A comparative cephalometric study for adult operated cleft palate and unoperated cleft palate patients

Comparison of a third surgical protocol for the treatment of unilateral cleft lip and palate: a multidisciplinary systematic review and meta-analysis

This systematic review and meta-analysis builds upon our previous publication on the outcomes of patients with unilateral cleft lip and palate (UCLP) treated with Oslo protocols (OP; vomerplasty during lip closure vs delayed hard palate closure protocols (DHPCP), comparing the outcomes of these two protocols with those of one-stage palatoplasty protocols (OSPP). A systematic search of the Embase, MEDLINE/PubMed, Web of Science, Cochrane, and Google Scholar databases was conducted until August 2024. In total, 162 articles (156 study groups) were reviewed, including 4040 UCLP patients following OSPP, 1632 following OP, and 791 following DHPCP. The results suggest that intrinsic maxillofacial growth disturbances are common in UCLP patients, regardless of the timing or type of palatal closure. The incidence of velopharyngeal insufficiency was significantly higher in OP (24%) when compared to DHPCP (9%), with OSPP showing an intermediate incidence (14%). However, these findings are of very low certainty due to evident non-reporting bias and limited data. In contrast, OP and OSPP showed lower oronasal fistula (ONF) rates (7% for OP, 10% for OSPP) compared to DHPCP (20%). Altogether, OSPP and OP are favoured over DHPCP due to the lower incidences of ONF, better overall speech outcomes, and fewer primary surgeries.

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.

Anatomical and Physiological Changes Following Primary Palatoplasty Using "The Buccal Flap Approach"

ObjectiveThe purpose of this study was to determine the anatomical differences among selected individuals with a cleft palate repaired using "The Buccal Flap Approach" during primary palatoplasty compared to aged-matched participants without cleft palate.DesignObservational, prospective.SettingTwo regional hospitals.ParticipantsA total of 30 adult males consisting of 15 adults born with cleft palate who received the Double Opposing Z-Plasty plus Buccal Flaps (DOZP  +  BF) repair at the time of primary palatoplasty and no history of secondary speech surgery or orthognathic surgery and 15 adults without a history of cleft palate.InterventionsAll participants underwent MRI to visualize anatomy.Main Outcome MeasuresTen velopharyngeal and craniofacial anatomical measures.ResultsNo statistically significant differences between groups were observed for velar thickness, velar length, pharyngeal depth, NSBa angle, SNB angle, or levator veli palatini length. Individuals with the DOZP  +  BF presented with a greater effective velar length (p < .001), greater effective VP ratio (p < .001), smaller SNA angle (p < .001), and smaller maximal velar stretch (p < .001) compared to the control participants.ConclusionsThis study suggests that adult males who received the DOZP  +  BF repair at the time of primary palatoplasty and no history of secondary speech surgery or orthognathic surgery present with a longer effective velar length and larger effective VP ratio in comparison to the non-cleft group. Future research is needed to compare patients with and without favorable outcomes from multiple surgical types to fully understand how surgical techniques alter the anatomy.

Comparative CBCT Analysis of Maxillofacial Skeletal Structures in Patients with Unilateral Cleft Lip and Palate and Non-Cleft Individuals

BACKGROUND

The aim of this study was to evaluate and compare the maxillofacial structures of individuals with unilateral cleft lip and palate (UCLP) and healthy controls using cone beam computed tomography (CBCT).

METHODS

The study included a total of 90 subjects, comprising 45 randomly selected individuals with UCLP (30 males and 15 females, mean age 14.69 ± 3.95 years) in the study group and 45 healthy individuals (30 males and 15 females, mean age 14.46 ± 3.65 years) in the control group. Maxillofacial measurements were taken in three different planes and categorized into five groups, namely vertical, facial, cranial, maxillary, and mandibular. In the statistical comparison between groups, the significance level was determined as p < 0.05.

RESULTS

There were no significant differences in the age and gender distributions between the groups (p > 0.05). Upper anterior face height and posterior face height in the UCLP group were found to be significantly shorter than the control group (p < 0.05). Midface width and depth were inadequate in the UCLP group (p < 0.05). Anterior and posterior cranial base lengths were significantly shorter in individuals with UCLP (p < 0.05). Nasal width and interorbital width were significantly greater in the UCLP group (p < 0.05). In addition, maxillary width, maxillary length, and mandibular width were significantly shorter in the UCLP group than in the control group (p < 0.05).

CONCLUSIONS

While the control group exhibited generally longer measurements in all three dimensions compared to the study group, the skeletal structures adjacent to the cleft demonstrated the most notable developmental deficiency.

The influence of three different primary treatment protocols on 5-year-old maxillary growth in patients with complete unilateral cleft lip and palate

The study evaluated the effects of three different primary treatment protocols on maxillary growth in patients aged 5 years with complete unilateral cleft lip and palate (UCLP). The secondary objective was to assess the influence of initial cleft severity, family history of class III, and status of permanent lateral incisor on maxillary growth. In total, 54 patients with non-syndromic complete UCLP were included and grouped as follows: group An underwent lip adhesion, cheilorhinoplasty associated with tibial periosteal graft for hard palate repair, and finally veloplasty; group B underwent lip adhesion, then cheilorhinoplasty with intravelar veloplasty, and finally a hard-palate repair; group C underwent cheilorhinoplasty with intravelar veloplasty and then a hard-palate repair. Five-year maxillary growth was assessed on dental models, both clinically and digitally. No difference was found with GOSLON-Yardstick scoring. Five-year measurements showed that group C tended to have the best maxillary arch morphology (p = 0.012). Initial cleft severity did not impact maxillary growth, but status of permanent lateral incisor and family history of class III did (p = 0.019 and p = 0.004, respectively). In patients aged 5 years, the two-stage approach appeared to be the least detrimental to growth development. Predictive factors for growth retardation included the absence of lateral incisor and a family history of class III.

Craniofacial Cephalometric Morphology in Polish Adolescents with Cleft Palate Only

Background: Cephalometric studies indicate that craniofacial morphology in patients with cleft palate only (CPO) differs from other forms of orofacial clefts and healthy patients. Planning orthodontic treatment for patients with different craniofacial deformities requires knowledge on the craniofacial complex. The aim of the present study was to describe the cephalometric craniofacial morphology in adolescents with cleft palate only compared to generally healthy orthodontic patients. Methods: The study comprised 100 lateral cephalograms (taken in the years 2003-2020) of Polish patients with cleft palate only aged from 11.1 to 14.2 (mean age 12.43 y) and a matched control group of 100 children without orofacial clefts aged 12-14 (mean age 12.25). All digital images were analyzed in specialized cephalometric software. Results: Statistically significantly lower values of both SNA (p < 0.001) and ANB (p < 0.001) were found in the study group versus the control group. Mandibular line to cranial base angle (ML-NSL) as well as maxillary base to cranial base (NL-NSL) were significantly higher in the CPO group. Both the maxilla and mandible were rotated distally in CPO. Moreover, the intermaxillary vertical angle (ML-NL) was reduced in CPO. Mandibular angle in CPO was significantly higher (p = 0.005), reflecting posterior mandibular rotation. Conclusions: In adolescents with CPO, maxillary deficiency is found, without a severe sagittal jaw discrepancy, with a slight compensatory lingual inclination of the lower incisors. Mandibular deficiency in CPO is concurrent with posterior rotation and an increased mandibular angle.

Craniofacial morphological variability in orthodontic patients with non-syndromic orofacial clefts: an approach using geometric morphometrics

OBJECTIVES

Orofacial clefts are complex congenital anomalies that call for comprehensive treatment based on a thorough assessment of the anatomy. This study aims to examine the effect of cleft type on craniofacial morphology using geometric morphometrics.

MATERIALS AND METHODS

We evaluated lateral cephalograms of 75 patients with bilateral cleft lip and palate, 63 patients with unilateral cleft lip and palate, and 76 patients with isolated cleft palate. Generalized Procrustes analysis was performed on 16 hard tissue landmark coordinates. Shape variability was studied with principal component analysis. In a risk model approach, the first nine principal components (PC) were used to examine the effect of cleft type.

RESULTS

We found statistically significant differences in the mean shape between cleft types. The difference is greatest between bilateral cleft lip and palate and isolated cleft palate (distance of means 0.026, P = 0.0011). Differences between cleft types are most pronounced for PC4 and PC5 (P = 0.0001), which together account for 10% of the total shape variation. PC4 and PC5 show shape differences in the ratio of the upper to the lower face, the posterior mandibular height, and the mandibular angle.

CONCLUSIONS

Cleft type has a statistically significant but weak effect on craniofacial morphological variability in patients with non-syndromic orofacial clefts, mainly in the vertical dimension.

CLINICAL RELEVANCE

Understanding the effects of clefts on craniofacial morphology is essential to providing patients with treatment tailored to their specific needs. This study contributes to the literature particularly due to our risk model approach in lieu of a prediction model.

Tendon-associated gene expression precedes osteogenesis in mid-palatal suture establishment

Orthodontic maxillary expansion relies on intrinsic mid-palatal suture mechanobiology to induce guided osteogenesis, yet establishment of the mid-palatal suture within the continuous secondary palate and causes of maxillary insufficiency remain poorly understood. In contrast, advances in cranial suture research hold promise to improve surgical repair of prematurely fused cranial sutures in craniosynostosis to potentially restore the obliterated signaling environment and ensure continual success of the intervention. We hypothesized that mid-palatal suture establishment is governed by shared principles with calvarial sutures and involves functional linkage between expanding primary ossification centres with the midline mesenchyme. We characterized establishment of the mid-palatal suture from late embryonic to early postnatal timepoints. Suture establishment was visualized using histological techniques and multimodal transcriptomics. We identified that mid-palatal suture formation depends on a spatiotemporally controlled signalling milieu in which tendon-associated genes play a significant role. We mapped relationships between extracellular matrix-encoding gene expression, tenocyte markers, and novel suture patency candidate genes. We identified similar expression patterns in FaceBase-deposited scRNA-seq datasets from cranial sutures. These findings demonstrate shared biological principles for suture establishment, providing further avenues for future development and understanding of maxillofacial interventions.

Evaluation of Orbitomalar Region Projection in Patients With Operated Cleft Lip and Palate (Cephalometric Study)

OBJECTIVE

The aim of this study was to compare the orbitomalar region projection in patients with cleft lip and palate (CLP) with skeletal class 1 cases.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Cephalometric data of 52 cases with unilateral CLP, 25 cases with bilateral CLP, and 60 healthy participants in skeletal class 1 without CLP were included.

MAIN OUTCOME MEASURE(S)

A total of 5 parameters, 3 in the orbital and 2 in the suborbital region, that determine the projection of the orbitomalar region on lateral cephalograms, and 13 parameters of the craniofacial region were evaluated.

RESULTS

Lateral, inferior, and anterior orbital parameters were similar between groups, while suborbital parameters were in a retrusive position in the CLP groups compared to the control group (P < .05). No significant difference was found between the CLP groups in terms of suborbital parameters. A moderate positive correlation was found between orbitomalar parameters and the anteroposterior positions of the maxilla and mandible. The lateral orbital region had a moderate negative correlation with anterior maxillary height, and the suborbital region had a negative moderate correlation with maxillary inclination.

CONCLUSION

Suborbital projection was more retrusive in CLP compared to the control group, but no difference was found between the CLP groups. On the other hand, the correlation between orbitomalar projection and maxillary and mandibular development was significant. The results show that there is a need for alternative treatment modalities for the suborbital region in patients with CLP.

Three-dimensional finite element analysis on stress distribution after different palatoplasty and levator veli palatini muscle reconstruction

OBJECTIVES

To establish a three-dimensional finite element model of the upper palate, pharyngeal cavity, and levator veli palatini muscle in patients with unilateral complete cleft palate, simulate two surgical procedures that the two-flap method and Furlow reverse double Z method, observe the stress distribution of the upper palate soft tissue and changes in pharyngeal cavity area after different surgical methods, and verify the accuracy of the model by reconstructing and measuring the levator veli palatini muscle.

MATERIALS AND METHODS

Mimics, Geomagic, Ansys, and Hypermesh were applied to establish three-dimensional finite element models of the pharyngeal cavity, upper palate, and levator veli palatini muscle in patients with unilateral complete cleft palate. The parameters including length, angle, and cross-sectional area of the levator veli palatini muscle etc. were measured in Mimics, and two surgical procedures that two-flap method and Furlow reverse double Z method were simulated in Ansys, and the area of pharyngeal cavity was measured by hypermesh.

RESULTS

A three-dimensional finite element model of the upper palate, pharyngeal cavity, and bilateral levator veli palatini muscle was established in patients with unilateral complete cleft palate ; The concept of horizontal projection characteristics of the palatal dome was applied to the finite element simulation of cleft palate surgery, vividly simulating the displacement and elastic stretching of the two flap method and Furlow reverse double Z method during the surgical process; The areas with the highest stress in the two-flap method and Furlow reverse double Z method both occur in the hard soft palate junction area; In resting state, as measured, the two flap method can narrow the pharyngeal cavity area by 50.9%, while the Furlow reverse double Z method can narrow the pharyngeal cavity area by 65.4%; The measurement results of the levator veli palatini muscle showed no significant difference compared to previous studies, confirming the accuracy of the model.

CONCLUSIONS

The finite element method was used to establish a model to simulate the surgical procedure, which is effective and reliable. The area with the highest postoperative stress for both methods is the hard soft palate junction area, and the stress of the Furlow reverse double Z method is lower than that of the two-flap method. The anatomical conditions of pharyngeal cavity of Furlow reverse double Z method are better than that of two-flap method in the resting state.

CLINICAL RELEVANCE

This article uses three-dimensional finite element method to simulate the commonly used two-flap method and Furlow reverse double Z method in clinical cleft palate surgery, and analyzes the stress distribution characteristics and changes in pharyngeal cavity area of the two surgical methods, in order to provide a theoretical basis for the surgeon to choose the surgical method and reduce the occurrence of complications.

Sagittal Growth Restriction of the Midface Following Isolated Cleft Lip Repair: A Systematic Review and Meta-Analysis

Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate repair, and is poorly understood. No study has examined the aggregate data on sagittal growth restriction of the midface following repair of the lip, but not palate, in these patients.

A systematic review of 3780 articles was performed. Twenty-four studies met inclusion criteria and 11 reported cephalometric measurements amenable to meta-analysis. Patients with Veau class I-III palatal clefts were included so long as they had undergone only lip repair. Groups were compared against both noncleft and unrepaired controls.

Cephalometrics were reported for 326 patients (31.3% female). Noncleft controls had an average SNA angle of 81.25° ± 3.12°. The only patients demonstrating hypoplastic SNA angles were those with unilateral CLP with isolated lip repair (77.4° ± 4.22°). Patients with repaired CL had SNA angles similar to noncleft controls (81.4° ± 4.02°). Patients with unrepaired CLP and CL tended toward more protruding maxillae, with SNA angles of 83.3° ± 4.04° and 87.9° ± 3.11°, respectively. Notably, when comparing SNA angles between groups, patients with CLP with isolated lip repair had significantly more hypoplastic angles compared to those with repaired CL (P < .0001). Patients with CLP with isolated lip repair were also more hypoplastic than noncleft controls (P < .0001). In contrast, there was no significant difference between the SNA of patients with repaired CL and controls (P = .648).

We found that cleft lip repair only appeared to contribute to MFH in the setting of concurrent cleft palate pathology, suggesting that scarring from lip repair itself is unlikely to be the predominant driver of MFH development. However, studies generally suffered from inadequate reporting of timing, technique, follow-up time, and cleft severity.

Craniofacial Cephalometric Morphology in Caucasian Adult Patients with Cleft Palate Only (CPO)

Orofacial clefts are common birth defects that affect the morphology of the skull. Cleft palate only (CPO) has a different etiology than other types of clefts, and craniofacial morphology in CPO differs from that of UCLP and BCLP. The long-term effect of the cleft and its surgery is visible after growth cessation. However, few studies exist describing cephalometric craniofacial morphology in adults with CPO. The aim of the present study was to describe the cephalometric craniofacial morphology of adult patients with CPO compared to healthy patients. The study included analysis of cephalometric lateral headfilms of 28 adults with CPO and 28 healthy subjects. It was found that the angles of SNA, ANB, 1-:NB angle (°) and Wits appraisal were significantly smaller in CPO, whereas NL-NSL (°), 1+:NA angle (°) and 1+:NA (mm) had significantly higher values in CPO compared to the control group. It has been concluded that CPO in adult patients is characterized by a sagittal jaw discrepancy due to maxillary deficiency, with a tendency for compensatory inclination of the upper and lower incisors.

Transverse differences between cleft lip and palate and non-cleft palate with skeletal Class III malocclusion using buccolingual inclination: a cone-beam computed tomography retrospective study

BACKGROUND

The purpose of this study was to evaluate the differences between buccolingual inclination (BI) of maxillary posterior teeth in patients with cleft lip and palate (CLP) and non-cleft palate with skeletal Class III malocclusion. We propose a method of maxillary expansion which is more suitable for patients with CLP.

METHODS

For this retrospective study, 40 patients with CLP and 21 patients with skeletal Class III malocclusion were selected. The CLP group was divided into the unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) groups. The BI of the maxillary first premolar (BI4), maxillary second premolar (BI5) and first molar (BI6) were measured using cone-beam computed tomography, and the differences between them were compared and analyzed by Student's t-test.

RESULTS

There were significant differences between cleft side BI4 and non-cleft side BI4 in the UCLP group, BI5 in the BCLP group, BI4 and BI5 in all CLP groups and the skeletal Class III malocclusion group. BI6 was similar across all three groups.

CONCLUSIONS

The premolars of patients with CLP do not exhibit the same regularity as those with Class III malocclusion; this may be related to surgical scarring of the cleft palate. Greater attention should be paid to the correction of BI in the maxillary expansion of patients with CLP.

Craniofacial and three-dimensional palatal analysis in cleft lip and palate patients treated in Spain

Growth alterations have been described in patients operated on for oral clefts. The purpose of this work was to analyze the craniofacial and palate morphology and dimensions of young adults operated on for oral clefts in early childhood in Spain. Eighty-three patients from eight different hospitals were divided into four groups based on their type of cleft: cleft lip (CL, n = 6), unilateral cleft lip and palate (UCLP, n = 37), bilateral cleft lip and palate (BCLP, n = 16), and cleft palate only (CPO, n = 24). A control group was formed of 71 individuals. Three-dimensional (3D) digital models were obtained from all groups with an intraoral scanner, together with cephalometries and frontal, lateral, and submental facial photographs. Measurements were obtained and analyzed statistically. Our results showed craniofacial alterations in the BCLP, UCLP, and CPO groups with an influence on the palate, maxilla, and mandible and a direct impact on facial appearance. This effect was more severe in the BCLP group. Measurements in the CL group were similar to those in the control group. Cleft characteristics and cleft type seem to be the main determining factors of long-term craniofacial growth alterations in these patients. Prospective research is needed to clearly delineate the effects of different treatments on the craniofacial appearance of adult cleft patients.

Clinical Applications of Artificial Intelligence and Machine Learning in Children with Cleft Lip and Palate-A Systematic Review

OBJECTIVE

The objective of this systematic review was (a) to explore the current clinical applications of AI/ML (Artificial intelligence and Machine learning) techniques in diagnosis and treatment prediction in children with CLP (Cleft lip and palate), (b) to create a qualitative summary of results of the studies retrieved.

MATERIALS AND METHODS

An electronic search was carried out using databases such as PubMed, Scopus, and the Web of Science Core Collection. Two reviewers searched the databases separately and concurrently. The initial search was conducted on 6 July 2021. The publishing period was unrestricted; however, the search was limited to articles involving human participants and published in English. Combinations of Medical Subject Headings (MeSH) phrases and free text terms were used as search keywords in each database. The following data was taken from the methods and results sections of the selected papers: The amount of AI training datasets utilized to train the intelligent system, as well as their conditional properties; Unilateral CLP, Bilateral CLP, Unilateral Cleft lip and alveolus, Unilateral cleft lip, Hypernasality, Dental characteristics, and sagittal jaw relationship in children with CLP are among the problems studied.

RESULTS

Based on the predefined search strings with accompanying database keywords, a total of 44 articles were found in Scopus, PubMed, and Web of Science search results. After reading the full articles, 12 papers were included for systematic analysis.

CONCLUSIONS

Artificial intelligence provides an advanced technology that can be employed in AI-enabled computerized programming software for accurate landmark detection, rapid digital cephalometric analysis, clinical decision-making, and treatment prediction. In children with corrected unilateral cleft lip and palate, ML can help detect cephalometric predictors of future need for orthognathic surgery.

Condylar Changes after Maxillary Expansion in Children with Cleft Lip and Palate—A Three-Dimensional Retrospective Study

Background: The presence of posterior crossbite can trigger aesthetic and functional changes as mandibular asymmetry in individuals, contributing to asymmetrical muscle function. Mandibular asymmetry and respective condyle adaptation may be an etiological factor in temporomandibular disorder. This study aims to evaluate the effects of maxillary expansion on the position and angulation of the condyles as well as the intercondylar distance in children with cleft lip and palate. Methods: Twenty-five individuals with cleft lip and palate who underwent maxillary expansion were selected. Condylar changes were evaluated by cone beam computed tomography using the Pullinger and Hollender formula. To determine the statistically significant differences between the variables, the Student t-test and the Benjamini–Hochberg correction method for multiple comparisons were used. Results: No statistically significant differences between angulation and condylar position before and after maxillary expansion were found. The intercondylar distance tended to increase in growing individuals with cleft lip and palate after maxillary expansion. Conclusions: Intercondylar distance shows a tendency to increase after expansion regardless of the cleft phenotype. No differences were found in angulation and condylar position with the changes in occlusion resulting from maxillary expansion.

Airway challenges in an adult with hemifacial microsomia along with neglected cleft palate: what to expect?

A female patient in her early 20s, with a known diagnosis of hemifacial microsomia (unilateral microtia and mandibular hypoplasia) accompanied with an unoperated cleft palate, came for an infected mandibular distraction plate removal. The anticipated difficult airway and lack of enough literature about what to expect in such a scenario, along with the psychological impact on the patient, made this case challenging and thought-provoking. Inability to perform the awake tracheal intubation because of the uncooperative patient, along with the difficult fibreoptic owing to narrowed nostrils, offered an extra set of challenges.

Craniofacial Growth Analysis of Individuals With and Without Cleft Lip and Palate in Colombia

INTRODUCTION

Craniofacial growth is a dynamic and unpredictable process influenced by genetic and environmental factors, presenting phenotypic and gender differences.

OBJECTIVE

Evaluate the differences in craniofacial growth and development in a group of Colombian individuals with complete unilateral and bilateral cleft lip and palate (CLP) and without CLP, classified by gender and age.

SETTING AND SAMPLE POPULATION

Five hundred forty-one profile radiographs of 126 patients with unilateral CLP, 126 with bilateral CLP, and 289 without CLP. All patients of affected groups had a history of CLP correction surgery without nasoalveolar molding with orthopedic and orthodontic treatments.

MATERIALS AND METHODS

This cross-sectional study was performed comparing 8 cephalometric measurements on radiographs, 5 linear/3 angular. Analysis was performed by median and interquartile range for all cephalometric measurements. Comparison between the groups was performed using Kruskal-Wallis and Mann-Whitney U, with a 95% confidence.

RESULTS

Significant differences between the groups of patients with and without CLP, between types of clefts and genders. The skeletal structures of patients with CLP were smaller than those of control but improved with growth. Patients with unilateral CLP presented flat profiles and predominant class III malocclusions, while patients with bilateral CLP, at early ages, were class II and in the prepubertal stage, the values were progressively negative until the end of the growth period, suggesting class III. Patients with CLP presented posteroinferior rotation of the mandible, vertical measurements increased, and deflection of the cranial base.

CONCLUSION

Given their growth alterations, patients with CLP benefit from orthopedic and orthodontic treatment.

Maxillofacial morphology in post-pubertal patients with unilateral cleft lip and palate following early vs. late secondary alveolar bone grafting

The study aimed at comparing maxillofacial morphology and burden of surgical treatment in post-pubertal patients with unilateral cleft lip and palate (UCLP) following early vs. late secondary alveolar bone grafting (SABG). In this retrospective study maxillofacial morphology was assessed on lateral cephalograms of skeletally matured patients with UCLP operated on consecutively in one center by the same method of one-stage primary cleft repair followed by SABG. Cephalometric analysis comprised 8 angular and 7 linear measurements. Maxillary growth restriction was evaluated by measuring SNA angle and Co-A and PNS-A distances. Five linear regression models with SNA, SNB, ANB, Co-A, and MP/SN as dependent variables and age at primary cleft repair, age at SABG, age at taking cephalogram, surgeon, and total number of surgical interventions as independent variables were also created. 135 patients were included in the study - 70 patients (47 males and 23 females) had early SABG (E-SABG group) and 65 patients (40 males and 25 females) had late SABG (L-SABG group). Mean age at bone grafting procedure was 2.7 years (range 1.5-5.9, SD 1.1) and 10.3 years (range 6.1-18.8, SD 3.2) in E-SABG and LSABG group respectively. The variables describing the degree of maxillary growth restriction - SNA, Co-A, and PNS-A - were comparable in both groups (p = 0.707, 0.116, and 0.932, respectively). Regression models demonstrated that independent variables were not associated with the values of SNA angle, SNB angle, ANB angle, MP/SN angle, and Co-A distance (p = 0.761, 0.088, 0.249, 0.380, and 0.363, respectively). The percentages of oronasal fistula repair, VPI repair, repeated SABG, upper lip correction, rhinoplasty, orthognathic surgery were 22.9, 7.1, 15.7, 24.3, 42.9, 2.9 in E-SABG group and 27.7, 7.7, 9.2, 36.9, 47.7, 3.1 in L-SABG group respectively. Mean number of all surgical interventions was 3.2 in E-SABG and 3.4 in L-SABG group, respectively (p = 0.271). Considering the comparable maxillofacial morphology and burden of surgical care in matured patients after early and late SABG, the choice of timing of bone grafting surgery could be left to the discretion of the surgeon.

Sagittal Jaw Relationship of Different Types of Cleft and Non-cleft Individuals

To investigate whether the craniofacial sagittal jaw relationship in patients with non-syndromic cleft differed from non-cleft (NC) individuals by artificial intelligence (A.I.)-driven lateral cephalometric (Late. Ceph.) analysis. The study group comprised 123 subjects with different types of clefts including 29 = BCLP (bilateral cleft lip and palate), 41 = UCLP (unilateral cleft lip and palate), 9 = UCLA (unilateral cleft lip and alveolus), 13 = UCL (unilateral cleft lip) and NC = 31. The mean age was 14.77 years. SNA, SNB, ANB angle and Wits appraisal was measured in lateral cephalogram using a new innovative A.I driven Webceph software. Two-way ANOVA and multiple-comparison statistics tests were applied to see the differences between gender and among different types of clefts vs. NC individuals. A significant decrease (p < 0.005) in SNA, ANB, Wits appraisal was observed in different types of clefts vs. NC individuals. SNB (p > 0.005) showed insignificant variables in relation to type of clefts. No significant difference was also found in terms of gender in relation to any type of clefts and NC group. The present study advocates a decrease in sagittal development (SNA, ANB and Wits appraisal) in different types of cleft compared to NC individuals.

Scandcleft trial of primary surgery for unilateral cleft lip and palate: Craniofacial cephalometrics at 8 years

BACKGROUND

The Scandcleft trial is a randomized controlled trial that includes children with unilateral cleft lip and palate where registrations are standardized and therefore provides the opportunity to describe craniofacial characteristics in a very large sample of patients.

OBJECTIVES

The aim of this study was to describe craniofacial growth and morphology in a large study sample of 8-year-old children with unilateral cleft lip and palate (UCLP); before orthodontic treatment and before secondary alveolar bone grafting; and to compare the cephalometric values with age-matched non-cleft children from previous growth studies to identify the differences between untreated cleft- and non-cleft children.

MATERIALS

There are 429 eight-year-old UCLP patients in the Scandcleft study group. A total of 408 lateral cephalograms with a mean age of 8.1 years were analysed. Cephalometric analyses were performed digitally. The results from three previously published growth studies on non-cleft children were used for comparison.

RESULTS

Cephalometric analyses showed a large variation in craniofacial morphology among the UCLP group. In general, they present with significant maxillary retrusion and reduced intermaxillary relationships compared to the age-matched non-cleft children. In addition, the vertical jaw relationship was decreased, mainly due to decreased maxillary inclination. The upper and lower incisors were retroclined. It can be expected that these differences will increase in significance as the children age.

CONCLUSION

Results from this study provide proposed norms for the young UCLP before any orthodontic treatment and can be valuable for the clinician in future treatment planning.

TRIAL REGISTRATION

ISRCTN29932826.

[Finite element analysis of the comprehensive impact of scar and maxillary expansion combined with protraction on the development of maxilla with cleft lip and palate after repair operation]

OBJECTIVE

To study the comprehensive impact of scar and maxillary expansion combined with protraction on the development of maxilla with cleft lip and palate after repair operation.

METHODS

In the original finite element model of the maxilla with cleft palate, a finite element model of the maxilla with cleft lip and palate was established by using Boolean operation in ANSYS. Scar force after cleft lip and palate repair and maxillary expansion force combined with protraction were added simultaneously to process the stress analysis.

RESULTS

Maxillary deformation occurred in the three-dimensional direction. The comparison of displacements was as follows: X-axis>Z-axis>Y-axis.

CONCLUSIONS

Maxillary growth is significantly inhibited in the three-dimensional direction under the comprehensive impact of scar and maxillary expansion combined with protraction after repair operation, especially transverse and sagittal growth.

Craniofacial Analysis May Indicate Co-Occurrence of Skeletal Malocclusions and Associated Risks in Development of Cleft Lip and Palate

Non-syndromic orofacial clefts encompass a range of morphological changes affecting the oral cavity and the craniofacial skeleton, of which the genetic and epigenetic etiologic factors remain largely unknown. The objective of this study is to explore the contribution of underlying dentofacial deformities (also known as skeletal malocclusions) in the craniofacial morphology of non-syndromic cleft lip and palate patients (nsCLP). For that purpose, geometric morphometric analysis was performed using full skull cone beam computed tomography (CBCT) images of patients with nsCLP (n = 30), normocephalic controls (n = 60), as well as to sex- and ethnicity- matched patients with an equivalent dentofacial deformity (n = 30). Our outcome measures were shape differences among the groups quantified via principal component analysis and associated principal component loadings, as well as mean shape differences quantified via a Procrustes distance among groups. According to our results, despite the shape differences among all three groups, the nsCLP group shares many morphological similarities in the maxilla and mandible with the dentofacial deformity group. Therefore, the dentoskeletal phenotype in nsCLP could be the result of the cleft and the coexisting dentofacial deformity and not simply the impact of the cleft.

The Soft Tissue Angular Analysis of Facial Profile in Unoperated Adult Patients with Unilateral Cleft Palate

OBJECTIVE

The purpose of this study was to investigate the differences in facial profile development between unoperated adult cleft palate (UACP) patients and normal controls and to analyse the reasons for the differences.

MATERIALS AND METHODS

A total of 50 individuals with a unilateral cleft palate and 20 normal controls were selected to undergo angular measurement of their facial profiles. Data with significant differences between the two groups were analysed.

RESULTS

Seven angle measurements of the facial profile showed that the mid-facial protrusion of the UACP patients had no significant differences from the control group (p > 0.05). But their angle of the medium face (N'-Trg-Sn) was significantly lower than the non-cleft controls (p < 0.05), suggesting a worse vertical development of the middle face. A significantly larger nasal tip angle (Cm-Sn/N'-Prn) for UACP patients suggested they had a rounder and blunter nasal tip (p < 0.05). The soft tissue facial angle and chin-lip angle of UACP patients had significant differences from non-cleft controls (p < 0.05), but the head position angle (Sn-Sm-THP) had no significant difference between two groups (p > 0.05), which suggested a steep mandibular plane for UACP patients but without severe retraction of the chin.

CONCLUSION

The development of facial protrusions in UACP patients is similar to that in normal adults, but the vertical development in the middle face is insufficient. Such hypoplasia may be related to the intrinsic deficiency of the maxilla. There is a tendency for flat nasal growth and insufficient development of the chin in UACP patients.

LEVEL OF EVIDENCE IV

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

Objective:

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

Design:

Retrospective study.

Setting:

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

Patients, Participants:

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

Interventions:

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

Main Outcome Measure(s):

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

Results:

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

Conclusions:

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

Growth and Development of Craniofacial Structures in Patients at Different Ages With Unrepaired Submucous Cleft Palate

PURPOSE

Submucous cleft palate (SMCP) is a particular subtype of cleft palate deformity; research related to the craniofacial features of patients with SMCP is comparatively rare. The study objective was to perform a cephalometric comparison of the craniofacial features of patients with SMCP and non-cleft controls at different ages.

MATERIALS AND METHODS

The sample in this cross-sectional study was composed of 2 groups: SMCP patients and non-cleft controls. The primary predictor variables were study group (cleft and non-cleft) and age. Age was divided into 3 groups. The outcome variables of interest were craniofacial measurements. The measurements used reflect cranial length, cranial angle, maxillary sagittal length and protrusion, maxillary vertical height, pharyngeal depth, facial height, mandibular length and protrusion, mandibular plane angle, and intermaxillary relation. Adjusted cephalometric craniofacial measurements between the groups were compared in 3 age groups using generalized linear models after being adjusted for age and gender.

RESULTS

The study included 60 SMCP patients and 60 non-cleft controls. SMCP patients and non-cleft controls were divided into 3 subgroups: those aged 5 to 7 years, those aged 9 to 11 years, and those aged 18 to 30 years. Patients with SMCP at age 5 to 7 years showed a shortened cranial base length, maxillary sagittal length and height, and bony pharynx depth. Patients with SMCP at age 9 to 11 years showed a smaller maxillary sagittal length and bony pharynx depth and an inharmonious jaw relationship. Patients with SMCP at age 18 to 30 years showed a smaller maxillary sagittal length and height and an inharmonious jaw relationship.

CONCLUSIONS

SMCP is associated with progressive maxillary retrognathism and reduced profile convexity from childhood to adulthood.

Predicting need for orthognathic surgery in early permanent dentition patients with unilateral cleft lip and palate using receiver operating characteristic analysis

INTRODUCTION

The purpose of this study was to predict the need for orthognathic surgery in patients with unilateral cleft lip and palate (UCLP) in the early permanent dentition.

METHODS

In this retrospective cohort study, we included 61 patients with complete UCLP (36 male, 25 female; mean age, 18.47 years; range, 16.92-26.17 years). The subjects were grouped into an orthognathic surgery group and a nonsurgery group at the time of growth completion. Lateral cephalograms obtained at the age of 11 years were analyzed to compare the 2 groups. The receiver operating characteristic analysis was applied to predict the probability of the need for orthognathic surgery in early adulthood by using the measurements obtained at the age of 11 years.

RESULTS

SNB, ANB, SN, overbite, overjet, maxillary length, mandibular body length, and L1-MP were found to be significantly different between the 2 groups. For a person with a score of 2 in the 3-variable-based criteria, the sensitivity and specificity for determining the need for surgical treatment were 90.0% and 83.9%, respectively (ANB, ≤-0.45°; overjet, ≤-2.00 mm; maxillary length, ≤47.25 mm).

CONCLUSIONS

Three cephalometric variables, the minimum number of discriminators required to obtain the optimum discriminant effectiveness, predicted the future need for orthognathic surgery with an accuracy of 86.9% in patients with UCLP.

Electromyographic analysis of superior orbicularis oris muscle function in children surgically treated for unilateral complete cleft lip and palate

PURPOSE

The aim of this study was to assess the electrical activity of the superior orbicularis oris muscle in children surgically treated for unilateral complete cleft lip and palate (UCCLP).

MATERIAL AND METHODS

The sample comprised 45 patients 6.38-12.68 years of age with UCCLP and 40 subjects 6.61-11.71 years of age with no clefts. Electromyographical (EMG) recordings were taken with a DAB-Bluetooth Instrument (Zebris Medical GmbH, Germany) in the rest position and during saliva swallowing, lip protrusion and reciprocal compression of the lips, as well as while producing the phonemes /p/, /b/, and /m/ combined with the vowel /a/.

RESULTS

The electrical activity of the upper lip during saliva swallowing and lip compression was significantly greater in the cleft group. Similar resting level activity was observed in both groups. During the production of the /p/, /b/, and /m/ phonemes combined with the vowel /a/ the results showed no significant differences in the EMG activity between children with UCCLP and noncleft subjects.

CONCLUSION

Patients with UCCLP have abnormal upper lip function characterized by increased activity of the superior orbicularis oris muscle during saliva swallowing and lip compression, and this may affect facial morphology.

Cephalometric comparison of early and late secondary bone grafting in the treatment of patients suffering from unilateral cleft lip and palate

The study was based on a retrospective cephalometric assessment of 10-year-olds in order to evaluate the influence of early secondary bone grafting on craniofacial development in patients suffering from non-syndromic complete unilateral cleft lip and palate. The study consisted of 79 patients in the early and 67 patients in the late secondary bone grafting group. The mean age at alveolar bone grafting was 2.5 years (SD 0.03) in the first group and 9.8 years (SD 2.3) in the second group. The primary cleft repair of these 146 patients was always performed in accordance with the one-stage method. Additionally, the non-cleft Control group was comprised of 56 children of the same ethnicity and age. The cephalometric analysis performed at age 10 revealed similar overall characteristics of observed growth disturbances in both cleft groups in comparison to the Control group, such as: inhibition of vertical and anterior maxillary development, the tendency of the mandible to rotate clockwise, and a prevalence of vertical over horizontal facial growth. The comparison between the cleft groups revealed a lack of growth differences in the vertical dimension and more pronounced anterior maxillary development inhibition in the early bone grafting group. This study will be followed by a similar evaluation after craniofacial development is complete by a significant number of these patients in order to ascertain our conclusions.

MEMO1 drives cranial endochondral ossification and palatogenesis

The cranial base is a component of the neurocranium and has a central role in the structural integration of the face, brain and vertebral column. Consequently, alteration in the shape of the human cranial base has been intimately linked with primate evolution and defective development is associated with numerous human facial abnormalities. Here we describe a novel recessive mutant mouse strain that presented with a domed head and fully penetrant cleft secondary palate coupled with defects in the formation of the underlying cranial base. Mapping and non-complementation studies revealed a specific mutation in Memo1 - a gene originally associated with cell migration. Expression analysis of Memo1 identified robust expression in the perichondrium and periosteum of the developing cranial base, but only modest expression in the palatal shelves. Fittingly, although the palatal shelves failed to elevate in Memo1 mutants, expression changes were modest within the shelves themselves. In contrast, the cranial base, which forms via endochondral ossification had major reductions in the expression of genes responsible for bone formation, notably matrix metalloproteinases and markers of the osteoblast lineage, mirrored by an increase in markers of cartilage and extracellular matrix development. Concomitant with these changes, mutant cranial bases showed an increased zone of hypertrophic chondrocytes accompanied by a reduction in both vascular invasion and mineralization. Finally, neural crest cell-specific deletion of Memo1 caused a failure of anterior cranial base ossification indicating a cell autonomous role for MEMO1 in the development of these neural crest cell derived structures. However, palate formation was largely normal in these conditional mutants, suggesting a non-autonomous role for MEMO1 in palatal closure. Overall, these findings assign a new function to MEMO1 in driving endochondral ossification in the cranium, and also link abnormal development of the cranial base with more widespread effects on craniofacial shape relevant to human craniofacial dysmorphology.

Evaluation of the mandibular volume and correlating variables in patients affected by unilateral and bilateral cleft lip and palate: a cone-beam computed tomography study

OBJECTIVES

The aims of the present study were to evaluate the mandibular volume in patients affected by unilateral (UCLP) and bilateral cleft lip and palate (BCLP) and to compare the findings with a well-matched normal occlusion sample without cleft.

MATERIALS AND METHODS

The study sample consisted of 66 patients divided into UCLP (24 patients; mean age, 14.46 ± 3.24 years), BCLP (17 patients; mean age, 14.28 ± 2.85 years), and control (25 patients; mean age, 14.40 ± 2.81 years) groups. The volume of the mandible including the condyle and the roots of the teeth and craniofacial measurements were performed using cone-beam computed tomography and analyzed using the one-way variance analysis and post hoc Tukey's tests. Regression analyses were used to evaluate the relationships of the measurements and the mandibular volume.

RESULTS

Patients affected by UCLP and BCLP had similar craniofacial features (p > 0.05), including decreased SNB, Co-A, Co-Gn, Co-Go, and Go-Gn and increased ANB and SN-MP measurements compared to the control group. Both UCLP and BCLP groups had decreased values of mandibular volume compared to the normal occlusion group, while these differences were found to be statistically insignificant (p > 0.05). Co-Go (Beta = 0.420; p = 0.014) and Co-Gn variables (Beta = 0.708; p = 0.045) were positively correlated with mandibular volume, while SNB (Beta = -0.669; p = 0.044) and SN-MP (Beta = -0.358; p = 0.049) variables were negatively correlated (R (2) = 60.3 and p = 0.000).

CONCLUSION

Mandibular volume insignificantly differs in cleft patients (p > 0.05), and the variables of Co-Go, Co-Gn, SNB, and SN-MP significantly correlate with the volume.

CLINICAL RELEVANCE

This article investigates mandibular volume in patients affected by UCLP and BCLP that has never been investigated in the literature. The present study showed that both UCLP and BCLP groups had insignificantly decreased values of mandibular volume compared to the normal occlusion group.