Isolated Influences of Surgery Repair on Maxillofacial Growth in Complete Unilateral Cleft Lip and Palate

Facial Analysis of Patients with Unilateral or Bilateral Cleft Lip and Palate Using 3D Stereophotogrammetry

ObjectivesTo evaluate the quantitative values of linear and angular facial anthropometrics in patients with unilateral cleft lip and palate (UCLP) and compare them with those of patients with bilateral cleft lip and palate (BCLP) using three-dimensional (3D) facial imaging.DesignRetrospective, observational, and cross-sectional study.SettingHospital for Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP).Patients/ ParticipantsIn total, 61 non-syndromic patients with CLP who underwent multidisciplinary treatment and rehabilitated with a prosthesis were enrolled and divided into those with UCLP (G1; n = 31) and those with BCLP (G2; n = 30).InterventionFacial images were captured using a 3D camera after landmarks were marked on each patient's face. The software evaluated linear and angular parameters. Statistical tests were applied. Significance was determined as P < 0.05.Main Outcome MeasurementsOverall, 22 linear and 13 angular measurements were evaluated.ResultsThe nasal length (P = 0.08), middle third of the face (P = 0.06), base nose width (P < 0.001), nasal root width (P < 0.001), nasal tip angle (P = 0.018), philtrum width (P < 0.001), lower face width (P = 0.039) and midfacial depth (P = 0.040) were significantly higher in G2; the upper cutaneous lip height was significantly higher in G1. Sexual dimorphism was observed except for linear measurements (linear distance between the labiale superius and labiale inferius landmarks, nasal root width, and upper cutaneous lip length) and angular measurements.ConclusionsG2 had a greater length and width of nose and nasal root, nasal tip angle, philtrum width, and lower face width, midfacial depth, and midface third than G1. These findings also revealed the presence of sexual dimorphism.

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.

Three-Dimensional Cone Beam Computed Tomography (CBCT)-Derived Soft Tissue Changes in Patients with Unilateral Cleft Lip, Alveolus, and Palate with Midfacial Deficiency after 1.5 Years of Bone-Anchored Maxillary Protraction

Background: Bone-anchored maxillary protraction (BAMP) aims to correct midfacial deficiencies, with proven positive skeletal changes without potential unwanted side effects. However, the influence of BAMP treatment on facial soft tissues, particularly in subjects with complete unilateral cleft lip, alveolus, and palate (CUCLAP), remains unclear. Methods: This single-center longitudinal cohort study examined the effects of 1.5 years of BAMP treatment on facial soft tissues in growing subjects with complete unilateral cleft lip, alveolus, and palate. The sample consisted of 25 patients, age range 9.7 to 12.6 years. Three-dimensional surface models derived from CBCT scans were superimposed on stable structures of the anterior cranial base and on the occipital area posterior of the foramen magnum to assess three-dimensional changes due to growth and BAMP therapy. Results: The results revealed a moderate positive correlation (Pearson's correlation coefficient from 0.203 to 0.560) between changes in hard tissue and soft tissue; some correlations were found to be weak (<0.300). Linear changes in soft tissue following BAMP were in the same direction as skeletal changes, showing downward, forward, and outward displacement. The only exception was in the vertical dimension. The lower facial third showed a slight but significant reduction, mainly in lip length (-1.2 mm), whereas the middle facial third showed a small increase (1.1 mm). Conclusions: It was concluded that during BAMP, soft tissue changes occur in the same direction as skeletal changes, although with a larger variability and less pronounced effects.

Cranial Base Angle in Patients With Cleft Lip and Palate-A Systematic Review and Meta-Analysis

Background: Diverse findings have been reported for the cranial base angle (CBA) in patients with CLP (cleft lip and palate) and non-CLP controls. Objective: The aim of this study is to assess and evaluate the CBA in patients with CLP and non-CLP controls. Methods: Data from PubMed, OVID Technologies, Inc., Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus, Web of Science, and EMBASE for Excerpta Medica dataBASE (EMBASE) with relevant terms was extracted until December 31, 2020. Inclusion criteria were data of patients with non-syndromic unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP). In the case of UCLP and BCLP, patients with craniofacial syndromes were excluded. The study proposal was registered with PROSPERO (Registration number: CRD42021228632). Results: Fifteen studies with a total of 2032 participants were included for the systematic review and 14 studies with a total of 1972 participants were included for the meta-analysis. The risk of bias was assessed using the Modified Newcastle Ottawa scale under seven domains by two authors. Thirteen studies were graded as "good" and two as "satisfactory." The CBA in patients with CLP were greater than the non CLP Class I controls in six of the 15 studies. CBA was greater in patients with CLP than non-CLP controls by 1.21° (95% CI of 0.19-2.22). Meta-analysis reported considerable heterogeneity (I² = 86%). Anterior (ACB) and posterior cranial base (PCB) lengths were shorter in patients with CLP than in the non-cleft Class I controls by 2.14 mm (95% CI of 0.99-3.30) and 2.06 mm (95% CI of 1.52-2.60), respectively. Conclusion: Most studies were graded as good. Patients with CLP had greater CBA and shorter ACB and PCB lengths when compared to non-CLP controls.

Three-Dimensional Evaluation of Deformed Noses in Patients With Unilateral Cleft Lip and Palate: A Meta-Analysis

ABSTRACT

Multiple surgeries for patients with cleft lip and palate may be required to repair secondary deformities after the completion of cleft repair. This meta-analysis aimed to evaluate the three-dimensional nasal morphology in patients with unilateral cleft palate who underwent cleft lip and palate repair but did not undergo terminal nasal repair. PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Data, and SINOMED databases were searched from inception until December 2020. Studies involving patients ages ≥6 years with cleft lip and palate who did not undergo terminal nasal repair were included. Quantitative data were obtained through three-dimensional evaluation. Mean weighted effect sizes with 95% confidence intervals, heterogeneities, and publication biases were assessed using raw data obtained from 13 studies. In general, patients with unilateral cleft lip and palate had a significantly wider nose; shorter bridge length and nasal height; larger forehead-nose angle, nasal tip angle, and alar slope angle; and smaller nasolabial angle. The number of studies that included patients with unilateral cleft lip, unilateral cleft lip and alveolus, and unclassified deformities was limited, and their results were similar to those involving patients with unilateral cleft lip and palate. Patients with unilateral cleft tend to have short, flat, and wide noses. Nasal tip elevation and alar base adduction should be prioritized during terminal nasal repair to achieve more normalized cleft-side nostrils.

Miniplate-anchored maxillary protraction in adolescent patients with cleft lip and palate: A literature review of study design, type and protocol, and treatment outcomes

OBJECTIVE

To review the study design, type, protocol, and treatment outcomes of miniplate-anchored maxillary protraction (MAMP) in adolescent patients with unilateral or bilateral cleft lip and palate.

SETTING/SAMPLE POPULATION

Five retrospective and two prospective studies (n = 138 patients) were selected as per the inclusion criteria.

MATERIALS AND METHODS

The study design, type, protocol of MAMP and the amount of skeletodental change were investigated.

RESULTS

Two studies adopted type 1 (two miniplates at the infrazygomatic crest with a facemask), four studies adopted type 2 (four miniplates at the infrazygomatic crest and mandibular symphysis and use of intermaxillary elastics), and one study compared the two types. The mean start age was older than 10 years except one study. The mean duration was less than 1 year in two studies, between 1 and 2 years in three studies, and more than 2 years in two studies. The type 1 used 500 g/side for 12-14 h/d, and the type 2 used three increase methods (100, 200, 250 g/side; 75, 150, 250 g/side; 150, 200, and 250 g/side) for 24 h/d. The ranges of A point advancement were 0.5°-4.2° in ΔSNA and 1.7-5.6 mm in ΔA-vertical reference plane, respectively. The ranges of rotation of the palatal plane, occlusal plane, and mandibular plane were -1.5° to 2.0°, -2.0° to 2.0°, -1.5° to 3.2°, respectively. The increase of overjet was ranged from 2.3 to 5.8 mm.

CONCLUSION

The MAMP therapy is effective for the correction of maxillary hypoplasia in adolescent cleft patients despite different types and protocols.

Unilateral Cleft Lip Nasal Deformity: Three-Dimensional Analysis of the Primary Deformity and Longitudinal Changes following Primary Correction of the Nasal Foundation

BACKGROUND

Objective assessment of the unilateral cleft lip nasal deformity and the longitudinal changes with treatment is critical for optimizing cleft care.

METHODS

Consecutive patients undergoing cleft lip repair and foundation-based rhinoplasty were included (n = 102). Three-dimensional images preoperatively, postoperatively, and at 5 years of age were assessed and compared to age-matched controls. Images were normalized to standard horizontal, craniocaudal, and anteroposterior axes.

RESULTS

Cleft subalare was similar in position relative to controls but was 1.6 mm retrodisplaced. Subnasale was deviated 4.6 mm lateral to midline and had the greatest displacement of any landmark. Noncleft subalare was displaced 2.3 mm laterally. Regression analysis with deviation of subnasale from the midline as a dependent variable revealed progressive lateral displacement of noncleft subalare, narrowing of noncleft nostril, and intercanthal widening. Surgery corrected nasal base displacements along all axes, resulting in landmark positions similar to controls. Symmetry of nasal base correction persisted at 5-year follow-up, with no recurrent cleft alar base retrusion, regardless of initial cleft type.

CONCLUSIONS

Unilateral cleft lip nasal deformity may be "driven" by displacement of the anterior nasal spine and caudal septum. The cleft alar base is normal in position but retruded, whereas the noncleft alar base is displaced laterally. Changes with surgery involve anterior movement of the cleft alar base but also include medial movement of the noncleft alar base and columella. Symmetry of correction, including alar base retrusion, was stable over time and did not rely on alveolar bone grafting.

Imaging study of midface growth with bone-borne trans-sutural distraction osteogenesis therapy in growing cleft lip and palate patients

Trans-sutural distraction osteogenesis (TSDO) promotes midface growth in growing cleft lip and palate (CLP) patients with midfacial hypoplasia. The superficial skeletal changes after therapy revealed rotation advancement of the midfacial skeleton associated with differential displacement in each segment, but reports rarely focus on the changes of internal structures, including circummaxillary sutures, the maxillary tuberosity and the maxillary sinus, which may play a crucial role during this process. This study evaluated the computed tomographic (CT) images of 26 growing CLP patients who received bone-borne TSDO therapy. The results revealed that the most prominent new bone formation occurred in the pterygomaxillary suture and pushed the P-point forward. The maxillary first molar exhibited significantly greater advancement compared with the P-point due to the growth of the maxillary tuberosity. The contribution ratio values of the advancement of the maxillary tuberosity and P-point to the maxillary first molar were 26% and 74%, respectively, in UCLP and 25% and 75%, respectively, in BCLP. Furthermore, the maxillary sinus volume was also significantly increased. In conclusion, midface growth with bone-borne TSDO therapy depends on both secondary displacement promoted by sutural bone formation mainly in the pterygomaxillary suture and primary displacement by growth of the maxillary tuberosity and maxillary sinus volume.

Anthropometric Analysis of the Dental Arches of Five-Year-Old Children With Cleft Lip and Palate

This study aimed to analyze the dimensional alterations of the dental arches of 5-year-old children with cleft lip and palate and to compare these dimensions with children without oral clefts. One hundred twenty children were divided into the following groups: unilateral cleft lip (UCL), unilateral cleft lip and palate (UCLP), cleft palate (CP), and control (C). A specific software was used to digitize the dental casts and perform the anthropometric analyses through the measurement of transversal linear intercanine and intermolar distances on the maxilla and mandible. The intergroup comparisons of the maxillary dimensions exhibited that the intercanine distances of groups C and UCL were statistically greater than that of groups UCLP and CP. The intermolar distance was significantly smaller in group UCLP than in the other groups. No statistically significant difference occurred in the mandibular intercanine and intermolar distance among groups. The analysis of the superposition of the maxillary over the mandibular transversal distances showed statistically significant differences among groups. This study showed that at 5-year old, the children with cleft involving the palate had more maxillary dimensional alterations than those without cleft palate.

Three-Dimensional Soft-Tissue Evaluation in Patients with Cleft Lip and Palate

BACKGROUND In cleft lip and palate (CLP) patients, the shape of the facial soft tissues shows variety in 3 dimensions (3D). Two-dimensional (2D) photographs and radiographs are insufficient in the examination of these anomalies. The aim of this retrospective study was to examine the soft tissue and craniofacial characteristics of individuals with nonsyndromic unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), skeletal Class III malocclusions, or skeletal Class I malocclusions using 3D facial imaging. MATERIAL AND METHODS The entire study group consisted of a total of 158 patients, aged 8-32 years: 29 of the patients had UCLP, 22 BCLP, 54 had skeletal Class III malocclusions, and 53 had skeletal Class I malocclusions. 3D stereophotogrammetric soft-tissue recordings of all patients were analyzed. ANOVA and the Kruskal-Wallis test were performed to compare the groups. RESULTS Statistically significant differences were observed among the groups in terms of linear, angular, proportional. and volumetric measurements. While nasal differences were not observed in the Class III group, nose and upper-lip deformities were common in the CLP groups. Upper-lip projection was reduced in all 3 groups. In the Class III patients, the lower lip and chin were more prominent than in the other groups. The facial convexity angle was increased in the CLP and Class III groups. The upper-lip volume was decreased in the BCLP, the UCLP, and the Class III groups. CONCLUSIONS Patients with skeletal Class III or CLP anomalies showed significantly different soft-tissue characteristics than the Class I control group. 3D stereophotogrammetric facial imaging is an easy and noninvasive method that can be used in examination and recording of these facial deformities. It is possible to make volumetric measurements using this method.

Bone-anchored maxillary protraction in patients with unilateral complete cleft lip and palate and Class III malocclusion

OBJECTIVE

This prospective controlled study evaluated the effect of bone-anchored maxillary protraction therapy in cleft children with Class III malocclusion using CBCT-derived 3D surface models.

MATERIALS AND SUBJECTS

Eighteen cleft patients between 10 and 12 years old were included. Intermaxillary elastics were worn after the placement of four zygoma bone plates for 18 months. Uniquely, three age-matched untreated groups including both cleft subjects and non-cleft subjects with Class III malocclusion served as controls. Profile photos and CBCT scans for each patient were taken before (T0) and 18 months after the protraction (T1). 3D measurements were made on CBCT surface models from the treatment group using tomographic color mapping method. Cephalometric measurements were made on lateral cephalogram reconstructed from the CBCT scans and were compared with those obtained from the control groups.

RESULTS

Two thirds of the treatment subjects showed improved lip projection towards more convex facial profile. The most significant skeletal changes on 3D surface models were observed at the zygomatic regions (mean 1.5-mm forward, downward, and outward displacement) and at the maxillary complex (mean 1.5-mm forward displacement). Compared with the control groups, the treatment subjects showed significant increase in the SNA and ANB angles, increased Wits appraisal, a more forward movement of point A and overjet improvement (p < 0.05).

CONCLUSIONS

BAMP in cleft patients gives a significant forward displacement of the zygomaxillairy complex in favor of the Class III treatment.

CLINICAL RELEVANCE

This treatment method shows clearly favorable outcome in cleft patients after 1.5 years of BAMP.

Three-dimensional evaluation of surgical techniques in neonates with orofacial cleft

BACKGROUND

Individuals with cleft lip and palate have many anatomic and functional alterations compromising esthetics, hearing, speech, occlusion, and development/craniofacial growth. The rehabilitative treatment of these patients is very challenging and starts at birth aiming at the best treatment for all functional demands. This study aimed to evaluate the dimensional alterations of the dental arches of neonates with cleft lip and palate after two different primary surgical techniques.

MATERIALS AND METHODS

The sample comprised 114 digital models of children aged from 3 to 36 months, with unilateral complete cleft lip and palate divided into two groups. Two different phases were evaluated: precheiloplasty and 1 year after palatoplasty. The evaluation was performed through the digital models of each child obtained by scanning digitalization (3D Scanner). Dental arches measurements were accomplished through Appliance Designer software. The following measurements were assessed: dental arch area, anterior amplitude of the cleft, total length of dental arch, intercanine distance, and intertuberosity distance. t-test was applied to compare differences between groups.

RESULTS

No statistically significant differences were observed between groups at precheiloplasty phase. At 1 year after palatoplasty, the groups differed in the total length of dental arch (P = 0.002), with greater values for Group I.

CONCLUSION

This study suggests that the results of the different surgical techniques may alter the growth and development of the dental arches of neonates with cleft lip and palate.