An optimized imaging protocol for orofacial cleft patients

Does the Surgical Protocol Impact the Burden of Care of Patients With Cleft Lip and/or Palate?

AIM

To compare the burden of care in the first 7 years of life of patients with cleft lip and palate (CLP) treated with 2 different surgical protocols.

METHODS

The burden of care of patients with cleft palate (CP), unilateral (UCLP), and bilateral cleft lip and palate (BCLP), surgically treated with Protocol A (soft palate closure at 1 year with Veau-Wardill-Kilner pushback technique and hard palate closure between 5 and 7 years with Von Langenbeck procedure) and B (soft palate closure at 1 year with intravelar veloplasty by Sommerlad and hard palate closure using a vomer flap at time of lip repair) was compared. The burden of care was assessed from the patient's file from birth until 7 years old through the following disciplines: surgical, dental, audiological, logopedic, radiologic, and logistic. Group comparisons were performed using multivariable models with correction for confounders. Continuous and binary variables were analyzed with linear and logistic regression models respectively.

RESULTS

One hundred nineteen CLP patients were included (62 CP, 40 UCLP, and 17 BCLP). Sixty-eight were treated with protocol A and 51 with protocol B. Patients treated with protocol B spent less days in the hospital after surgery (P=0.628), had less postsurgical complications (P<0.001), lower need for secondary interventions (P=0.016), needed less orthodontic maxillary expansion (P=0.004), less ventilation tube insertions (P<0.001), less speech therapy (P<0.001), less extractions of deciduous teeth (P = 0.040), less consultations (P=0.008) and traveled less distance (P=0.019). Patients treated with protocol A were younger when their first orthopantomogram (P<0.001) and craniofacial x-rays (P<0.001) were taken, and these radiographs were taken more often (P=0.013 and <0.001, respectively).

CONCLUSIONS

Patients treated with protocol B experience a significantly lower burden of care in the first 7 years of life.

Dose Reduction by Field of View Optimisation in Cone-Beam Computed Tomography of Unilateral Alveolar Clefts

OBJECTIVE

This study aimed to investigate how much the field of view (FOV) can be decreased while still depicting the necessary anatomical structures. A secondary aim was to assess how many incidental findings were missed with a reduced FOV.

MATERIAL AND METHODS

In this retrospective study, 170 CBCT volumes from children with a mean age of 9.4 years were collected. All CBCT had a FOV of 80 × 50 mm covering the maxilla. The present study analysed whether a smaller FOV can be used while still including necessary anatomical structures. Measurements of the minimal height and width that include vital anatomical structures were performed with two FOV reduction protocols: one smaller (includes the cleft, adjacent central incisor and adjacent canine) and one larger (includes both canines, nasal floor and the cleft).

RESULTS

The use of the larger protocol resulted in a FOV of 44.3 × 36.5 mm (95th percentile); for the smaller protocol, the FOV was 28.1 × 34.9 mm (95th percentile). In the larger protocol, incidental findings were missed in 22%. In the smaller protocol, 35% of the incidental findings were missed. However, most of these findings were irrelevant to the planning of the bone graft.

CONCLUSION

A FOV of 50 × 40 mm (41% dose reduction compared with the original FOV) is suggested to fully depict the cleft area, central incisors, nasal floor and both canines. A FOV of 35 × 40 mm (56% dose reduction compared with the original FOV) is suggested to depict the cleft and the ipsilateral canine and central incisor adjacent to the cleft.

Radiographic Assessment of Cleft Alveolar Bone Defects: A Preliminary Comparison of Periapical and Cone Beam Computed Tomography Images

Background & PurposeAccurate radiographic assessment of secondary alveolar bone grafting (SABG) is critical in evaluating SABG outcomes in patients with cleft lip and palate. This study compared Periapical (PA) and Cone beam computed tomography (CBCT) grading of SABG outcomes and conducted an analysis of agreement rate between the two imaging modalities.MethodsA retrospective chart review was performed of patients who underwent secondary alveolar bone grafting at a single institution. Bone quality of the alveolar cleft site was assessed at three root levels of the adjacent teeth on PA and CBCT images.Results48 patients had pre- or post-operative images with both CBCT and PA that were appropriate for comparison. A total of 174 alveolar bone sections (three root levels of adjacent teeth in 58 pairs) were graded on CBCT and PA images. Agreement of CBCT grading with PA grading was 41.3% (72/174) overall. CBCT assessments rated bone quality lower than PA grading in 51.2% (89/174) of sections. CBCT had higher grading than PA image grading in 7.5% (13/174) of sections. The weighted Cohen Kappa value for comparison of CBCT and PA readings was 0.17, indicating a low rate of agreement. Wilcoxon signed rank test demonstrated that the difference between grading on CBCT and PA assessments was statistically significant (P < .001).ConclusionsCBCT and PA readings demonstrated an overall low rate of agreement in the assessment of cleft alveolar bone. This investigation suggests that PA radiographs have lower sensitivity in detecting poor bone grafting outcomes.

A novel cone beam-CT approach for quantifying maxillary changes following secondary alveolar bone grafting in unilateral cleft patients

OBJECTIVES

To quantify longitudinal bone changes in the maxilla after secondary alveolar bone grafting (SABG) in patients with unilateral cleft lip and/or cleft palate (CL/P), and to describe the maxillary dimensions before and after SABG in all orthogonal planes using a Cone Beam Computed Tomography (CBCT)-based methodology.

METHODS

Ethical approval was obtained to retrospectively analyze CBCT scans of children treated for unilateral alveolar clefts. Inclusion criteria encompassed individuals who underwent SABG before the eruption of the cleft-side permanent lateral incisor or, if absent, the permanent ca-nine, and had both preoperative and postoperative CBCT scans. A total of seven measurements of maxillary dimensions in all orthogonal planes, as well as in panoramic reconstruction, were conducted in the CBCT images. The normality of the data was confirmed with the Shapiro-Wilk test. A paired t-test was applied to assess significant differences between the preoperative and postoperative measurements (p < 0.05). The impact of age, gender, and their interrelation was evaluated by two-way ANOVA (p < 0.05).

RESULTS

A total of 47 patients, comprising 32 males and 15 females, were selected based on the specified criteria. Notably, we observed a significant increase in sagittal, vertical, and transverse dimensions between the preoperative scans and those taken one year postoperatively (p < 0.05), irrespective of the patients' ages and genders. When considering gender, data indicated that male patients exhibited wider transverse dimensions in both the preoperative and postoperative measurements.

CONCLUSIONS

This study introduced a CBCT-based method to quantitatively assess maxillary changes in unilateral CL/P patients after SABG. The approach demonstrated continuous dimensional changes in all orthogonal planes. In addition, it described the maxillae dimensions in all planes. Future research can utilize this method for precise measurement of maxillary alterations and dimensions.

Cephalometric Parameters as Predictive Factors for Orthognathic Surgery in Unilateral Cleft Lip and Palate Patients: A Systematic Review and Meta-Analysis

To identify cephalometric parameters that could predict future need for orthognathic surgery (OGS) in patients with unilateral cleft lip and palate (UCLP).

Final search was conducted on July 7, 2024, across PubMed, Scopus, Embase, Web of Science, Cochrane, Ovid Medline, EBSCO, and LILACS, without any language and publication time restriction. Studies comparing surgical versus nonsurgical UCLP patients were included. Two independent reviewers screened studies, and those included were evaluated using Quality in Prognostic Studies (QUIPS) tool. Random-effects meta-analysis of various sagittal and vertical cephalometric parameters (SNA, SNB, ANB, mandibular plane angle [MPA], and lower anterior face height [%LFH]) was performed.

Ten studies were included in systematic review and 5 in meta-analysis. Quality in Prognostic Studies tool assessment indicated moderate risk in 6 studies, with 2 demonstrating high and low risks of bias. Meta-analysis revealed that in the 5- to 8-year age group, significant differences were observed in SNA and ANB angles between surgical and nonsurgical groups, with mean differences of 2.25° (95% confidence interval [CI] = 1.12, 3.39) and 3° (95% CI = 1.86, 4.15), respectively. In 9- to 14-year age group, significant differences were found in all 3 sagittal parameters: SNA angle difference of 2.65° (95% CI = 1.44, 3.86), SNB angle difference of 3.23° (95% CI = -4.69, -1.77), and ANB angle difference of 5.54° (95% CI = 3.66, 7.42). Vertical parameters (MPA and %LFH) were not statistically significant between groups in any age group.

Cephalometric parameters could be a valuable predictive factor for determining the future need for OGS in patients with UCLP. ANB angle has been shown to be a significant predictor for distinguishing between surgical and nonsurgical patients.

Artificial Intelligence for Tooth Detection in Cleft Lip and Palate Patients

Introduction: Cleft lip and palate patients often present with unique anatomical challenges, making dental anomaly detection and numbering particularly complex. The accurate identification of teeth in these patients is crucial for effective treatment planning and long-term management. Artificial intelligence (AI) has emerged as a promising tool for enhancing diagnostic precision, yet its application in this specific patient population remains underexplored. Objectives: This study aimed to evaluate the performance of an AI-based software in detecting and numbering teeth in cleft lip and palate patients. The research focused on assessing the system's sensitivity, precision, and specificity, while identifying potential limitations in specific anatomical regions and demographic groups. Methods: A total of 100 panoramic radiographs (52 males, 48 females) from patients aged 6 to 15 years were analyzed using AI software. Sensitivity, precision, and specificity were calculated, with ground truth annotations provided by four experienced orthodontists. The AI system's performance was compared across age and gender groups, with particular attention to areas prone to misidentification. Results: The AI system demonstrated high overall sensitivity (0.98 ± 0.03) and precision (0.96 ± 0.04). No statistically significant differences were found between age groups (p > 0.05), but challenges were observed in the maxillary left region, which exhibited higher false positive and false negative rates. These findings were consistent with the prevalence of unilateral left clefts in the study population. Conclusions: The AI system was effective in detecting and numbering teeth in cleft lip and palate patients, but further refinement is required for improved accuracy in the cleft region, particularly on the left side. Addressing these limitations could enhance the clinical utility of AI in managing complex craniofacial cases.

Low-Dose Cone-Beam Computed Tomography in Swedish Pediatric Patients With Alveolar Clefts Following Alveolar Bone Grafting-A Clinical Study

OBJECTIVES

The aim of this study was to investigate whether a low-dose cone-beam computed tomography (CBCT) protocol provides diagnostically acceptable image quality for assessing bone healing after alveolar bone grafting.

MATERIAL AND METHODS

The study cohort comprised 11 patients (aged 7-14 years) with orofacial clefts who had undergone alveolar bone grafting at Skåne University Hospital in Malmö, Sweden. During the postsurgical follow-up at 6 months, each patient was assessed twice: once with a standard-dose CBCT protocol and once with a low-dose CBCT protocol, which in total corresponds to one CBCT examination made with the exposure settings recommended by the manufacturer. Among others, the assessed parameters included subjective image quality, as well as bone graft height, thickness, and integration.

RESULTS

No significant differences were found between the standard- and low-dose protocols for most parameters (p > 0.05). Exceptions included subjective image quality (one observer, p = 0.05) and confidence levels during the assessment (three observers, p = 0.01, 0.01, 0.02).

CONCLUSIONS

The low-dose protocol yielded adequate image quality for postoperative CBCT healing assessment in patients who have undergone alveolar bone grafting. However, the confidence level of observers during the assessment with the low-dose protocol was reduced. This study is registered on ClinicalTrials.gov (NCT06395077).

CLINICAL TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov (NCT06395077).

Do Tunisian children with unilateral cleft lip and palate differ from normal individuals in dental maturity? A pilot study

INTRODUCTION

Cleft lip and palate (CLP) is the most common congenital malformation of the head and neck. Children with CLP often exhibit dental anomalies.

AIM

To evaluate the dental age (DA) of unilateral CLP in Tunisian children.

METHODS

This was a cross-sectional study carried out in the department of pediatric dentistry at the University Hospital La Rabta, Tunis. Patients aged between 5 and 14 years, with no other congenital anomalies or syndromes in the craniofacial region other than CLP, were included. The patients' chronological ages were first calculated in years and months. DA was assessed in panoramic radiographs using Demirjian's method. The score of each stage is allocated, and the sum of the scores provides an evaluation of the subject's dental maturity.

RESULTS

Fifty-three patients were included in the present study. No difference was observed between the two groups regarding the dental age. A strong and positive correlation between the DA and the chronological age in the two groups was observed (r=0.826). Estimated regression showed that chronological age alone explained 57,4% (r2=0.574) of the dental age variation in the study group and 64.5% (r2=0.645) in the control group.

CONCLUSION

For dental management, CLP children should have the same approach in orthodontics and pediatric dentistry as individuals without clefts, with a focus on the individualization of diagnosis and treatment planning.

Optimization of orofacial cleft imaging protocols using device-specific low-dose cone-beam computed tomography

OBJECTIVE

The aim of this study was to present optimized device-specific low-dose cone-beam computed tomography (CBCT) protocols with sufficient image quality for pre-surgical diagnostics and three-dimensional (3D) modelling of cleft defects.

METHODS

Six paediatric skulls were acquired, and an artificial bony cleft was created. A high-resolution CBCT scan acted as a reference standard (Accuitomo 170, Morita, Kyoto, Japan) for comparing eight low-dose protocols of Newtom VGi-evo (QR Verona, Cefla, Verona, Italy), which included Eco and Regular protocols with different field of views (FOVs). Delineation of lamina dura, cementoenamel junction (CEJ), trabecular bone and bony bridge were assessed. A 3D model of the defect was also evaluated.

RESULT

The dose area product of low-dose protocols ranged from 31 to 254 mGy*cm2. Despite the dose difference of up to eight times between applied protocols, trabecular bone and CEJ exhibited appropriate image quality in all scans. However, Regular small FOV protocols (5 × 5 and 8 × 5 cm2), for both lamina dura and bony bridge, demonstrated a significant improvement in image quality compared to Eco FOV counterparts. Based on 3D defect analysis, no significant difference existed between low-dose protocols and the reference standard.

CONCLUSION

The findings highlight the possibility of achieving a considerable reduction (up to eight times) in the radiation dose using low-dose CBCT protocols while maintaining sufficient image quality for assessing anatomical structures and 3D modelling in cleft cases.

Three-dimensional evaluation of secondary alveolar bone grafting in patients with unilateral cleft lip and palate: A 2-3 year post-operative follow-up

OBJECTIVES

The present study aims to quantitatively assess secondary alveolar bone graft (SABG) resorption in unilateral cleft lip, alveolus and palate (UCLAP) patients in a 2-3 year longitudinal follow-up setting by using a validated 3D protocol. Furthermore, the potential relation of SABG resorption with maxillary canine position and a number of patient-related factors was investigated.

METHODS

UCLAP patients who underwent SABG and had good quality CBCT images at the following timepoints were included in the study: pre-operative (T0), immediate (T1), 6 months (T2) and either 1-2 years (T3) or 2-3 years (T4) post-operative. The final bone grafted region was defined on the T1 scans and refined in the registered T0 scans. The bone graft after resorption was determined by applying threshold-based segmentation on the registered T2, T3 or T4 scans within the segmented bone graft volume. The position of the canines was determined at every timepoint at the cleft and non-cleft side.

RESULTS

Forty-five UCLAP patients (mean age 9.0 ± 1.3 years) were included. In the first 6 months after SABG, 43.6% bone resorption was recorded. 2-3 years post-operative, 56% bone resorption was found if the maxillary canine was not yet erupted and 42.7% if it erupted through the graft. The vertical position of the canines was significantly higher on the cleft side at T3.

CONCLUSIONS

The present study reports significant SABG resorption over time. However, no correlation was found between SABG resorption and canine position, nor between other patient-related factors.

Repeat Buccal Flaps Successfully Reduce Hypernasality in a Patient with Cleft Palate

Surgical intervention can contribute to the development of velopharyngeal insufficiency (VPI) leading to hypernasality and regurgitation. In this case, a patient with a history of bilateral buccal flaps used for her primary CP repair presented to clinic with hypernasality and VPI as assessed by speech exam and imaging. She underwent repeat bilateral buccal flap palatal lengthening with division of the pedicles 3 months later. Three months after her division, her hypernasality score improved from moderate to mild and her posterior gap decreased. This study concluded buccal flaps can be used a second time for patients needing palatal revisions for VPI.

Validation and comparison of 2D grading scales and 3D volumetric measurements for outcome assessment of bone-grafted alveolar clefts in children

BACKGROUND

Several methods have been proposed to assess outcome of bone-grafted alveolar clefts on cone beam computed tomography (CBCT), but so far these methods have not been compared and clinically validated.

OBJECTIVES

To validate and compare methods for outcome assessment of bone-grafted clefts with CBCT and provide recommendations for follow-up.

METHODS

In this observational follow-up study, two grading scales (Suomalainen; Liu) and the volumetric bone fill (BF) were used to assess the outcome of 23 autogenous bone-grafted unilateral alveolar clefts. The mean age at bone grafting was 9 years. The volumetric BF was assessed in five vertical sections. The bone-grafted cleft outcome was based on a binary coding (success or regraft) on a clinical multidisciplinary expert consensus meeting. Grading scales and volumetric assessment were compared in relation to the bone-grafted cleft outcome (success or regraft). Reliability for the different outcome variables was analyzed with intra-class correlation and by calculating kappa values.

LIMITATIONS

The study had a limited sample size. Clinical CBCT acquisitions had a varying tube current and exposure time.

RESULTS

Volumetric 3D measurements allowed for outcome assessment of bone-grafted alveolar clefts with high reliability and validity. The two grading scales showed highly reliable outcomes, yet the validity was high for the Suomalainen grading scale but low for the Liu grading scale.

CONCLUSIONS

Volumetric 3D measurement as well as the Suomalainen grading can be recommended for outcome assessment of the bone-grafted cleft. Yet, one must always make a patient-specific assessment if there is a need to regraft.

Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate?

SUMMARY

Velopharyngeal insufficiency (VPI) is a complication following primary palatoplasty that can lead to hypernasality of the voice and other speech problems. The conversion Furlow palatoplasty for VPI can be performed with the addition of buccal flaps to provide additional tissue for palatal repair. In this study, the authors aimed to determine the effectiveness of buccal flaps with conversion Furlow palatoplasty in secondary management of VPI. A retrospective review of patients undergoing surgical repair of VPI between 2016 and 2020 was performed. Patients underwent either conversion Furlow palatoplasty alone (FA) or conversion Furlow palatoplasty with buccal flaps (FB) for VPI after primary straight-line repair of the palate. The authors reviewed medical records to collect demographics, operative information, and preoperative and postoperative speech scores. Of the 77 patients in the study, 16 (21%) had a revision that incorporated buccal flaps. The median age at cleft palate revision surgery was 8.97 years in the FA group and 7.96 years in the FB group ( P = 0.337). In the FA group, four patients (7%) developed a postoperative fistula, compared with zero patients in the FB group. The average time to follow-up after revision surgery was 3.4 years (range, 7 months to 5.9 years). Both cohorts demonstrated a decrease in hypernasality and total parameter scores postoperatively. The use of buccal flaps in revision Furlow palatoplasty could decrease the risk for postoperative complications. The use of data from a larger patient population from multiple institutions is warranted to determine true significance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Cumulative exposure and lifetime cancer risk from diagnostic radiation in patients undergoing orthognathic surgery: a cross-sectional analysis

Radiation doses in dentomaxillofacial imaging are typically very low. However, diagnostic and follow-up protocols in orthognathic surgery result in a patient-specific risk in effective dose. Estimating the cancer risks from these exposures remains abstract for many maxillofacial surgeons. In this study, 40 orthognathic patients were randomly sampled and their cumulative effective dose (ED) calculated. The lifetime attributable risk of cancer (LAR) was calculated based on the standard radiological protocol for orthognathic surgery follow-up using methods described in the BEIR VII report and RadRAT. The mean cumulative ED of the 40 sampled patients at the end of their 2-year follow-up period was 1.91 ± 0.58 mSv. The LAR at the end of follow-up was 17.65 (90% confidence interval 6.46-32.90) per 100,000 person-years for male orthognathic patients and 13.93 (90% confidence interval 6.27-25.24) per 100,000 person-years for female orthognathic patients. This represents 0.70% and 0.68%, respectively, of the baseline cancer risk for oral, thyroid, and brain cancer combined. Although theoretical, these results provide a framework for interpreting radiation doses and cancer risks in patients undergoing orthognathic surgery. Considering the increased radiation sensitivity in children and adolescents, indication-oriented and patient-specific imaging protocols should be advised.

Moving toward patient specificity for devising cone-beam computed tomography field-of-views: A normative maxillary skeletal dimensional analysis

BACKGROUND

A lack of evidence exists comprehensively assessing skeletal dimensions in a Caucasian population group at different ages.

AIM

To provide age- and gender-specific normative skeletal dimensional measurements of the maxillary region using cone-beam computed tomography (CBCT) imaging.

DESIGN

Cone-beam computed tomography images of Caucasian patients were acquired and divided into different age groups ranging from 8 to 20 years. Linear measurements were taken to evaluate seven distance-based variables, which included anterior nasal spine-posterior nasal spine (ANS-PNS) distance, bilateral maxillary first molar's central fossae (CF) distance, palatal vault depth (PVD), bilateral palatal cementoenamel junction (PCEJ) distance, bilateral vestibular CEJ (VCEJ) distance, bilateral jugulare distance (Jug) and arch length (AL).

RESULTS

A total of 529 patients (243 male, 286 female) were selected. ANS-PNS and PVD showed the highest change in dimensions from 8 to 20 years of age. On the contrary, AL had the least variability in all age groups. Male patients had larger dimensions and showed a significant change in all dimensional measurements (p < .001) than female patients.

CONCLUSION

The maxillary linear dimensions varied across different age groups. The presented maxillary normative data could serve as a reference guide for devising patient-specific CBCT field of views.

Validation of a novel method for canine eruption assessment in unilateral cleft lip and palate patients

Objective

The aim of this study was to propose and validate a three‐dimensional (3D) methodology for the assessment of canine eruption in patients born with unilateral cleft lip and palate (UCLP) following secondary alveolar bone graft (SABG).

Methods and Materials

A total of 10 patients (four females, six males; mean age: 8.8 years) with UCLP who underwent SABG were recruited. Pre‐ and 6‐month post‐operative cone‐beam computed tomography (CBCT) was acquired for all patients. Post‐operative data was registered onto pre‐operative data utilizing voxel‐based registration. Following superimposition, a segmentation process was applied to segment maxillary canine on both cleft and non‐cleft side. Thereafter, translational and rotational changes in canine position were assessed for both cleft and non‐cleft side by two observers.

Results

The intra‐class correlation coefficient (ICC) indicated excellent reliability (≥0.90) with inter and intra‐observer error of less than 0.05 mm. The overall ICC was found to be high for assessing both translational and rotational changes. The mean absolute inter‐ and intra‐observer difference for translational and rotational changes was found to be less than 1 mm and 3°.

Conclusion

The present method was found to be reliable proving to be clinically applicable for assessing maxillary canine eruption changes in both cleft and non‐cleft bone.

Dental development in patients with and without unilateral cleft lip and palate (UCLP): a case control study

OBJECTIVE

To evaluate if the presence of unilateral cleft lip and palate (UCLP) causes delay in dental age and tooth development.

MATERIALS AND METHODS

Panoramic radiographs of 189 non-syndromic UCLP patients, aged from 6 to 20 years, were collected. Two measures of tooth development were examined: dental maturity scale for the seven left mandibular teeth (dental age-DA) and the degree of each tooth development (developmental score-DS). All the teeth except third molars were staged according to the Demirjian's method. The data of the cleft group were compared with a control group matched for age and gender, based on the findings observed in other 189 panoramic radiographs.

RESULTS

At all ages, DA was lower in the UCLP group, but not always significantly; the highest difference was - 1.411 for females at 13 years old and - 0.776 for males at 12 years old. DS of all teeth was significantly lower in the UCLP group, at all ages under 17 in females, and at all ages under 18 in males. In UCLP group, tooth development was more delayed in the maxilla compared with the mandible. No evidence of a slower development at the cleft side compared with the non-cleft side was highlighted.

CONCLUSIONS

Significant lower dental development was observed in UCLP patients compared with control ones by using DS and DA indexes.

CLINICAL RELEVANCE

These findings can help the clinicians in establishing a proper orthodontic and surgical diagnosis and treatment planning in UCLP patients and for forensic age estimation's purposes.