A novel method for fabricating nasoalveolar molding appliances for infants with cleft lip and palate using 3-dimensional workflow and clear aligners

Accuracy and Retention of Molding Plates Used for Infants with Cleft Lip and Palate Fabricated from Different Materials: A Cross-Sectional Clinical Study

ObjectivesThe study aimed to comparatively assess the accuracy and retention of molding plates made of polyethylene terephthalate modified with glycol (PET-G) and polymethyl methacrylate (PMMA) materials, while also investigating the effect of adhesive addition on retention.DesignA cross-sectional clinical study.Patients/settingThe study included 30 infants diagnosed with non-syndromic cleft lip and palate (16 unilateral, 14 bilateral). Two molding plates were fabricated for each infant, and their accuracy and retention were evaluated. The data were analyzed using independent t-tests, Mann-Whitney U tests, and Wilcoxon rank tests.Main outcome measuresAccuracy: The accuracy of the molding plates was assessed by measuring the virtual gap between the inner surface of the plates and their working cast using Exocad software. The accuracy was evaluated in different regions (anterior, middle, and posterior) and compared between PET-G and PMMA materials. Retention: The retention of the molding plates was measured using a digital force gauge, which recorded the force required to dislodge the plates from the infant's mouth. The retention was compared between PET-G and PMMA materials, as well as the effect of adhesive addition on retention. Overall adaptation; PET-G plates showed a significantly smaller gap (mean= 0.264 ±0.106) compared to PMMA (mean= 0.362 ±0.130). Region-specific adaptation: PET-G plates demonstrated better accuracy in all regions (means of anterior =0.246, middle =0.262, posterior =0.282 µm). Significant differences in accuracy were observed in the middle and posterior regions compared to PMMA. Retention assessment revealed that the PET-G groups (with or without adhesive) exhibited significantly higher retention compared to the PMMA groups (P<0.01).ConclusionPET-G plates demonstrated superior accuracy and retention compared to PMMA, with a significant difference observed in both accuracy and retention. Furthermore, the addition of denture adhesive had a positive effect on retention for both materials.

Comparison of Lip Revision Rates in Traditional Versus Early Cleft Lip Repair: An Institutional Review

BACKGROUND

Traditional cleft lip repair (TLR) is performed between 3 and 6 months of age. For over 10 years, our institution has transitioned from offering presurgical nasoalveolar molding (NAM) before cleft lip repair to performing early cleft lip repair (ECLR) within 2 to 5 weeks of life, circumventing the use of NAM.

PURPOSE

This study aimed to estimate and compare the lip revision rates between patients who underwent ECLR versus TLR ± NAM.

STUDY DESIGN, SETTING, SAMPLE

A retrospective cohort study was conducted. Patients with nonsyndromic unilateral cleft lip who underwent primary repair between 2004 and 2021 at Children's Hospital Los Angeles were included. Exclusion criteria were as follows: American Society of Anesthesiologists classification III or higher, syndromic or bilateral cases, gestational-corrected age of more than 6 months at lip repair, and less than 2 years of follow-up.

PREDICTOR VARIABLE

The predictor variable was the timing of primary cleft lip repair. Subjects were allocated to 1 of 2 treatment cohorts: ECLR (<3 months) and TLR ± NAM (3 to 6 months).

MAIN OUTCOME VARIABLE

The primary outcome was lip revision surgery at any time during the patient's cleft care. Secondary outcomes included the extent and timing of the revision surgeries.

COVARIATES

Data collection included presurgical NAM use, surgeon, cleft phenotype, and cleft width ratio.

ANALYSES

A 2-phased coarsened exact matching process was performed to match cohorts based on surgeon, cleft phenotype, and cleft width ratio at a 1:1 ratio. Kaplan-Meier analyses were used to estimate and compare the revision rates.

RESULTS

A total of 1,101 patients underwent primary repair during the study period. After applying the exclusion criteria, 362 patients remained before matching. Among these, 154 patients (77 ECLR, 77 TLR ± NAM) were included after matching. Kaplan-Meier analysis estimated a lower 5-year revision rate for the ECLR cohort compared to the TLR ± NAM cohort (17.3 vs 32.6%, log-rank P < .05). Median follow-up time was 6.6 years [interquartile range 4.4 to 9.2].

CONCLUSIONS AND RELEVANCE

ECLR resulted in approximately a 2-fold reduction in lip revision rates compared with TLR ± NAM. These findings suggest that cleft lip repair at approximately 1 month of age may decrease the burden of secondary procedures later in life.

Clinical Efficacy of Nasoalveolar Moulding Using Aligner NAM During Presurgical Infant Orthopaedics (PSIO) in Infants With Unilateral Cleft Lip and Palate (UCLP): A Retrospective Study

OBJECTIVE

The study compares and evaluates planned virtual outcomes with actual post-treatment outcomes to assess the accuracy and predictability of clinical results during presurgical infant orthopaedics (PSIO) with AlignerNAM in infants with unilateral cleft lip and palate.

SETTING

Institutional study.

PARTICIPANTS

14 UCLP patients.

MATERIALS AND METHODS

Digital models for infants with unilateral cleft lip and palate (UCLP) who had undergone PSIO with AlignerNAM between 1 and 6 weeks were obtained at three stages-pretreatment (To), planned (Tp) and post-treatment (T1). Linear and angular measurements were made on these using the OrthoAnalyser software (3Shape, Copenhagen, Denmark). A paired t-test and Bland-Altman analysis assessed the accuracy between predicted and achieved movements, while inter- and intra-rater reliabilities were also calculated using digital records of seven patients.

RESULTS

The study found no significant difference (p > 0.05) between the clinical outcome (post-treatment) values and the predicted values (obtained from the virtual post-treatment simulation/planned movement). The sagittal reduction in the cleft defect demonstrated the highest accuracy (97.71%), followed by the transverse reduction (95.1%). Overall, linear measurements achieved an accuracy of 94.57% and angular measurements an accuracy of 93.64%. All measurements were within the limits of agreement based on the Bland-Altman plots. The widths of limits of agreement were narrow and similar for both linear and angular measurements showing high levels of agreement.

CONCLUSION

AlignerNAM showed high accuracy in reducing cleft size and aligning alveolar segments in UCLP patients, achieving accuracy rates above 90% in both linear and angular dimensions. AlignerNAM appliance is a suitable alternative to conventional PSIO techniques.

Exploring the potential applications of intraoral scanners in the treatment of cleft lip and palate deformity-A scoping review of literature

BACKGROUND

In the realm of cleft lip and palate (CLP) care, the integration of intraoral scanners (IOS) may offer a promising avenue, enabling precise digital imaging, record-keeping, treatment planning and execution. This scoping review aimed to explore the current applications of IOS in CLP patients and discuss potential future directions for optimizing the utilization of IOS in cleft care.

MATERIAL AND METHODS

The review was registered apriori in the Open Science Framework (OSF) Registries (https://doi.org/10.17605/OSF.IO/KPD34). A systematic search was conducted across various databases like Ovid MEDLINE, PubMed, Cochrane Library, Embase, Web of Science, Scopus, Google Scholar, Grey literature, and Trial registries using a broad search strategy. The articles published in any language till December 20, 2023 were considered. Studies that demonstrated the application of intraoral scanning in nonsyndromic CLP patients were included. A validated sixteen-item content assessment tool was used to evaluate the included studies. Two independent reviewers performed data extraction and content assessment.

RESULTS

Fifteen research studies and thirteen case reports/series were included in the final analysis. Various applications included capturing intraoral and extraoral images, scanning orthodontic study models, assessing dental changes, monitoring treatment changes related to nasoalveolar molding therapy, and fabricating appliances. The content assessment showed below-average mean scores of 34.79 ± 9.37% for research studies and 39.7 ± 0.14% for case reports/series. This can be attributed to insufficient information on scanning parameters, methodology, accuracy, patient outcomes, limitations, and potential solutions. The reproducibility of landmark identification in IOS was within 0.2 mm. Patients and caregivers preferred digital impressions over traditional alginate methods, reporting positive experiences in 84.8% of cases.

CONCLUSION

Intraoral scanners offer good clinical accuracy and validity in assessing dentofacial and nasolabial morphology in cleft patients. Adopting IOS can streamline clinical workflows, enhance treatment accuracy, and improve patient outcomes in managing cleft lip and palate.

Enhancing Effective Scanning Techniques for Digital Impression in Neonates with Cleft Lip and/or Palate: A Laboratory Study Investigating the Impact of Different Scanners, Scanning Tip Sizes, and Strategies

Background/Objectives: Digital impressions are increasingly used to manage Cleft lip and/or palate (CL/P), potentially offering advantages over traditional methods. This laboratory investigation sought to evaluate the impact of scanning tip sizes, different scanners, and scanning strategies on intraoral scanning in neonates with CL/P. Methods: Ten soft acrylic models were used to simulate the oral anatomy of neonates with CL/P, evaluating parameters such as the ability of different scanning tips to capture alveolar cleft depth, scanning time, number of scan stops, and scan quality. The study utilised various scanning tips, including the Carestream normal tip, Carestream side tip, and Trios 4 scanner tip to assess the alveolar cleft depth measurements. The Trios 4, Carestream, and iTero scanners were evaluated for the time taken, number of scan stops during cleft-unobstructed scanning and cleft-obstructed scanning. The quality of all scanned images was analysed. Results: The findings showed comparable accuracy in capturing alveolar cleft depth with the three-scanning tip (p > 0.05). Scanning time and the number of scan stops did not significantly differ across the three scanners and various scanning strategies employed (p > 0.05). However, scanning with the cleft obstructed required less time and resulted in fewer scan stops compared to cleft -unobstructed scanning. Despite these results, all scanners failed to record the deepest part of the alveolar cleft, highlighting a limitation in current scanning technology for neonates with CL/P. Conclusions: The study recommends enhancing intraoral scanning in this population by adjusting tip size, improving clinician training, optimizing protocols, and conducting further research to improve techniques.

Three-Dimensional Changes of Alveolar Ridges and Nasolabial Structures Following a Digital Nasoalveolar Molding Therapy With a Novel Nasal Stent Activation Protocol

Digital orthodontics has been integrated into NasoAlveolar Molding (NAM) therapy to overcome challenges in the conventional NAM method. This study introduced an individualized Digital NAM (iDNAM) and evaluated the changes in the alveolar ridges and nasolabial morphology after iDNAM treatment. Prospective data were collected from 15 infants with complete unilateral cleft lip and palate who underwent iDNAM therapy. An intraoral-and-nasolabial scan was used to create a virtual setup model and plate generation. A total of 2 plates were required under the iDNAM treatment protocol. The first iDNAM plate has a specific interior and exterior design to allow continuous force application with minimal plate adjustment. After an intermediate scan, a nasal stent was meticulously incorporated into the second plate for nasal molding. To activate the nasal stent, a silicone molding extension was used instead of manually adding acrylic. The alveolar cleft gap was significantly reduced by 7.48 ± 2.06 mm. On the cleft side, statistically significant increases occurred in nostril height, columellar length, and nasal base-columellar angle (2.08 ± 0.63 mm, 2.58 ± 0.28 mm, and 22.29 ± 0.88 degrees, respectively). By using 2 serial plates, iDNAM improved the alveolar cleft gap and the nasal morphology in complete unilateral cleft lip and palate. An addition of a nasal extension to the second iDNAM plate presents a challenge as accurate positioning is required for appropriate activation force. The iDNAM plate design and nasal activation protocol reduce the need for chairside adjustment and the number of appointments.

Use of nasal retainers in the primary management of cleft lip: Current practices in France

BACKGROUND

The primary surgical management of cleft lip (CL) or cleft lip and palate (CLP) aims to achieve harmonious lip and nasal symmetry while ensuring satisfactory ventilation. Postoperative nasal retainers are commonly used, though both duration of use and conformer type used vary widely. This study aimed to establish an inventory of current practices for primary cheilorhinoplasty and nasal retainer use in France.

METHODS

A survey was sent to surgeons within and outside the French National Clefts and Facial Malformations (MAFACE) network. Questions focused on age when primary cleft closure is performed, retainer types used, conformation duration, and estimated patient compliance. Responses were collected March-July 2023.

RESULTS

Thirty-two surgeons responded with substantial variations in practices. For isolated CL, the age for primary cleft closure was 1-6 months, with 28 % performing surgery at 3 months, 12.5 % between 3 and 6 months, 44 % at 6 months. In cases with CLP, 63 % performed simultaneous surgery at 6 months. Two surgeons (6 %) reported preoperative nasoalveolar molding and 30 surgeons (94 %) reported postoperative nasal retainer use. Retainer type used immediately after surgery varied, with equal use of commercial retainers (31 %), silicone sheets (31 %), and in-house retainers (31 %). Duration of retainer prescription was in majority 3-4 months. Notably, 44 % of surgeons reported <70 % adherence rates for the recommended conformation duration, while 25 % reported very good compliance.

CONCLUSION

Primary cheilorhinoplasty and nasal conformation practices are highly diverse in France. Suboptimal patient compliance demonstrates the need for improved retainer design and strategies to enhance compliance.

The Accuracy of Digital Impressions versus Conventional Impressions in Neonates with Cleft Lip and/or Palate: A Laboratory-Based Study

Cleft lip and palate (CL/P) are a common congenital craniofacial anomaly requiring precise impressions for effective treatment. Conventional impressions (CIs) pose challenges in neonates with CL/P due to their delicate oral anatomy. While digital impressions (DIs) are increasingly recognised for their potential benefits over conventional methods in dentistry, their accuracy and application in neonates with cleft lip and palate (CL/P) remain underexplored. This study aimed to assess the accuracy of DIs compared to CIs in neonates with CL/P, using alginate and putty materials as references. A laboratory-based case-control study was conducted, utilising soft acrylic models resembling neonatal mouths with CL/P. Alginate and putty impressions were obtained conventionally, while digital impressions were captured using an intraoral scanner (IOS). A total of 42 models were analysed, divided evenly into three groups, with each group comprising 14 models. Superimposition and surface discrepancy analyses were performed to evaluate impression accuracy. The results revealed no statistically significant differences between the digital and conventional impressions in their intra-arch measurements and surface discrepancies. The mean measurement values did not significantly differ among groups, with p values indicating no significant variations (p > 0.05), confirmed by an analysis of variance. High intra-examiner reliability with Intra Class Coefficient (ICC) values close to 1 indicated consistent measurements over time. The current study demonstrates that DIs are equally accurate as conventional alginate and putty impressions in neonates with cleft lip and palate, offering a viable and less invasive alternative for clinical practise. This advancement holds promise for improving the treatment planning process and enhancing patient comfort, particularly in vulnerable neonatal populations. Further research is warranted to explore the clinical implications and factors affecting DI accuracy in this population.

Individualized Digital Nasoalveolar Molding: A Proof of Concept

Nasoalveolar molding (NAM) is a recognized adjunctive therapy to primary cheiloplasty in patients with complete cleft lip and palate (CLP). The conventional technique can be time-consuming, costly, and requires experienced clinicians. Over the past decade, CAD/CAM technology has been employed to facilitate NAM therapy, showing promising results. This study introduces an individualized Digital NAM (iDNAM), a digital approach revolutionizing NAM treatment using CAD/CAM technology, and evaluates treatment outcomes. A 57-day-old infant with complete UCLP underwent intraoral and nasolabial scans, along with 3D photogrammetry. Open-source software was utilized for virtual alveolar segmentation and NAM plate design. iDNAM incorporates a nasal molding extension, introducing an innovative nasal stent activation protocol. Changes in alveolar and nasal morphology were compared between the initial and presurgery stages. After treatment with iDNAM, the alveolar cleft gap was reduced to 4.22 mm. Nostril height on the cleft side, columellar length, and nose projection increased by 0.98, 2.40, and 1.90 mm, respectively. The nasal base-columellar angle improved by 29.50 degrees. The results demonstrate a significant reduction in the alveolar cleft gap and improved nasal morphology, making iDNAM as an alternative to NAM therapy.

The accuracy and retention of presurgical infant orthopaedics constructed from different polymer materials: A comparative study

Objectives

This laboratory-based study aimed to evaluate and compare the accuracy and retention of moulding plates when used as pre-surgical orthopaedic appliances (PSIOs) for infants with cleft lip and/or palate (CL/P).

Methods

Ten moulding plates were fabricated from three different materials (total sample size: 30), including polymethyl methacrylate (PMMA), a hard clear aligner (PET-G polymer), and a dual-layered hard and soft clear aligner (mixed PET-G/EVA) on ten three-dimensional (3D) printed working models. Accuracy was evaluated by measuring the virtual gap between the data acquired from the moulding plate and the working model after the optical scanning at each of the designated 36 points for each plate. Exocad software was used to facilitate all virtual alignments and measurements. Retention was measured using a digital gauge that quantified the traction force required to separate the plates from the retention test cast (a soft resin printed cast).

Results

PET-G plates exhibited the best fit with the working cast, with overall adaptations of 0.146 ± 0.012 for PET-G, 0.250 ± 0.073 for PET-G/EVA, and 0.294 ± 0.113 for PMMA. For region-specific misfit, PET-G plates exhibited superior accuracy across all regions, with mean discrepancies of 0.16 ± 0.08 mm, 0.15 ± 0.061 mm, and 0.12 ± 0.128 mm in the anterior, middle, and posterior regions, respectively. Retention for PET-G was significantly higher than the other materials, with a mean of 3.34 N ± 0.487, as opposed to 1.65 N ± 0.331for PMMA and 1.27 N ± 0.239 for PET-G/EVA (P < 0.05).

Conclusions

Moulding plates constructed from PET-G exhibited a better fit and higher retention than those made from PET-G/EVA and PMMA.

Clinical significance

Collectively, our findings suggest that the selection of PET-G for PSIO appliances could have clinical significance by potentially improving treatment outcomes in infants with CL/P.

The Burden of Care of Nasoalveolar Molding: An Institutional Experience

Nasoalveolar molding (NAM) is an early presurgical intervention to facilitate primary cleft lip repair by reducing cleft severity and improving labial and nasal form. However, it continues to be associated with the burden of care that influences access and completion of therapy. The authors, therefore, aim to determine the burden of care of NAM therapy for families seeking treatment at a high-volume urban cleft center. A retrospective study of all patients undergoing primary cleft repair between 2012 and 2020 was performed. Patients were grouped based on whether or not NAM therapy was offered. Variables including physical, psychosocial, and financial factors were assessed. Two hundred and thirty patients underwent primary cleft repair between 2012 and 2020. Of these, 176 patients were indicated for NAM, with 4% discontinuing, and 54 patients did not undergo NAM. The 169 patients who completed NAM had a mean duration of treatment of 13.6±8.8 wks consisting of 15±6 scheduled NAM adjustment visits and 1±1 unscheduled visit made urgently to assess caregiver concerns. The mean travel distance was 28.6±37.1 miles. Eighty-four percent of caregivers were married, and 16% did not have English as a primary language. Though 57% had private insurance, 43% of patients received charity support for their treatment. NAM is a finite presurgical intervention that requires caregivers to participate in patient care for approximately three months of their early life. The decision to pursue NAM should be considered alongside the burden of care for caregivers to complete treatment.

A comparative evaluation of presurgical infant orthopedics of modified Grayson's technique with clear aligners incorporating a nasal elevator in patients with unilateral cleft lip and palate

OBJECTIVE

To assess the differences between 2 methods of presurgical infant orthopedics: the modified Grayson's technique and a new technique using clear aligners in patients with complete unilateral cleft lip and palate.

METHODS

For this prospective comparative cohort study, 30 patients were divided into 2 groups: group A (modified Grayson technique) and group B (clear aligner trays), with 15 patients each. Scanned cast measurements were taken before and after treatment and evaluated using an appropriate 3-dimensional software assessing treatment changes in the alveolus (eg, reduction of width between major and minor segment, angulation change of each respective segment [intragroup and intergroup, respectively]). This was supplemented with standardized anterioposterior, Worms-eye view, and profile photographs assessing changes in columellar angle, nostril width, height, nasolabial angle, and soft-tissue cleft gap. Furthermore, the number of visits for each patient group was also tabulated and assessed. The differences were compared using the independent t test and Mann-Whitney U test for the respective parameters.

RESULTS

Groups A and B showed similar posttreatment changes, with no overt significant differences. However, there was a statistically significant difference in the number of visits (P <0.05), with group B having much lower visits to the center than group A. The posttreatment values matched previously established growth reference values. The analysis of photographic measurements showed improved nasal asymmetry in both groups without any significant difference.

CONCLUSIONS

Because there was no difference in the treatment results between the 2 methods and a reduction in the number of required patient visits, presurgical infant orthopedics via clear aligners could pave the way for a more patient-efficient approach.

Telemedicine as an Alternative Way to Provide Multidisciplinary Cleft Care During the COVID-19 Pandemic

The current coronavirus pandemic is changing the way healthcare professionals provide services to patients. Healthcare professionals are required to provide quality care while reducing the risk of viral transmission. This pandemic has disrupted the timely multidisciplinary team care for patients with clefts across the globe. Thus, telemedicine has been recognized and accepted by various medical and dental specialists as a viable alternative to face-to-face consultation. In addition, telemedicine incorporating a digital workflow in cleft management will further reduce the risk of viral transmission and enhance the quality of treatment being provided to these patients.

Does Infant Orthopedics and Neonate Lip Surgery Influence the Occlusal Relationship in Patients With Unilateral Cleft Lip and Palate (UCLP)?

OBJECTIVE

To compare occlusal relationship in patients undergoing neonate versus conventional lip surgery (LS) with and without infant orthopedics (IO) by assessment of dental arch relationship in individuals with complete unilateral cleft lip and palate.

MATERIAL AND METHODS

Three groups treated by different protocols; Group I: neonate LS (1-15 days) + IO and palatoplasty (13-31 months); Group II: LS (3-12 months) + IO and palatoplasty (15-35 months); and Group III: LS (3-6 months) without IO and palatoplasty (12-18 months). The 112 intraoral photographs of individuals of all groups, obtained between 6 and 12 years of age, were assessed by the occlusal index for intraoral photograph rating. The groups were compared by the χ² test. The correlation between surgical timing and the scores was tested by the Spearman test (P < .05).

RESULTS

Group I presented the highest percentage of score 5, group II exhibited highest percentage of score 1, and group III presented the lowest percentage of score 5 according to the χ² test (P = .029). The Spearman correlation test revealed statistically significant difference between timing of LS and the occlusal index. The earlier the surgical timing, the higher the occlusal index (P = .019).

CONCLUSIONS

Infant orthopedics has demonstrated the possibility of postponing primary plastic surgeries. Patients submitted to late lip and palate repair had the best prognosis, while patients undergoing lip repair from 1 to 15 days of life, even operating the palate later, had the worst prognosis. Neonate LS negatively influenced the occlusal relationships.