study long-term maxillofacial development in a sample of patients born with unilateral cleft lip and palate. The patients’ palatal repair had been performed according to a two-stage protocol with early velar closure and delayed hard palate surgery.

Design

Retrospective, longitudinal cohort study.

Subjects

The sample consisted of 50 consecutive patients with unilateral cleft lip and palate born from 1980 to 1989. All of them had been operated on at the Sahlgrenska University Hospital in Gothenburg, Sweden.

Methods

Certain maxillary casts as well as lateral roentgencephalograms, obtained at 5, 10, 16, and 19 years of age, were analyzed.

Results

Our patients’ maxillofacial growth was very good even up to the final examination in early adulthood. We ascribe the advantageous midfacial morphology of our patients particularly to limited growth restriction from palatal scars due to the surgical protocol used in our cleft center.

Conclusion

The two-stage protocol we advocate for repair of the palatal cleft resulted in very satisfactory growth outcome. A palatal scar, which might impair maxillary development, was created only by the velar surgery. If this scar is located close to the posterior border of the hard palate, it might result in less maxillary growth restriction than if it is positioned further anteriorly.

Protocols in cleft lip and palate treatment: systematic review

Objectives. To find clinical decisions on cleft treatment based on randomized controlled trials (RCTs). Method. Searches were made in PubMed, Embase, and Cochrane Library on cleft lip and/or palate. From the 170 articles found in the searches, 28 were considered adequate to guide clinical practice. Results. A scarce number of RCTs were found approaching cleft treatment. The experimental clinical approaches analyzed in the 28 articles were infant orthopedics, rectal acetaminophen, palatal block with bupivacaine, infraorbital nerve block with bupivacaine, osteogenesis distraction, intravenous dexamethasone sodium phosphate, and alveoloplasty with bone morphogenetic protein-2 (BMP-2). Conclusions. Few randomized controlled trials were found approaching cleft treatment, and fewer related to surgical repair of this deformity. So there is a need for more multicenter collaborations, mainly on surgical area, to reduce the variety of treatment modalities and to ensure that the cleft patient receives an evidence-based clinical practice.

Nasal outcomes of presurgical nasal molding in complete unilateral cleft lip and palate

Objective. Short-term nasal forms following primary lip repair were compared between presurgical nasal molding and control groups. Aim. To compare nasal symmetry between patients that had nasal molding and lip repair with those that had only lip repair. Design. Retrospective case-control study Patients. Complete unilateral CL+P patients had basilar and frontal photographs at two time points: (1) initial (2) postsurgical. 28 nasal molding patients and 14 control patients were included. Intervention. Presurgical nasal molding was performed prior to primary lip repair in intervention group. No nasal molding was performed in control group. Hypothesis. Nasal molding combined with lip surgery repair according to the Millard procedure provides superior nasal symmetry than surgery alone for nostril height-width ratios and alar groove ratios. Statistics. Shapiro-Wilk test of normality and Student's t-tests. Results. A statistically significant difference was found for postsurgical nostril height-width ratio (P < .05). No other statistically significant differences were found. Conclusions. Nasal molding and surgery resulted in more symmetrical nostril height-width ratios than surgery alone. Alar groove ratios were not statistically significantly different between groups perhaps because application of nasal molding was not early enough; postsurgical nasal splints were not utilized; overcorrection was not performed for nasal molding.

Primary Treatment for Cleft Lip and/or Cleft Palate in Children in Japan

Objective

To investigate current trends in primary treatment for children with cleft lip and/or cleft palate in Japan.

Design

Nationwide, retrospective study under the direction of the Academic Survey Committee of the Japanese Cleft Palate Association based on analysis of data obtained via a booklet-style questionnaire completed by institutions providing primary treatment for cleft lip and/or palate patients.

Participants, Patients

Patients were 4349 children undergoing primary repair for cleft lip and/or palate at 107 participating institutions between 1996 and 2000.

Main Outcome Measure(s)

Cleft type, laterality; use of infant palatal plate; and timing and technique of primary repair for cleft lip and/or palate were evaluated by cleft surgeons at 107 participating institutions.

Results

Of a total of 2874 patients with cleft lip and palate or cleft palate only, infant palatal plates were used with 1087 (37.8%) and were not used with 1787 (62.2%). Primary unilateral lip repair was performed at the age of 2 to 6 months in more than 90% of patients. Bilateral cleft lip was treated by one-stage repair in 285 patients (44.5%) and by two-stage repair in 258 (40.2%). Primary one-stage palatal repair was performed in 2212 (76.9%) and two-stage palatal repair in 262 (9.1%) cleft palate patients. Information on treatment of the remaining 400 (14%) patients was unavailable.

Conclusion

This investigation clarified current trends in primary treatment for cleft lip and/or palate in Japan. The results suggest the need for an increase in regional core hospitals and greater variation in treatment options.

Longitudinal Study of Effect of Hotz's Plate and Lip Adhesion on Maxillary Growth in Bilateral Cleft Lip and Palate Patients

Objective

To investigate the effects of infant orthopedic treatment and lip adhesion on maxillary growth of patients with bilateral cleft lip and palate (BCLP).

Design

Prospective longitudinal study.

Setting

The present study was conducted at the Cleft Lip and Palate Center, Harapan Kita Children and Maternity Hospital, Indonesia, and the Department of Oral and Maxillofacial Surgery, Kyushu University Hospital, Japan.

Subjects

The study sample consisted of 53 patients with complete BCLP and 10 noncleft patients with other diseases. Patients with BCLP were divided into three groups: H (-), 11 patients treated without Hotz's plate; H (+), 24 treated with Hotz's plate; and LA-H, 18 treated with lip adhesion and Hotz's plate.

Methods

Serial dental casts were obtained from each BCLP child at the following four time points: first visit, labioplasty, palatoplasty, and 5 years of age. Each maxillary dental cast was scanned, and the linear and angular dimensions were measured.

Results and Conclusion

Lip adhesion showed a temporary negative effect. In all patients with BCLP, the surgeries affected the growth of the anterior arch width until the age of 5 years. Collapse of the premaxilla following labioplasty in the H (-) group affected the growth of dental arch length until the age of 5 years. Treatment using Hotz's plate prevented collapse of the premaxilla, and the growth of the arch length was comparable to that observed in the noncleft group.

Presurgical Orthopedics Has No Effect on Archform in Unilateral Cleft Lip and Palate

Objective

Evaluation of the effect of presurgical orthopedics on maxillary archform up to 6 months of age.

Design

Retrospective, single-blinded, case-control study.

Participants

Study model sets of 75 infants with consecutive, nonsyndromic, complete unilateral cleft lip and palate (excluding Simonart bands) from 1995 to 2005.

Interventions

All patients (PSO group, n = 14; non-PSO group, n = 61) received lip repair/vomer flap at 3 months and soft palate repair at 6 months by the same consultant surgeon. The two groups were comparable at birth ( p > .01) in all archform variables.

Main Outcome Measures

Sixteen variables were computed, following single-blinded analysis using the Reflex Microscope to describe the archform in the transverse, anteroposterior, and vertical dimensions and the arch circumference. Data were analyzed using a repeated-measures hierarchical analysis of variance with a significance level of 1%.

Results

Repeatability studies showed good measurement precision. Presurgical orthopedics produced no statistically significant mean change in any archform variable when compared with the non-PSO group. The difference in the mean reduction in the alveolar cleft width between the groups was 0.69 mm (95% confidence interval, −0.89 to 2.28 mm, p = .52). Lip repair produced greater change in archform than did presurgical orthopedics, reducing the mean alveolar cleft width by 4.45 mm (95% confidence interval, 3.53 to 5.37 mm; p < .001).

Conclusions

There was no evidence that presurgical orthopedics produced any significant effect on archform, raising questions for its continued use in this context. Lip repair had a greater impact on arch dimensions than did presurgical orthopedics.

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.

Modified presurgical nasoalveolar molding in the infants with complete unilateral cleft lip and palate: a stepwise approach

Presurgical orthopedics in one or the other form has been an important part of the multidisciplinary approach towards the better cleft care. Presurgical nasoalveolar molding (PNAM) was described as a modified approach to the conventional form of orthopedics. PNAM not only reduces the severity of the alveolar defect before surgery, it also reduces the nasal deformity bringing it near to the normal. Nonsurgical nasal correction forms an important adjunct to the primary nasal repair at the time of primary lip repair. However, acceptance of nasoalveolar molding in Indian set-up has not been wide spread due to various reasons such as lack of the resources and inability of the parents to comply with the frequent adjustment schedule. At the Nitte Meenakshi Institute of Craniofacial surgery at the Nitte University, Mangalore, authors have developed a modification of the PNAM appliance previously described in the literature. The key modification is done at the time of fabrication of the occlusal prosthesis. This modification has made the overall procedure simpler and at the same time helped to reduce the recall visits by half of the originally required. This article describes the fabrication procedure of the modified nasal alveolar molding appliance and the modified treatment protocol in a stepwise manner.

Dental arch relationship in children with complete unilateral cleft lip and palate following one-stage and three-stage surgical protocols

The objective of this study is to compare dental arch relationship following one-stage and three-stage surgical protocols of unilateral cleft lip and palate. Dental casts of 61 children (mean age, 11.2 years; SD, 1.7), consecutively treated in one center with one-stage closure of the complete cleft at 9.2 months (SD, 2.0), were compared with a sample of 97 patients (mean age, 8.7 years; SD, 0.9), consecutively treated with a three-stage protocol including delayed hard palate closure in another center. The dental casts were assigned random numbers to blind their origin. Four raters graded dental arch relationship and palatal morphology using the EUROCRAN index. The strength of agreement of rating was assessed with kappa statistics. Independent t tests were run to compare the EUROCRAN scores between one-stage and three-stage samples, and Fisher's exact tests were performed to evaluate differences of distribution of the EUROCRAN grades. The intra- and inter-rater agreement was moderate to very good. Dental arch relationship in the one-stage sample was less favorable than in three-stage group (mean scores, 2.58 and 1.97 for one-stage and three-stage samples, respectively; p < 0.000). Palatal morphology in the one-stage sample was more favorable than in the three-stage group (mean scores, 1.79 and 1.96 for one-stage and three-stage samples, respectively; p = 0.047). The dental arch relationship following one-stage repair was less favorable than the outcome of three-stage repair. The palatal morphology following one-stage repair, however, was more favorable than the outcome of three-stage repair.

Infant orthopedics and facial growth in complete unilateral cleft lip and palate until six years of age (Dutchcleft)

OBJECTIVE

To evaluate longitudinally the effect of infant orthopedics (IO) on dentofacial cephalometric variables in unilateral cleft lip and palate (UCLP) patients from 4 to 6 years of age.

DESIGN

Prospective two-arm randomized controlled clinical trial in three cleft palate centers in The Netherlands (Dutchcleft trial).

PATIENTS

Fifty-four children with complete UCLP.

INTERVENTIONS

Patients were divided randomly into two groups. Half of the patients (IO+) had IO until surgical closure of the soft palate at the age of +/-52 weeks; the other half (IO-) received no intervention.

MEAN OUTCOME MEASURES

Cephalometric values representing soft tissue, hard tissue, and dental structures, measured on lateral headfilms made at 4 and 6 years of age.

RESULTS

In the IO+ group, 21 patients were analyzed; in the IO- group, 20 patients were analyzed at age 4 and 22 at age 6. No differences were found between IO+ and IO-, except for two measurements: The interincisal angle was larger and the mentolabial angle was smaller in the IO+ group.

CONCLUSIONS

For infants with UCLP whose surgical management included soft palate repair at 12 months and delayed hard palate closure, cephalometric outcomes at ages 4 and 6 provide no indication for the type of IO used in this study.

Effect of infant orthopedics on facial appearance of toddlers with complete unilateral cleft lip and palate (Dutchcleft)

OBJECTIVE

To evaluate the effect of infant orthopedics (IO) on facial appearance of 54 patients with unilateral cleft lip and palate (UCLP), aged 4 and 6 years.

DESIGN

Prospective two-arm randomized controlled clinical trial in three Cleft Palate Centers in the Netherlands (Dutchcleft-trial).

INTERVENTIONS

Patients were divided randomly into two groups. Half of the patients (IO+) had a plate until surgical closure of the soft palate at the age of +/- 52 weeks; the other half (IO-) received no intervention.

MAIN OUTCOME MEASURES

Facial appearance at 4 and 6 years of age assessed on full face photographs and photographs showing only nose and mouth. Ratings were performed on a VAS-scale by professionals and laymen.

RESULTS

At 4 years of age the full face pictures of IO+ children were scored to be more attractive than those of IO- children. However, this difference had disappeared at 6 years of age. At the age of 6, only professionals saw a significant difference on nasolabial photographs between IO+ and IO-. Regression analysis showed a minor effect of occlusion, lip revision, or type of nose reconstruction on the esthetic results.

CONCLUSIONS

IO had a positive effect on full facial appearance of UCLP children at the age of 4 years, but at the age of 6, only professionals saw a positive effect of IO on the nasolabial photographs. This is irrelevant for UCLP patients since they deal with laymen in their daily life.

Current surgical practices in cleft care: unilateral cleft lip repair

BACKGROUND

The purpose of this study was to report objectively on practice trends in unilateral cleft lip repair in the United States and Canada. This study details current technique preferences, modifications, and adjunct procedure use.

METHODS

All surgeons in the American Cleft Palate-Craniofacial Association and the Canadian Society of Plastic Surgeons (n = 1138) were mailed a survey inquiring about their management of unilateral cleft lip.

RESULTS

Responses were received from 622 surgeons (55 percent response rate), of whom 269 currently perform cleft surgery. The results arise from this group of 269 active cleft surgeons. Eight-four percent of surgeons perform rotation advancement for complete unilateral cleft lip repair. Nine percent perform a variation of the triangular flap repair. Among those using rotation advancement, 45 percent use a modified technique. The most common modifications are the Noordhoff vermilion flap, the Mohler modification, and the Onizuka triangular advancement flap. Surgeons rarely use more than one technique in their practice, and 86 percent use the same repair for every unilateral cleft lip. Over half of surgeons routinely perform some form of primary nasal correction. Lip adhesion, presurgical orthopedics, nasoalveolar molding, and postoperative nasal stenting are performed by limited numbers of respondents, and the use of these surgical adjuncts is discussed.

CONCLUSIONS

Rotation advancement remains the most frequently used technique for unilateral cleft lip repair. However, almost half of those using rotation advancement perform a modification to the original technique. Surgeons should be familiar with both the rotation advancement repair and its common modifications. Among adjunct procedures, only primary nasal correction currently garners widespread use.

Presurgical Orthopedics and Satisfaction in Motherhood: A Randomized Clinical Trial (dutchcleft)

Objective:

To study the effect of infant orthopedics on satisfaction in motherhood.

Design:

Prospective two-arm randomized controlled trial in parallel with three participating academic cleft palate centers. Treatment allocation was concealed and was performed by means of a computerized balanced allocation method.

Setting:

Cleft palate centers of Amsterdam, Nijmegen, and Rotterdam, the Netherlands.

Patients:

Two groups of infants with complete unilateral cleft lip and palate and no other malformations.

Interventions:

Group IO+ (n  =  27) wore passive maxillary plates during the first year of life, group IO− (n  =  27) did not.

Main Outcome Measure(s):

Mean satisfaction scores were obtained from completed questionnaires at 6, 24, and 58 weeks of age. A 4-point scale was used (1  =  very satisfactory to 4  =  very unsatisfactory).

Results:

The range of the mean scores for the individual items on the questionnaires for both groups ranged between 1.1 and 2.4. No differences were found between groups. Mothers appear to be satisfied in motherhood, least satisfied with the available time for themselves, and very satisfied with hugging and walking their babies. No differences were found between groups.

Conclusions:

Results from the present study show that infant orthopedics, with a passive plate during the first year of life, in children with a unilateral cleft lip and palate has no influence on the mothers’ satisfaction in motherhood.

Correction of the alveolar gap and nostril deformity by presurgical passive orthodontia in the unilateral cleft lip

The use of the nasoalveolar molding technique (NAM) aims to reduce passively the width of the alveolar gap, while improving the AP discrepancy but also focusing on the nose. We developed a within-subjects study in which 11 infants with unilateral lip deformity and varying degrees of alveolar gaps were treated by NAM. Patients included in the study presented alveolar gap at the first appointment to configure the molding device. Alveolar gap was then measured again at the time of lip repair to evaluate the impact of the appliance utilization, and the nostril shape was reassessed to verify the benefit relative to nose symmetry. All patients obtained significant reduction of the alveolar gap. The appliance also facilitated primary nasal positioning, significantly improving nasal symmetry and nostril shape. NAM constitutes an important adjunct to ameliorate the results of primary definitive lip repair while also improving the surgeon's ability to provide nasal symmetry.

A cephalometric intercenter comparison of patients with unilateral cleft lip and palate: analysis at 5 and 10 years of age and long term

OBJECTIVE

To compare the short- and long-term craniofacial growth of patients operated with the Milan protocol to those operated with the Oslo protocol.

DESIGN

The Milan sample included 88 patients with unilateral cleft lip and palate (UCLP) at 5 years, 26 at 10 years, and 23 at the end of growth. The Oslo samples included 48 UCLP patients at 5 years, 29 at 10, and 23 at growth completion. Lateral cephalograms were used for comparison. An unpaired t test was run for the 5- and 10-year-old samples. The samples long term were matched for age and sex, and a paired t test was run.

RESULTS

There was no significant cephalometric difference in the maxillary prominence at 5 years, a mild but significant difference at 10 years, and again no difference at the end of growth. Nevertheless, at an older age, the need for orthognathic surgery was larger in the Milan sample (26%) than in the Oslo sample (13%).

CONCLUSION

Although no statistically significant differences in the cephalometric measurements were found long term, the need for orthognathic surgery was clinically judged to be larger in the Milan sample. On the other hand, although the Milan protocol seemed to require more final jaw surgery, only the cases that needed an additional orthognathic procedure in the Milan group will undertake a third surgical step, while the Oslo protocol included three surgical steps for all the patients.

Results of randomized controlled trial of soft palate first versus hard palate first repair in unilateral complete cleft lip and palate

OBJECTIVE

To compare the outcomes for primary repair of unilateral cleft lip and palate, operating on the soft palate first versus the hard palate first.

DESIGN

Randomized controlled trial.

SETTING

The Regional Cleft Service of West Nepal.

PATIENTS

Forty-seven consecutive patients with nonsyndromic unilateral cleft lip and palate, of whom 37 were assessed 4 to 6 years after completing primary surgical repair.

INTERVENTIONS

Primary repair of unilateral cleft lip and palate by two differing sequences: (1) soft palate repair, with hard palate and lip repair 3 months later; and (2) lip and hard palate repair, followed by the soft palate repair 3 months later.

MAIN OUTCOME MEASURES

Analysis of dental study models, weight gain, and speech recordings.

RESULTS

Four to 7 years after completing the cleft closure, there was no significant difference in facial growth between the two types of repair sequencing. Completing posterior repair first had no effect on anterior alveolar gap width. It narrowed the hard palate gap by reducing the intercanine distance. Anterior repair dramatically closed the anterior alveolar gap, and narrowed the intercanine distance. Comparing anterior alveolar gap width with age at first presentation demonstrated that there was no spontaneous narrowing of the cleft in older children. Completing posterior closure first had a weight gain advantage over anterior closure first. Improved oropharyngeal closure, and thus swallowing, is the likely explanation.

CONCLUSION

Changing the sequencing of cleft closure has no demonstrable difference in facial growth at 4 to 7 years after completion of the primary surgery.