Predictors for long-term relapse of orthodontic treatment in patients with cleft lip and palate. A clinical follow-up study

OBJECTIVES

To identify predictors for long-term relapse of orthodontic therapy in patients with cleft lip and palate (CLP).

MATERIALS AND METHODS

Patients with uni- and bilateral non-syndromal CLP were followed up at least two years after completion of their orthodontic therapy. Plaster casts of the start of treatment (T1), after completion of treatment (T2), and at follow-up (T3) were measured using the modified Huddart Bodenham Index. Characteristics of multidisciplinary therapy were taken from the patient files. Potentially influencing factors of relapse were investigated using logistic regression analyses and Spearman correlations.

RESULTS

In total 58.07% of the included 31 patients showed a stable treatment outcome at follow-up after an average of 6.9 years. Even if relapse occurred, 61.54% of these patients still showed improvement regarding their occlusion compared to baseline. Predictors for the occurrence of relapse were the severity of dysgnathia at baseline (p = 0.039) and the extent of therapeutic change (p = 0.041). The extent of therapeutic change was additionally a predictor for the extent of post-therapeutic relapse (ρ = 0.425; p = 0.019).

CONCLUSIONS

Patients with CLP benefit from their orthodontic therapy in the long term despite an increased tendency to relapse.

CLINICAL RELEVANCE

Results of this long-term study could be used to adapt the treatment concept for patients with CLP and reinforce the significance of a patient-centered orthodontic treatment concept for affected patients.

Primary vomerine osteotomy with gingivoperiosteoplasty for bilateral cleft lip and palate patients with protrusion and/or torsion of the premaxilla

In patients with bilateral cleft lip and palate (BCLP) with protrusion and/or torsion of the premaxilla, achieving a favorable outcome with adequate facial and maxillary development remains challenging. In the present study, we report a retrospective cohort of patients with complete BCLP who were treated between 2017 and 2020 at a single center in Japan. We investigated the effects and complications of primary vomerine osteotomy (PVO) with gingivoperiosteoplasty (GPP) following pre-surgical orthodontics (PSO) for premaxillary protrusion and/or torsion. For patients with residual premaxillary protrusion and/or torsion after PSO, PVO, and GPP were performed. The distances and angles of the premaxilla were measured on dental casts before PSO, on the day of PVO, after PVO, and on the day of palatoplasty after cheiloplasty. We further assessed postoperative complications. From a total of 36 patients with complete BCLP after PSO, seven patients underwent PVO with GPP. Proper positioning of the premaxilla was achieved in all seven patients. The distance between the anterior edge of the premaxilla and the anterior edge of the lateral segment and the length of the premaxillary-lateral segment on both sides continued to decrease over time. Loosening of GPP sutures occurred in two cases, although no major complications such as necrosis of the premaxilla or fistula formation occurred. Vomerine osteotomy with GPP before primary cheiloplasty is a potential treatment option in BCLP when the premaxilla still protrudes despite PSO or because PSO cannot be applied.

Maxillary canine position of patients with non-syndromic craniofacial disorder: a retrospective evaluation of panoramic radiographs

BACKGROUND

The study evaluates the position and displacement tendency of unerupted maxillary canines in orthodontic patients with non-syndromic craniofacial disorders (CD) compared to a control (C) group.

METHODS

Canine position and displacement tendency were evaluated using panoramic radiographs (PAN) examined with parameters such as sector classification (sectors 1-5) and inclination angles (α and β). The displacement tendency was defined as the positioning of the tip in sectors 1 or 2, as well as its combination with increased angles (α > 30° and β > 39°). In addition, the correlation of the tooth position and agenesis, cleft side, and sex was assessed.

RESULTS

A total of 116 pre-treatment PAN, divided into the CD group (n = 50; mean age 8.32 ± 2.27 years) and the C group (n = 66; mean age 10.80 ± 2.82 years), were evaluated in this study. The sector classification showed no displacement tendency in both groups. Inclination angles α/β showed a statistically significant higher displacement tendency (p = 0.01) of the CD group (n = 5) on the right side, compared to healthy subjects (n = 1). Male CD patients had a statistically significant higher displacement tendency on the right side (p = 0.03). A statistically significant correlation between cleft and non-cleft-side (p = 0.03) was found.

CONCLUSION

Patients with CD showed a statistically significant higher displacement tendency of the maxillary canine affected by the cleft side. The inclination angle was found to be the better predictor compared to the sector classification which should be considered in the orthodontic treatment planning.

Modified presurgical nasoalveolar molding for patients with neonatal complete bilateral cleft lip and palate having a severely malpositioned premaxilla

OBJECTIVE

To develop a modified presurgical nasoalveolar molding (MPNAM) with a premaxillary appliance, connected with two stainless steel wires and evaluate its therapeutic efficacy in newborns with complete bilateral cleft lip and palate (BCLP).

METHOD

A total of 41 patients with neonatal complete BCLP having a severely protruded and deviated premaxilla were retrospectively selected from January 2017 to November 2019. All patients received the MPNAM device with a premaxillary appliance which was worn until cheilorrhaphy. Plaster casts from pre- and post-MPNAM treatments were scanned using a three-dimensional laser scanner, and the changes were recorded. Facial photographs of patients were taken during the treatment.

RESULT

The average MPNAM treatment duration was 59.8 days. In all cases, the protrusive and deviated premaxilla was rapidly retracted and set into a suitable position after MPNAM treatment. The relative deviation distance and alveolar cleft width were significantly reduced. Both mid-palatal arch width and posterior arch width were increased. In addition, none of the patients developed any complications during the MPNAM treatment.

CONCLUSION

Our MPNAM device was able to rapidly centralize the malpositioned premaxilla and reduce the alveolar cleft defect. This device can be applied in presurgical orthodontic treatments for patients with complete BCLP having a severely protruded and deviated premaxilla.

Tooth agenesis in German orthodontic patients with non-syndromic craniofacial disorder: a retrospective evaluation of panoramic radiographs

Objectives

The study objective was to evaluate the tooth agenesis in German orthodontic patients with non-syndromic cleft lip and/or palate and Robin sequence compared to a control group without craniofacial disorder.

Materials/methods

A total of 108 panoramic radiographs were examined using the binary system of Tooth Agenesis Code (TAC) (excluding the third molar). Patients were divided into the craniofacial disorder group 1 (n = 43) and the healthy control group 2 (n = 65). Parameters such as skeletal class malformation, sex, localization of the cleft, craniofacial disorder, and interobserver reliability were assessed.

Results

Permanent tooth agenesis was observed in 44% of group 1 and 14% in group 2 with a statistically significant higher prevalence (p = 0.00162 (χ²)). Fourteen different TAC patterns were observed in group 1, ten of these occurring only once in separate patients. The distribution of the TAC codes in group 2 showed nine different possibilities of TAC code patterns; seven TACs were unique. In group 1, the most frequently absent teeth were the maxillary lateral incisor of the left side (30%); in group 2, the second premolar of the lower jaw on the right side (9%). Male patients with craniofacial disorder showed a higher percentage of tooth agenesis than female.

Conclusion

The data presented here shows a statistically significant higher prevalence of tooth agenesis in German patients with non-syndromic craniofacial disorder.

Clinical relevance

Radiographic evaluation enables the diagnosis of tooth agenesis. Recognizing early on the higher prevalence of tooth agenesis in patients exhibiting a craniofacial disorder is an important issue when developing long-term and comprehensive interdisciplinary treatment.

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.

Palatal growth changes in newborns with unilateral and bilateral cleft lip and palate from birth until 12 months after early neonatal cheiloplasty using morphometric assessment

OBJECTIVES

To compare palatal growth changes in infants with complete unilateral (UCLP) or bilateral (BCLP) cleft lip and palate during the first year of life.

MATERIALS AND METHODS

Upper dental arches of 68 neonates with UCLP and BCLP were evaluated using 2D and 3D morphometry based on dental casts obtained in two age categories (T0 before early neonatal cheiloplasty-UCLP 4 ± 3 days, BCLP 6 ± 5 days; T1 before palatoplasty-UCLP 10 ± 2 months, BCLP 12 ± 3 months).

RESULTS

Intensive palatal growth was manifested in both directions of the palate. Palatal growth in the anterior direction was not restricted, despite the intercanine (CC´) and anterior (LL´) widths being significantly narrowed in the BCLP group (CC´ p = 0.019, LL´ p = 0.009). The posterior dental arches were significantly enlarged (UCLP p ≤ 0.001; BCLP p ≤ 0.001). The negative effect of cleft severity on palatal length was not confirmed (p = 0.802). Variability of the palate was immense mainly in BCLP infants (T0); however, it decreased in both cleft types, confirming the formative effect of palatal growth leading to alveolar cleft closure (UCLP p ≤ 0.001; BCLP p = 0.006 on the right, 0.005 on the left).

CONCLUSIONS

Both analyzed cleft groups (UCLP, BCLP) grew favorably during the first year of life, and the palatal growth was not limited in any direction.

CLINICAL RELEVANCE

Geometric morphometry allowed a comprehensive analysis of the palate, which can contribute to the improvement of surgical methods.

Retrospective analysis of clinical outcomes in bilateral cleft lip and palate patients after secondary alveolar bone grafting and premaxilla osteotomy, using a new dento-maxillary scoring system

Evaluation of relevant clinical outcomes in patients with bilateral cleft lip and palate (BCLP) after secondary aveolar bone grafting (SABG) and premaxilla osteotomy (PMO), through the use of a new scoring system. Data were collected retrospectively from all patients with BCLP who were operated on between 2004 and 2014, at the end of follow-up. The treatment protocol consisted of SABG + PMO in patients aged between 9 and 13 years. At the end of follow-up, the following parameters were scored: (un)interrupted dental arch, skeletal sagittal relationship, bone height using the Bergland/Abyholm criteria, and the presence of postoperative fistula. These parameters were combined to produce a dento-maxillary scoring system, giving a final score between 1 and 10. For statistical analysis, the independent t-test was used. Of 55 children, 45 were suitable for analysis. The mean age at time of surgery was 12.0 years (8.9-16.4 yrs), and the mean follow-up time was 11.7 years (5.8-15.8 yrs). The average number of surgeries executed under general anesthesia was 6 (range: 3-11). The average dento-maxillary score in this patient cohort was 7.6 (1-10; median: 8). Among these patients, 31 had an uninterrupted dental arch; the average Bergland/Abyholm score was 2.07; 30 patients exhibited an Angle class I incisor relationship; and, in 38 cases, the oronasal communication was closed after SABG + PMO treatment. A significant effect of fistulas was seen on dento-maxillary score (p = 0.001). Specifically, a significant effect of fistulas was seen on interrupted dental arch (p = 0.002) and on Bergland/Abyholm score (p = 0.037). The proposed dento-maxillary scoring system is a straightforward tool that can be used to describe and analyze the amount of dento-maxillary rehabilitation at the end of the treatment. Persistence of oronasal fistulas in patients with BCLP has a significant impact on interruption of the dental arch, and can influence dental results at the end of the second decade.

Orthodontics for Unilateral and Bilateral Cleft Deformities

Orthodontic treatment of patients with unilateral and bilateral cleft palate requires an extensive interdisciplinary approach to achieve optimal functional and esthetic rehabilitation. Intervention is divided into 3 main stages: early mixed, late mixed, and permanent dentition. Treatment modalities can vary according to developmental stage, severity of cleft, and presence of other dentofacial abnormalities. This article describes the use and efficacy of different orthodontic, orthopedic, and surgical approaches at each developmental stage of unilateral and bilateral clefts, whereby the orthodontist plays a pivotal role in the different phases of growth and development of the cleft lip and the patient.

Three-dimensional development of the palate in bilateral orofacial cleft newborns 1 year after early neonatal cheiloplasty: Classic and geometric morphometric evaluation

OBJECTIVES

The aim of this study was to assess palatal growth in newborns with complete bilateral cleft lip and palate (cBCLP) and bilateral cleft lip and palate with tissue bridges (BCLP + B) 1 year after early neonatal cheiloplasty (ENC).

MATERIAL AND METHODS

The methodology was based on classic and morphometric analysis of dental models of newborns with cBCLP or BCLP + B. These analyses included metric analysis, coherent point drift-dense correspondence analysis, superprojection methods, and multivariate statistics. Dental casts were observed in two age categories, which were compared with each other. The first cast was obtained from each patient before ENC (T0, 5 ± 5 days) and the second one prior to palatoplasty (T1, 12 ± 6 months).

RESULTS

Fifty-two dental models obtained from 26 newborns with cBCLP and BCLP + B were evaluated. The results showed that over the 12-month period, alveolar clefts were narrowed in both cleft types due to anterior growth combined with the formative effect of suturing. This was confirmed by decreases in the dimensions of the right (T0 9.93 ± 2.80 mm, T1 6.64 ± 2.43 mm; p ≤ 0.003) and left (T0 10.71 ± 4.13 mm, T1 6.69 ± 4.29 mm; p ≤ 0.003) alveolar clefts in cBCLP patients. Similar reductions in alveolar cleft widths occurred on the left side (T0 11.69 ± 4.75 mm, T1 4.34 ± 2.97 mm; p ≤ 0.001) of BCLP + B patients, while on the right side, which was connected by a combined tissue bridge, there was non-significant narrowing of the alveolar cleft (T0 1.61 ± 1.34 mm, T1 1.04 ± 0.70 mm; p = 0.120). The ENC did not restrict posterior palatal growth, meaning that intertuberosity width was extended in cBCLP (T0 32.80 ± 3.15 mm, T1 35.86 ± 2.80 mm; p ≤ 0.001) and in BCLP + B neonates (T0 34.01 ± 2.15 mm, T1 36.21 ± 2.14 mm; p ≤ 0.004). Width and length measurements in the observed groups showed growth tendencies equivalent to those in noncleft or LOP patients. Palatal variability was greater in neonatal cBCLP, but was reduced during the monitored period, approximating that for BCLP + B. Regions with the most notable palatal growth were located primarily at the premaxilla and at the anterior and partially posterior ends of the maxillary segments.

CONCLUSION

Early neonatal cheiloplasty had no negative effect on palatal growth in any direction. There was no reduction in the length or width of the palate during the first year of life, nor was there narrowing of the dentoalveolar arch. The formative effect of the operated lip on the anterior part of the palate was confirmed. This, in combination with the favorable growth, lead to closure of the alveolar cleft.

Orthodontic premaxillary setback versus premaxillary osteotomy with gingivoperiosteoplasty for Bilateral cleft lip and palate patients: 4-year observation outcomes

Patients with bilateral cleft lip and palate (BCLP) generally require several stages of treatment, and adequate maxillary development without orthognathic surgery is not easy to achieve. The purpose of this study was to determine short-term outcomes of orthodontic premaxillary setback (OPS) and premaxillary osteotomy (PO) for complete BCLP treatment.

PATIENTS AND METHODS

Twenty-six patients with BCLP were consecutively treated for 4 years by a single surgeon. All patients were categorized by three indications for the first operation: OPS1, cheiloplasty + gingivoperiosteoplasty (GPP) + palatoplasty; OPS2, cheiloplasty + GPP; and PO, cheiloplasty + GPP + PO. Cephalograms for maxillary growth and velopharyngeal function (VPF) were judged at 4 years old, before orthodontic treatment.

RESULTS

OPS1 was performed in 14 cases, OPS2 in 8 cases, and PO in 4 cases. As for cephalometric analysis at 4 years old, no significant differences between groups were seen in any cephalometric measurements. As for speech outcomes, assessment of VPF at 80.8±14.8 months was good in 17 cases, slightly impaired in 8 cases, and marginally impaired in 1 case, with no severely impaired cases.

DISCUSSION

No significant differences in maxillary growth or speech outcomes were seen between OPS1, OPS2, and PO groups at 4 years old, possibly because all groups showed the same position of the premaxilla after the first operation.

CONCLUSIONS

No significant differences in maxillary growth or speech outcomes were seen for 26 patients with BCLP between OPS1, OPS2, and PO groups at 4 years old. However, the long-term growth characteristics remain unclear.

Incidence of complications in secondary alveolar bone grafting of bilateral clefts with premaxillary osteotomy: a retrospective cohort study

OBJECTIVE

To evaluate factors affecting incidence of complications after secondary alveolar bone grafting with premaxillary osteotomy (SABG + PO) in children with complete bilateral cleft of lip and palate (BCLP).

MATERIALS AND METHODS

Data were collected from children with BCLP treated with SABG + PO from 2004 to 2014 at our institute. Preoperative parameters included age, donor site, race, gingival health, bone quality around cleft-related teeth, premaxilla position, graft timing, presence of canines in the cleft, and presence of deciduous teeth around the cleft area. Logistic regression and the chi-squared test were used to assess correlations and the incidence of complications.

RESULTS

In the 64 patients, a significant correlation was found between complication rate and timing of bone grafting with respect to early versus late SABG + PO (p = 0.041), age > 12 years (p = 0.011; odds ratio (OR) 5.9; 95% confidence interval (CI) 1.49-23.93), malposition of the premaxilla (p = 0.042; OR 3.3; 95% CI 1.04-10.13), and preoperative bone quality around cleft-related teeth (p = 0.005; OR 5.3; 95% CI 1.6-17.2).

CONCLUSIONS

The timing of SABG + PO is essential, as early SABG + PO is associated with fewer complications. A malpositioned premaxilla and poor bone quality around cleft-related teeth are associated with more complications. Therefore, preoperative orthodontic repositioning of the malpositioned premaxilla before SABG + PO should be considered.

CLINICAL RELEVANCE

Analysis of treatment protocols and complications for BCLP patients underscores that proper timing of SABG + PO and correct premaxilla repositioning help reduce complications.

Bilateral cleft lip repair with simultaneous premaxillary setback and primary limited rhinoplasty

Background

Functional closure of the orbicularis oris muscle and esthetic reconstruction of nasolabial components are impossible in patients with severely deformed premaxilla. Here, we review a surgical strategy for patients with unremedied premaxilla retrospectively.

Results

Vomerine ostectomy and premaxillary setback with nasolabial repair were performed in 12 patients with bilateral cleft lip and palate. The mean age of patients was 21.7 months. The extent of ostectomy varied between 3 and 11 mm. There were no serious complications from defective perfusion to the premaxilla or the philtral flap. The follow-up period ranged from 2 to 25 months. Proper positioning of the premaxilla and satisfactory nasolabial esthetics were achieved in all patients.

Conclusions

We performed nasolabial repair after premaxillary setback without jeopardizing the premaxillary segment or the philtral flap. Our surgical strategy could be recommended in poor socio-economic circumstances due to the cost effectiveness of limiting the number of surgeries.

Midfacial growth and dental arch relationships in bilateral cleft palate following secondary alveolar bone grafting and orthodontic intervention: Factors predicting a Le Fort I osteotomy at age 18

OBJECTIVE

To evaluate midfacial growth and dental arch relationships in patients treated for bilateral cleft lip and palate (BCLP).

MATERIALS AND METHODS

Data were collected from all patients with BCLP treated at our hospital between 2004 and 2014, with or without premaxillary osteotomy (PO). Dental casts for pre-secondary alveolar bone grafting with PO (SABG + PO) and end-point dental casts were analyzed using the BAURU yardstick scoring system. Pre-SABG + PO, post-SABG + PO, and end-point SABG + PO lateral cephalograms were analyzed. The correlation between both scoring systems was calculated.

RESULTS

There were no significant differences between the BAURU scores for centers in a previous study and those collected here. A negative correlation was found between the pre-SABG + PO ANB (Angle between A-point, Nasion and B-point) angle and pre-SABG + PO BAURU scores (R = -0.58; p = 0.000), the long-term post-SABG + PO ANB and mean end-point BAURU (R = -0.50; p = 0.000), and the pre-SABG + PO ANB and mean end-point BAURU (R = -0.51; p = 0.000).

CONCLUSION

We found no significant difference between pre-SABG + PO and end-point BAURU scores. There was a decrease in the SNA (Angle between Sella, Nasion and A-point) and ANB angle over time, indicating delayed growth of the maxilla. We found a negative correlation between the pre-SABG ANB and end-point BAURU scores. Pre-SABG ANB can be used to predict the need for Le Fort I osteotomy at age 18.

Presurgical Nasoalveolar Molding of Bilateral Cleft Lip and Palate Infants: An Orthodontist's Point of View

Nonsyndromic complete cleft lip and palate deformity is primarily functional, then esthetic, and finally but not least importantly, a dental challenge. Feeding and facial appearance are important during the first years of a newborn. Nutrition is universally provided by passive feeding plates. If the Cleft Team prefers to use active plates, alveolar molding combined with nasal approaches in infants is the best method to improve esthetics to date. Orthodontists are predominantly responsible for achieving both the goals. After those difficulties have been met in early days of the life, dentists are mainly responsible for the treatment thereafter. If the infants have a dentoalveolar unity without any fistulas and correctly aligned maxillary deciduous teeth, this is a real success. Therefore, this article is an overview of presurgical infant orthopedics and its contribution to subsequent dental practice.

Amniotic constriction band: a report of two cases with unique clinical presentations

Amniotic constriction band is a rare clinical entity with varied manifestations that range from a combination of congenital malformations to isolated malformations that are unique to each patient. The etiology of this entity remains unknown. Herein, we highlight two cases of amniotic constriction band that presented to our unit with unique clinical characteristics. To the best of our knowledge, an isolated circumferential band of scarring on the face with ocular involvement, as demonstrated by the first case, and a combination of bilateral complete cleft lip and palate with bilateral microphthalmia, auto-amputation of the right thumb, and a constriction band on the left thumb, as demonstrated by the second case, are extremely rare presentations of amniotic constriction band that were not previously reported in the literature and therefore necessitate a special mention. We discuss potential etiologies for these cases and review the existing literature on this entity.

Craniofacial cephalometric morphologies in different cleft types: a retrospective cross-sectional study of 212 patients

OBJECTIVE

The aim of this study was to evaluate and compare the craniofacial cephalometric morphologies among different cleft types in a Spanish population.

METHODS

A retrospective cross-sectional study was carried out on 212 patients. The patients were subdivided into four groups according to their cleft types: unilateral cleft lip and palate; bilateral cleft lip and palate; cleft lip; and cleft palate. Angular and linear cephalometric measurements were taken on lateral radiographs.

RESULTS

Unilateral cleft lip and palate was associated with a dolichofacial growth pattern, skeletal Class III with correct maxillary position, and lingual incisor inclination. Bilateral cleft lip and palate was associated with a mesofacial growth pattern, skeletal Class I with protruded maxillary position, and lingual incisor inclination. Cleft palate was associated with a mesofacial growth pattern, skeletal Class III with correct maxillary position, and lingual incisor inclination. Cleft lip was associated with a brachyfacial growth pattern, skeletal Class I with protruded maxillary position, lingual upper incisor inclination, and corrects lower incisor inclination. Significant correlations were observed between cleft types and their craniofacial cephalometric measurements.

CONCLUSIONS

The present information can be used for the determination of orthodontic treatment and even future orthognathic surgery planning, a requirement in most cleft patients.

The Soft Palate Friendly Speech Bulb for Velopharyngeal Insufficiency

Velopharyngeal insufficiency is an anatomic defect of the soft palate making palatopharyngeal sphincter incomplete. It is an important concern to address in patients with bilateral cleft lip and palate. Speech aid prosthesis or speech bulbs are best choice in cases where surgically repaired soft palate is too short to contact pharyngeal walls during function but these prosthesis have been associated with inadequate marginal closure, ulcerations and patient discomfort. Here is a case report of untreated bilateral cleft lip and palate associated with palatal insufficiency treated by means of palate friendly innovative speech bulb. This modified speech bulb is a combination of hard acrylic and soft lining material. The hard self-curing acrylic resin covers only the hard palate area and a permanent soft silicone lining material covering the soft palate area. A claw-shaped wire component was extended backwards from acrylic and was embedded in soft silicone to aid in retention and approximation of two materials. The advantage of adding the soft lining material in posterior area helped in covering the adequate superior extension and margins for maximal pharyngeal activity. This also improved the hypernasality, speech, comfort and overall patient acceptance.

Presurgical nasoalveolar molding: A boon to facilitate the surgical repair in infants with cleft lip and palate

Cleft lip and palate (CLP) is the most common congenital craniofacial anomaly. Rehabilitation of CLP generally requires a team approach. Alveolar and nasal reconstruction for these patients is a challenge for the reconstructive surgeon. Various procedures have been attempted to reduce the cleft gap, so as to obtain esthetic results postsurgically. The presurgical nasoalveolar molding (PNAM) technique, developed by Grayson, is a new approach to presurgical infant orthopedics. PNAM reduces the severity of the initial cleft alveolar and nasal deformity. Thus, it enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This article presents a brief insight into PNAM with a case series of three different cases (one unilateral and two bilateral) which underwent PNAM treatment and gave an excellent surgical prognosis.

Maxillary growth after maxillary protraction: Appliance in conjunction with presurgical orthopedics, gingivoperiosteoplasty, and Furlow palatoplasty for complete bilateral cleft lip and palate patients with protruded premaxilla

BACKGROUND AND AIMS

In bilateral cleft lip and palate (BCLP) with premaxillary protrusion, a good outcome with adequate maxillary development is difficult to achieve. The purpose of this article is to evaluate the maxillary growth after using presurgical orthopedics (PSO), gingivoperiosteoplasty (GPP), Furlow palatoplasty, and maxillary protraction appliance (MPA) for BCLP with premaxillary protrusion.

PATIENTS AND METHODS

Seven patients with complete BCLP with premaxillary protrusion were treated by PSO, cheiloplasty, GPP, and Furlow palatoplasty. MPA was used as part of the protocol for 6 months to 1 year for postoperative retardation of maxillary growth cases. Maxillary growth was evaluated by cephalometric analysis at 4 and 10 years of age, and bone formation at the alveolar cleft was evaluated by computed tomography (CT) imaging at 5 years of age.

RESULTS

At 4 years of age, three of seven patients had apparent retardation of maxillary growth. The maxillary growth at 10 years of age was equivalent to the average value of normal Japanese after using MPA in three cases. At 5 years of age, only two of seven patients showed sufficient bone formation at the alveolar cleft to avoid alveolar bone grafting (ABG). Subsequently, ABG was performed in five patients.

DISCUSSION

Although three of seven patients had apparent crossbite at 4 years of age, the maxillary growth of all patients at 10 years of age was approximately equivalent to the average value of normal Japanese after using MPA. A treatment protocol based on PSO, GPP, Furlow palatoplasty, and MPA may be an option, but long-term growth is unknown.

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

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

The modified "Wunderer" osteotomy for stabilization of the cleft-premaxilla--a new operative technique

The operative closure of bilateral cleft lip and palate is a difficult procedure that requires in most cases secondary corrections. Besides aesthetic improvements of lip and nose also the rehabilitation of the teeth, in particular of the maxillary arch is important for the improvement of the chewing function and also for the well being of the patient. One of the most disturbing factors for the construction of any type of prosthetic devices, like removable denture, fixed bridge or dental implants is the mobility and often also malposition of the premaxilla. This problem can only be solved by the insertion of bone grafts into the bilateral gaps of the anterior maxillary arch. This procedure however, is difficult due to the narrowness and poor overview that complicates the closure of the nasal mucosa, which is the precondition for the success. For facilitating the operation the premaxilla is osteotomized and reflected anteriorly according to the method of Wunderer (1962). Then, after the much easier closure of the nasal mucosa the bony defects can be filled with autogenous cancellous bone and finally the oral mucosa can be closed. A preoperatively prepared palatal acrylic plate helps to protect the palatal tissue and also stabilizes the position of the premaxilla. The blood supply to the osteotomized premaxilla is secured by a sound soft tissue pedicle of the buccal muco-periosteum. The effectiveness of the blood supply of the premaxilla was examined in experimental studies by several authors. Also investigations of the growth impediments of the premaxilla and the midface revealed that early osteotomies will interfere with the development of this region. Therefore it is advisable to carry out this procedure not before the patient has reached the age of 12-14 years, which is also depending on the race and the gender of the patient.

The use of SymNose for quantitative assessment of lip symmetry following repair of complete bilateral cleft lip and palate

INTRODUCTION

The SymNose computer program has been proposed as an objective method for the quantitative assessment of lip symmetry following unilateral cleft lip repair. This study aims to demonstrate the use of SymNose in patients with complete bilateral cleft lip and palate (BCLP), a group previously excluded from computer-based analysis.

METHODS

A retrospective cohort study compared several parameters of lip symmetry between BCLP cases and non-cleft controls. 15 BCLP cases aged 10 (±1 year) who had undergone primary repair were recruited from the patient database at the South West Cleft Unit, Frenchay Hospital. Frontal facial photographs were selected for measurement. 15 age-matched controls were recruited from a local school. Lip symmetry was expressed as: percentage mismatch of left vermillion border and upper lip area over the right, horizontal lip tilt and lateral deviation of the lip.

RESULTS

A significant increase in lip asymmetry was found in the BCLP group expressed as upper vermillion border mismatch across computer-defined and user-defined midlines (mean difference was 16.4% (p < 0.01) and 17.5% (p < 0.01) respectively).

CONCLUSIONS

The results suggest that a significant degree of lip asymmetry remains in BCLP patients even after primary repair. This challenges previous assumptions that those with bilateral defects would be relatively symmetrical.

Pre: Surgical orthopedic pre-maxillary alignment in bilateral cleft lip and palate patient

Pre-surgical orthopedic appliances are mainly used to retract and align the protruded and deviated pre-maxilla and to facilitate initial lip repair. This article presents a case report of a five year old male child patient with bilateral cleft lip and palate in whom a special custom made pre-surgical orthopedic appliance was delivered. Use of a special custom made presurgical orthopedic appliance for repositioning pre-maxilla in bilateral cleft lip and palate patient is discussed in this article.

Modified Intraoral Repositioning Appliance in Complete Bilateral Cleft Lip and Palate

OBJECTIVE

The purpose of the modified repositioning appliance was to overcome the shortcoming of existing design for repositioning protruded premaxilla in a child with bilateral cleft lip and palate.

METHODS

The basic principles of design were similar to Latham's appliance but the surgical pinning of premaxillary segment was avoided and instead acrylic splint was prepared.

CONCLUSIONS

This technique avoids any invasive procedure, is useful to reposition protruded premaxillary segment in bilateral cleft lip and palate cases specifically in child who reports late with deciduous dentition.