CT appearances of unilateral cleft palate 20 years after bone graft surgery

Long-Term Computed Tomographic Evaluation of Alveolar Bone Formation in Patients with Unilateral Cleft Lip and Palate after Early Secondary Gingivoalveoloplasty

BACKGROUND

The goal of this study was to evaluate with a three-dimensional method the long-term quality of alveolar ossification in unilateral cleft lip and palate patients who underwent early secondary gingivoalveoloplasty according to the Milan surgical protocol.

METHODS

The sample consisted of 63 computed tomographic scans of unilateral cleft lip and palate patients in permanent dentition. The average age at the time of assessment was 15.7 years. Alveolar thickness, nasoalveolar height, nasal floor ossification, and hard palate morphology were evaluated using dental, axial, and coronal cuts on computed tomographic scans and three-dimensional models. All measurements were normalized and ratios of the affected side versus the nonaffected side were provided. Volume measurements and ratios of each hemimaxilla were added. The presence or absence of the permanent lateral incisor on the cleft side was also recorded.

RESULTS

Alveolar thickness and height were ideal or good, respectively, in 89.5 and 91.4 percent of the sample. Insufficient ossification (<25 percent) was found in three patients (5.2 percent), and only one of them (1.7 percent) presented no bone bridging. A statistically significant association was detected between the degree of alveolar ossification, the type of nasal floor ossification, and volume ratio.

CONCLUSIONS

Early secondary gingivoalveoloplasty seemed to allow an adequate ossification of both the alveolar and nasal region. Three-dimensional evaluation of the alveolar cleft ossification provided further information on alveolar bridging and allowed evaluation of the bone availability for implant placement.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Multivariate Analysis of Unilateral Cleft Lip and Palate Facial Skeletal Morphology

Unilateral cleft lip and palate (UCLP) occurs when the maxillary and nasal facial prominences fail to fuse correctly during development, resulting in a palatal cleft and clefted soft and hard tissues of the dentoalveolus. The UCLP deformity may compromise an individual's ability to eat, chew, and speak. In this retrospective cross-sectional study, cone beam computed tomography (CBCT) images of 7-17-year-old individuals born with UCLP (n = 24) and age- and sex-matched controls (n = 24) were assessed. Coordinate values of three-dimensional anatomical landmarks (n = 32) were recorded from each CBCT image. Data were evaluated using principal coordinates analysis (PCOORD) and Euclidean distance matrix analysis (EDMA). Approximately 40% of morphometric variation is captured by PCOORD axes 1-3, and the negative and positive ends of each axis are associated with specific patterns of morphological differences. Approximately 36% of facial skeletal measures significantly differ by confidence interval testing (α = 0.10) between samples. Although significant form differences occur across the facial skeleton, strong patterns of morphological differences were localized to the lateral and superioinferior aspects of the nasal aperture, particularly on the clefted side of the face. The UCLP deformity strongly influences facial skeletal morphology of the midface and oronasal facial regions, and to a lesser extent the upper and lower facial skeletons. The pattern of strong morphological differences in the oronasal region combined with differences across the facial complex suggests that craniofacial bones are integrated and covary, despite influences from the congenital cleft.

Nasal airway and septal variation in unilateral and bilateral cleft lip and palate

Cleft lip and palate (CLP) affects the dentoalveolar and nasolabial facial regions. Internal and external nasal dysmorphology may persist in individuals born with CLP despite surgical interventions. 7-18 year old individuals born with unilateral and bilateral CLP (n = 50) were retrospectively assessed using cone beam computed tomography. Anterior, middle, and posterior nasal airway volumes were measured on each facial side. Septal deviation was measured at the anterior and posterior nasal spine, and the midpoint between these two locations. Data were evaluated using principal components analysis (PCA), multivariate analysis of variance (MANOVA), and post-hoc ANOVA tests. PCA results show partial separation in high dimensional space along PC1 (48.5% variance) based on age groups and partial separation along PC2 (29.8% variance) based on CLP type and septal deviation patterns. MANOVA results indicate that age (P = 0.007) and CLP type (P ≤ 0.001) significantly affect nasal airway volume and septal deviation. ANOVA results indicate that anterior nasal volume is significantly affected by age (P ≤ 0.001), whereas septal deviation patterns are significantly affected by CLP type (P ≤ 0.001). Age and CLP type affect nasal airway volume and septal deviation patterns. Nasal airway volumes tend to be reduced on the clefted sides of the face relative to non-clefted sides of the face. Nasal airway volumes tend to strongly increase with age, whereas septal deviation values tend to increase only slightly with age. These results suggest that functional nasal breathing may be impaired in individuals born with the unilateral and bilateral CLP deformity.

Three-dimensional imaging methods for quantitative analysis of facial soft tissues and skeletal morphology in patients with orofacial clefts: a systematic review

Background

Current guidelines for evaluating cleft palate treatments are mostly based on two-dimensional (2D) evaluation, but three-dimensional (3D) imaging methods to assess treatment outcome are steadily rising.

Objective

To identify 3D imaging methods for quantitative assessment of soft tissue and skeletal morphology in patients with cleft lip and palate.

Data sources

Literature was searched using PubMed (1948–2012), EMBASE (1980–2012), Scopus (2004–2012), Web of Science (1945–2012), and the Cochrane Library. The last search was performed September 30, 2012. Reference lists were hand searched for potentially eligible studies. There was no language restriction.

Study selection

We included publications using 3D imaging techniques to assess facial soft tissue or skeletal morphology in patients older than 5 years with a cleft lip with/or without cleft palate. We reviewed studies involving the facial region when at least 10 subjects in the sample size had at least one cleft type. Only primary publications were included.

Data extraction

Independent extraction of data and quality assessments were performed by two observers.

Results

Five hundred full text publications were retrieved, 144 met the inclusion criteria, with 63 high quality studies. There were differences in study designs, topics studied, patient characteristics, and success measurements; therefore, only a systematic review could be conducted. Main 3D-techniques that are used in cleft lip and palate patients are CT, CBCT, MRI, stereophotogrammetry, and laser surface scanning. These techniques are mainly used for soft tissue analysis, evaluation of bone grafting, and changes in the craniofacial skeleton. Digital dental casts are used to evaluate treatment and changes over time.

Conclusion

Available evidence implies that 3D imaging methods can be used for documentation of CLP patients. No data are available yet showing that 3D methods are more informative than conventional 2D methods. Further research is warranted to elucidate it.

Systematic review registration

International Prospective Register of Systematic Reviews, PROSPERO CRD42012002041

Three-dimensional evaluation of midfacial asymmetry in patients with nonsyndromic unilateral cleft lip and palate by cone-beam computed tomography

Objective

To compare three-dimensionally the midfacial hard- and soft-tissue asymmetries between the affected and the unaffected sides and determine the relationship between the hard tissue and the overlying soft tissue in patients with nonsyndromic complete unilateral cleft lip and palate (UCLP) by cone-beam computed tomography (CBCT) analysis.

Methods

The maxillofacial regions of 26 adults (18 men, 8 women) with nonsyndromic UCLP were scanned by CBCT and reconstructed by three-dimensional dental imaging. The frontal-view midfacial analysis was based on a 3 × 3 grid of vertical and horizontal lines and their intersecting points. Two additional points were used for assessing the dentoalveolar area. Linear and surface measurements from three reference planes (Basion-perpendicular, midsagittal reference, and Frankfurt horizontal planes) to the intersecting points were used to evaluate the anteroposterior, transverse, and vertical asymmetries as well as convexity or concavity.

Results

Anteroposteriorly, the soft tissue in the nasolabial and dentoalveolar regions was significantly thicker and positioned more anteriorly on the affected side than on the unaffected side (p < 0.05). The hard tissue in the dentoalveolar region was significantly retruded on the affected side compared with the unaffected side (p < 0.05). The other midfacial regions showed no significant differences.

Conclusions

With the exception of the nasolabial and dentoalveolar regions, no distinctive midfacial hard- and soft-tissue asymmetries exist between the affected and the unaffected sides in patients with nonsyndromic UCLP.

Computed tomography of alveolar bone grafts 20 years after repair of unilateral cleft lip and palate

The aim of this study was to estimate the clinical condition and amount of remaining grafted bone 20 years after final repair of unilateral cleft lip and palate. Eighteen consecutive patients had computed tomograms (CT) and clinical examination 20 years or more after secondary bone grafting which had been done at ages of 7-11 years. The images were obtained with a spiral CT with 1 mm collimation, and reconstructed as three-dimensional volumes with reformatted cut planes. The area of grafted bone was measured in a plane perpendicular to the curved axis of the alveolar arch and compared with the area corresponding section through the non-cleft side. The clinical examination showed satisfactory results in all. CT indicated a mean cross sectional area of 97 mm2 on the cleft side compared with 157 mm2 on the non-cleft side. The bone mass was significantly less on the grafted cleft side (p < 0.001), but the functional results were satisfactory.

Craniofacial computerized tomography analysis of the midface of patients with repaired complete unilateral cleft lip and palate

INTRODUCTION

Computerized tomography (CT) makes regional anatomy available as a series of cross-sectional axial images that can be analyzed unobstructed by other anatomic features. In this study, we aimed to analyze the maxillary dentoalveolar and deeper structures in patients with surgically repaired complete unilateral cleft lip and palate (CLP) and to investigate whether significant asymmetry existed in the deeper midfacial structures, using axial CT.

METHODS

Axial CT scans of 15 children (7 boys, 8 girls; mean age, 11.59 +/- 1.34 years) with repaired complete unilateral CLP were acquired parallel to Reid's base line. Specific landmarks applicable for CT were defined and plotted to undertake a comprehensive Craniofacial CT Analysis of the midface. Twenty-six pairs of transverse and sagittal measurements made to a cranial base midsagittal construct and interspinosum fit line, respectively, were compared by using the paired t test.

RESULTS

Significant reduction of 19.05% in the nasal chamber width (2.54 +/- 1.49 mm; P <0.001), more distal position of the bony alar base (2.28 +/- 1.71 mm; P <0.001), and the sagittal position of the most prominent anterolateral point on the maxillary alveolar process (1.62 +/- 1.85 mm; P <0.01) were noted on the cleft side. The lower half of the bony nasal septum was consistently deviated toward the cleft side, and the nasal tip was deviated to the noncleft side in 60% of the subjects. The anterior nasal spine was deviated to the noncleft side in 73.3% of the subjects and a mean deviation of the anterior nasal spine of 2.84 +/- 3.90 mm toward the noncleft side was measured. Significant sagittal and transverse asymmetry in deeper midfacial regions was not observed. Unilateral dental-arch collapse was observed in 73.3% of the sample, bilateral collapse in 20%, and no collapse in 6.7%. The soft-tissue support of the alveolar margins of the cleft did not show significant differences between the cleft and noncleft sides.

CONCLUSIONS

CT is an excellent method for quantifying surface and deep craniofacial structures. Most asymmetries and deformities in the 10- to 14-year-old patients with repaired complete unilateral CLP we studied were in the dentoalveolar area near the cleft and the nasal chamber and not in the deeper regions of the maxillary complex.

Assessment of Cleft Lip and Palate Patients Treated With Presurgical Orthopedic Correction and Either Primary Bone Grafts, Gingivoperiosteoplasty, or Without Alveolar Grafting Procedures

The effects of alveolar grafting on the development of the craniofacial complex have been reported by numerous investigators. The reported results vary in the literature from significant to very little impediment of maxillary growth. The present work evaluates and compares facial form at age six years in complete unilateral cleft lip and palate patients treated with presurgical orthopedic correction and primary reconstruction with (1) primary bone grafts (n = 14), (2) gingivoperiosteoplasty (n = II), or (3) without alveolar grafting procedures at the time of lip repair (n = 13). The cohort groups were analyzed with a one-way analysis of variance (ANOV A). Statistical analysis revealed significant differences between the three groups for only one of the 12 parameters analyzed. The primary bone grafted group demonstrated less vertical descent-of the anterior maxilla compared to the gingivoperiosteoplasty and non-grafted groups (P = .0027).

Cleft-orthognathic surgery

For the cleft patient presenting in adolescence with a jaw discrepancy and malocclusion, misinformation and limited available surgical and dental expertise often prevents a favorable facial reconstruction and dental rehabilitation. A major advantage of the modified Le Fort I osteotomy is its ability to simultaneously close cleft dental gap(s), resolve oronasal fistulas, manage skeletal defects, stabilize dentoalveolar segments, and correct jaw deformities. When a thoughtful staging of reconstruction is undertaken, individuals born with cleft lip and palate can reach adolescence after undergoing only a limited number of operations and interventions, without negative attention being drawn to their original malformation.