Comparative Evaluation of the Pharyngeal Airway Space in Unilateral and Bilateral Cleft Lip and Palate Individuals with Noncleft Individuals: A Cone Beam Computed Tomography Study

Seasonal, Geographic, and Ethnic Influence on the Prevalence of Orofacial Clefts in Kuwait: A Nationwide Study

OBJECTIVE

Accurate nationwide epidemiological evidence is vital to study the seasonal, geographic, and ethnic influence on the trends of orofacial cleft prevalence in Kuwait.

DESIGN

Data obtained from the National Center for Health Information and Ministry of Health Hospital digital records were reviewed retrospectively to identify patients with orofacial clefts (OFC) using the ICD-10 diagnostic codes. The Jonckheere-Terpstra test was used to assess the trend of birth prevalence across the different years. The associations of types of OFC with ethnic and geographic influences were tested with chi-square or Fisher's exact tests, while the strength of that association was tested with multi-nominal logistic regression.

RESULTS

Birth prevalence in Kuwait ranged from 0.75-2.55 per 1000 live births (0.73- 2.73 among Kuwaitis, 0.60-3.27 among non-Kuwaitis), with no statistically significant change observed during the past 28 years. The risk of unilateral cleft lip and palate was eight times higher during summer compared to Autumn, while the risk of cleft lip and palate remained lower during winter. Jahra (OR-7.76, CI- 1.51-39.80), Farwaneya (OR-6.65, CI- 1.34-33.06), and Hawalli (OR-6.72, CI- 1.26-35.98) governorates had higher odds of bilateral cleft lip when compared to Mubarak Alkabeer.

CONCLUSIONS

The study outcome is an indicator to improve patient care and customize healthcare infrastructure in the Ministry of Health. It also provides insight to develop projections of future needs. Future studies should focus on understanding the factors that might be a potential contributor to the seasonal change observed in the prevalence of OFC.

Assessment of Internal Nasal Dimensions of Individuals With Cleft Lip and Palate and Obstructive Sleep Apnea Syndrome by Computed Tomography

To evaluate nasal cavity (NC) dimensions of individuals with cleft lip and/or palate (CL/P), obstructive sleep apnea (OSA), and primary snoring, by tomographic image analysis, compared to individuals with OSA without CL/P (N-CL/P).

Cross-sectional and retrospective.

Tertiary referral center.

Patients were divided into 2 groups: (G1) CL/P + OSA or primary snoring, n = 11; (G2) N-CL/P + OSA, n = 13.

NC tomographic images were reconstructed using ITK-SNAP software, and measurements were obtained from these three-dimensional models using SpaceClaim software.

Total NC volumes, right and left NC volumes, and volumes of the nostril to the nasal valve (V1) and from the nasal valve to the superior limit of the nasopharynx (V2), cross-sectional areas, and perimeters.

NC volumes (total, right, and left sides), V1, and V2, though smaller in the CL/P + OSA, did not differ significantly from the N-CL/P + OSA. Cross-sectional areas and perimeters of the superior limit of the nasopharynx, in the CL/P + OSA, presented significantly higher values compared to the N-CL/P + OSA (P ≤ .05).

The internal nasal dimensions of patients with CL/P do not seem to be part of the etiopathogenesis, nor constitute a risk factor for OSA with greater severity, in this special group of patients.

Upper Airway Changes in Diverse Orthodontic Looms: A Systematic Review and Meta-Analysis

Upper airway assessment is particularly important in the daily work of orthodontists, because of its close connection with the development of craniofacial structures and with other pathologies such as Obstructive Sleep Apnea Syndrome (OSAS). Three-dimensional cone-beam computed tomography images provide a more reliable and comprehensive tool for airway assessment and volumetric measurements. However, the association between upper airway dimensions and skeletal malocclusion is unclear. Therefore, the current systematic review evaluates the effects of different surgical movements on the upper airway. Materials and Methods: Medline (PubMed, OVID Medline, and EBSCO), Cochrane Library (Cochrane Review and Trails), Web of Knowledge (social science, and conference abstracts), Embase (European studies, pharmacological literature, and conference abstracts), CINAHL (nursing and allied health), PsycInfo (psychology and psychiatry), SCOPUS (conference abstracts, and scientific web pages), and ERIC (education) databases were searched. Two authors independently performed the literature search, selection, quality assessment, and data extraction. Inclusion criteria encompassed computed tomography evaluations of the upper airway spaces with retrospective, prospective, and randomised clinical trial study designs. To grade the methodological quality of the included studies a GRADE risk of bias tool was used. Results and conclusion: In total, 29 studies were included. Among these, 17 studies had a low risk of bias, whereas 10 studies had a moderate risk of bias. A meta-analysis was performed with the mean differences using a fixed-effects model. Heterogeneity was assessed with the Q-test and the I2 index. The meta-analysis revealed significant (p ≤ 0.001, 95% confidence interval) increases in upper airway volume after rapid maxillary expansion and surgical advancement for the correction of Class II.

Three-dimensional assessment of airway volumes in patients with unilateral cleft lip and palate

Background

Considering the adverse consequences of respiratory insufficiency in cleft lip and palate (CLP) patients, this study aimed to assess the pharyngeal airway dimensions in 9–12-year-old patients with unilateral CLP. This historical cohort evaluated the cone-beam computed tomography (CBCT) scans of 30 patients with non-syndromic unilateral CLP between 9 and 12 years and 30 age- and sex-matched non-cleft controls. Three-dimensional (3D) images were reconstructed by the Mimics software, and the nasopharyngeal, oropharyngeal, and total airway volumes, as well as the minimal cross-sectional area of the airway (minAx), and posterior airway length (PAL) were all measured in the sagittal plane. Data were analyzed by the Student’s t test.

Results

The oropharyngeal and the total airway volumes, as well as the minAx and PAL in CLP patients, were significantly smaller than the corresponding values in the control group (P < 0.05). Despite smaller nasopharyngeal airway volume in CLP patients than controls, this difference was not statistically significant (P > 0.05).

Conclusions

Nine- to twelve-year-old non-syndromic unilateral CLP patients have smaller pharyngeal airway dimensions than non-cleft controls, and are therefore at higher risk of respiratory insufficiency.

Furlow Palatoplasty: Should We Also Focus on the Size of the Nasopharynx?

OBJECTIVES

(1) To determine the incidence rate of velopharyngeal dysfunction (VPD) according to 7 speech criteria post-Furlow palatoplasty. (2) To find an anatomical measurement of the cleft palate (or combination of measurements) associated with the occurrence of VPD.

STUDY DESIGN

Retrospective cohort study.

PARTICIPANTS AND METHODS

Fifty-six patients with cleft palate ± cleft lip underwent palatoplasty with the Furlow technique at the age of 10 months. Pre-and post-palatoplasty cleft palate measurements were collected during the procedure. Three blinded speech-language pathologists (SLPs) retrospectively scored the patients from the chart data at age 4. Student t test and receiver operating characteristic curve analysis were used to evaluate the association and predictive capacity between cleft measurements and parameters (M&P) with all VPD criteria.

RESULTS

The SLPs found an incidence of VPD according to 7 criteria: hypernasality (11%), audible nasal emission (4%), nasal rustle (14%), compensatory errors (4%), impairment of speech understandability (7%), and impairment of speech acceptability (16%). The SLPs recommended a secondary surgical procedure in 5 patients (9%). A statistically significant association was found between, respectively, 17 and 5 M&P and the occurrence of compensatory errors and audible nasal emission. Our data suggest that the length of the cleft, the cleft area, and the postoperative transversal size of the nasopharynx are the best indicators of the future positivity of VPD criteria.

CONCLUSION

The size of the postoperative transverse nasopharyngeal area during the primary cleft palate procedure may become the focus of the next generation of cleft surgeons to reduce the incidence of VPD.

Nasopharyngeal structure development in patients with cleft palate who underwent repair surgery

OBJECTIVE

This study aimed to compare the developmental characteristics of bony nasopharyngeal (NP) in children with cleft palate (CP) and non-cleft subjects.

METHODS

This study was conducted on 64 non-syndromic CP patients who underwent repair surgery and 23 non-cleft subjects as controls. Lateral cephalograms were performed on participants at rest in the natural head position. The X-coordinate and the Y-coordinate of three points on cephalograms were determined as Hormion (Ho), posterior maxillary point (PMP) and anterior point of the atlas (At) representing the anterior-posterior (AP) and vertical dimension of the NP. The linear dimension of the NP (i.e. Ho-At, Ho-PMP, At-PMP) and its area was also calculated.

RESULTS

The bony structures of NP in the clef-affected subjects in isolated CP subgroup, had a significantly greater downward development in the maxillary region (PMP) (both with p = 0.001), more linear growth in cranial-maxillary (Ho-PMP) dimension (p = 0.017 and 0.004, respectively), and larger area (p = 0.017 and <0.001, respectively), when compared to normal subjects. There was no significant difference between either the unilateral cleft lip and palate (CLP) or bilateral CLP group with the control group regarding AP, vertical, and linear growth of the NP and its area (P > 0.05).

CONCLUSIONS

Patients with repaired CP had downward deviated posterior maxilla, more linear growth in cranial-maxillary dimension and larger area compared to normal subjects. Among CP subtypes, a balanced growth was observed among repaired UCLP and BCLP patients, suggesting that with appropriate repaired surgery, normal development of the NP region could be expected in these subtypes.

Three-Dimensional Analysis of the Pharyngeal Airway Volume and Craniofacial Morphology in Patients With Bilateral Cleft Lip and Palate

OBJECTIVE

This study aimed to determine the correlations between the craniofacial morphology and pharyngeal airway volume in patients with complete bilateral cleft lip and palate (BCLP).

DESIGN

Retrospective study.

SETTING

Tertiary hospital.

PARTICIPANTS

Twenty-seven patients with complete BCLP and 27 class I control patients, aged 10 to 14 years.

MAIN OUTCOME MEASURE

The pharyngeal airway volume and craniofacial morphology were evaluated using cone-beam computed tomography. Measurements were compared between groups and any correlations were identified.

RESULTS

A significantly smaller total pharyngeal airway volume (TPV), oropharyngeal airway volume, and upper (UOPV) and lower (LOPV) oropharyngeal airway volume were found in patients with BCLP than in class I control patients, with no difference in the nasopharyngeal volume between groups. Furthermore, the craniofacial morphology measurements of N-Me, S-Go, Or-C, Ptm-C, Me-C, Co-Go, Go-Me, Ptm-Or, N-S-Ar, and Ar-Go-Me significantly differed between the BCLP and control groups (all P < .05). Multiple regression analysis indicated that Ptm-C and Me-C; Ptm-C, Or-C, and Me-C; and Me-C explained 20.3%, 38.9%, and 17.1% of the variations in TPV (P = .025), UOPV (P = .002), and LOPV (P = .018), respectively.

CONCLUSIONS

Total pharyngeal airway volume, TPV, OPV, UOPV, and LOPV were significantly smaller in patients with BCLP than in class I controls. In patients with BCLP, the maxilla showed inhibited sagittal development and a retrograde position; moreover, the pharyngeal airway volume was weakly associated with the position of the maxilla and mandible relative to the coronal plane.

Three-Dimensional Computed Tomography Analysis of Pharynx in Juvenile Patients With Unrepaired Isolated Cleft Palate

Previous research showed that pharynx in adult patients with unrepaired isolated cleft palate (UICP) significantly enlarged. However, the literature lacks studies in juvenile patients. Thus, this study aimed to conduct a 3-dimensional evaluation of pharynx in juvenile patients with UICP using cone beam computed tomography. Cone beam computed tomography images of 58 nonsyndromic patients with UICP and 60 noncleft controls aged from 4 to 13 years were acquired. Both patients and controls were divided into 3 groups according to their ages. Image processing and analyses were performed using Mimics and ZWCAD. Linear, angular, planar, and volumetric measurements and comparisons were made. Statistical analyses comparing patients with controls were performed using independent-samples t test, with the threshold of significance set at P = 0.05. Results showed that, in all age groups, anterior height (P = 0.002, P = 0.004, P = 0.004) and length of the floor (P = 0.023, P = 0.000, P = 0.024) of bony nasopharynx; transverse (P = 0.028, P = 0.031, P = 0.043) and posteroanterior (P = 0.000, P = 0.000, P = 0.000) diameters of pharyngeal airway at palatal plane; cross-sectional area of pharyngeal airway at palatal plane (P = 0.006, P = 0.001, P = 0.001); total volume (P = 0.005, P = 0.003, P = 0.038), volume above palatal plane (P = 0.001, P = 0.000, P = 0.005), and volume between palatal plane and C2 plane (P = 0.047, P = 0.025, P = 0.048) were larger in UICP patients. Based on this study, the authors can conclude that pharynx in juvenile UICP patients around the palatal plane was significantly enlarged, and narrowing of velopharyngeal orifice in palatoplasty was seemed important.

Furlow Palatoplasty, Nasopharyngeal Size, and Sleep Oximetry

Objectives:

(1) To assess the evolution of prepalatoplasty sleep oximetry (PRESO) and postpalatoplasty sleep oximetry (POSSO) in cleft patients and (2) to evaluate the impact of the size of the nasopharynx on PRESO and POSSO values.

Study Design:

Retrospective cohort study.

Patients and Methods:

In 81 patients with cleft palate and/or cleft lip, the following data were prospectively collected: patient demographics and prepalatoplasty cleft palate measurements. All the patients had at least 1 PRESO and POSSO. A Kaplan-Meier curve was obtained from all the sleep oximetry results. Transverse nasopharyngeal area (TNA) pre- and postvalues were compared for each group with paired t tests, while analysis of variance was used to compare TNA pre- and postscores between the groups with a Bonferroni correction for multiple comparisons.

Results:

POSSO results were normal or showed mild desaturations in most patients in the few weeks following palatoplasty. For the cohort, no statistically significant changes were found between PRESO and POSSO values. A 2-fold variation in the area of the TNA was found before palatoplasty within identical cleft malformation cases. No statistically significant association was found between the TNA or the a/30 − b 1 parameter values and the sleep study scores.

Conclusions:

The patients with the smaller nasopharyngeal areas presented identical PRESO and POSSO results when compared to those with larger nasopharyngeal sizes. Future studies should address the possible association between prepalatoplasty and postpalatoplasty TNAs and the occurrence of velopharyngeal deficiency later in life.

Effect of maxillary expansion and protraction on the oropharyngeal airway in individuals with non-syndromic cleft palate with or without cleft lip

Introduction

The aim of this study was to evaluate three dimensionally the effect of the combined maxillary expansion and protraction treatment on oropharyngeal airway in children with non-syndromic cleft palate with or without cleft lip (CP/L).

Methods

CBCT data of 18 preadolescent individuals (ages, 8.4 ± 1.7 years) with CP/L, who underwent Phase I orthodontic maxillary expansion with protraction, were compared before and after treatment. The average length of treatment was 24.1± 7.6 months. The airway volume and minimal cross-sectional area (MCA) were determined using 3DMD Vultus imaging software with cross-sectional areas calculated for each 2-mm over the entire length of the airway. A control group of 8 preadolescent individuals (ages, 8.7 ± 2.6 years) with CP/L was used for comparison.

Results

There was a statistically significant increase in pharyngeal airway volume after phase I orthodontic treatment in both groups, however, there was no statistically significant change in minimal cross-sectional area in neither study nor control group.

Conclusion

The findings showed that maxillary expansion and protraction did not have a significant effect on increasing oropharyngeal volume and MCA in patients with CP/L.

Cone-Beam Computed Tomography Evaluation of Skeletal Deformities and Pharyngeal Airway in Chinese Han Individuals With Nonsyndromic Unilateral Cleft Lip and Palate

Objective:

This study examined the relationships between skeletal deformities and the pharyngeal airway of patients with nonsyndromic unilateral cleft lip and palate (UCLP).

Design:

Retrospective study.

Setting:

Orthodontics and Oral and Maxillofacial Surgery Departments in the Affiliated Hospital of Stomatology, Nanjing Medical University, China.

Patients, Participants:

The sample comprised 30 nonsyndromic UCLP patients and 30 healthy controls. Each group has 23 males and 7 females.

Interventions:

All cone-beam computed tomography images were obtained with the participant in the standard supine position and asked to bite with intercuspal position without swallowing or moving their heads and tongues during scanning.

Main Outcome Measure(s):

SNA, SNB, ANB, anterior cranial base, Wits appraisal, maxillary length (PTM-ANS || FH), maxillary position (S-PTM || FH), mandibular length (Go-Pog || MP), FMA, posterior face height, anterior face height, Posterior-Anterior face height, lower face height, pharyngeal airway volumes, and areas were evaluated by Dolphin imaging software.

Results:

The UCLP group showed significantly decreased SNA, SNB, ANB, PTM-ANS || FH, S-PTM || FH, P-A Face Height compared with the controls. However, the airway volumes and areas showed no significant difference between 2 groups. The total airway volume and minimum cross-sectional area in UCLP patients were related to the Go-Pog || MP and FMA.

Conclusions:

Patients with UCLP have both the maxillary and mandibular deficiencies in the sagittal dimension. Both the sagittal and vertical relationships of the jaw might affect the airway volume and area. However, no significant difference was detected in airway volume and area in UCLP patients when compared with the controls.

Three-dimensional assessment of the pharyngeal airway in Japanese preschoolers with orofacial clefts

OBJECTIVES/HYPOTHESIS

Individuals with orofacial clefts often experience respiratory problems because of nasopharyngeal abnormalities. Pharyngeal airway morphology is thought to differ among the various cleft types. We measured three-dimensional (3D) airway volume using cone-beam computed tomography (CBCT) analysis to evaluate and compare pharyngeal airways in Japanese preschoolers with and without orofacial clefts.

STUDY DESIGN

Retrospective case-control study.

METHODS

We enrolled 83 subjects (37 boys, 46 girls; mean age = 4.66 ± 0.56 years) with nonsyndromic orofacial clefts and 16 noncleft healthy subjects (seven boys, nine girls; mean age = 5.30 ± 0.52 years) as controls. The subjects were divided into five groups. Four groups were based on the cleft type: isolated cleft palate, unilateral cleft lip and alveolus), unilateral cleft lip and palate, and bilateral cleft lip and palate. The fifth group included the noncleft controls. All subjects were examined with CBCT, and the 3D airway volume was measured. We analyzed group differences statistically using analysis of covariance with the Bonferroni post hoc pairwise comparison tests for the corrected means.

RESULTS

Compared with the noncleft group, each cleft group exhibited significantly decreased total and nasal airway volumes and increased superior and inferior pharyngeal airway volumes. The differences were all statistically significant.

CONCLUSIONS

Our findings suggest that anatomical differences exist in pharyngeal airway volumes among various cleft groups and in those without a cleft.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:533-540, 2020.

Upper Airway 3D Changes of Patients With Cleft Lip and Palate After Orthognathic Surgery

Objectives:

The purpose of this study was to 3-dimensionally assess the airway characteristics of patients with unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) who underwent orthognathic surgery.

Design:

This was a retrospective study.

Setting:

The study took place at a national referral center for cleft lip and palate rehabilitation.

Patients and Participants:

The sample comprised cone-beam computed tomography (CBCT) scans obtained before and after orthognathic surgery of 15 individuals (30 CBCT scans), divided into 2 groups: UCLP group (n = 9 patients/18 CBCT scans) and BCLP group (n = 6/12 CBCT scans). All patients had a nonsyndromic UCLP or BCLP and a skeletal class III malocclusion at the preoperative period.

Interventions:

Airway volume, pharyngeal minimal cross-sectional area (mCSA), location of mCSA, sella-nasion-A point (SNA) and sella-nasion-B point (SNB) angles, and condylion-A point and condyloid-gnathion linear measurements were assessed in open-source software (ITK-SNAP and SlicerCMF).

Main Outcome Measure:

Airway dimensions of patients with UCLP and BCLP increase after orthognathic surgery.

Results:

After orthognathic surgery, UCLP group showed a significant 20% increase in nasopharynx volume. Although not significant, BCLP group also showed an increase of 18% in the same region. Minimal cross-sectional area remained dimensionally stable after surgery and was all located in the oropharynx region, on both groups. Additionally, a positive correlation was observed between volume and mCSA on both groups.

Conclusion:

Overall, individuals with UCLP and BCLP showed an increase in the upper airway after orthognathic surgery and this might explain the breathing and sleep improvements reported by the patients after the surgery.

Update on complications in cleft orthognathic surgery

PURPOSE OF REVIEW

To give an update on recent publications and tendencies concerning complications in cleft orthognathic surgery.

RECENT FINDINGS

Cleft-specific changes after orthognathic surgery and their impact on surgical outcomes are discussed. Focus lays on the causes and mechanisms of cleft-related surgical complications and strategies to prevent or minimize these complications. Bimaxillary surgery is seen as a safe procedure for cleft patients. Maxillary distraction, total or segmental, is pointed out as an alternative method to improve outcomes. Different techniques for osteotomies and maxillary mobilization could decrease adverse events.

SUMMARY

Cleft patients are more susceptible to the occurrence of complications because of peculiar presurgical conditions. Different surgical approaches and techniques are presented to overcome these difficulties, to achieve better results and to increase patient safety. The importance of communication between patient, family and cleft team members is emphasized.