Upper dental arch morphology of adult unoperated complete bilateral cleft lip and palate

Evaluation of transpalatal distraction in cleft palate patients

PURPOSE

The aim of this study was to evaluate the effect of combining a bone-borne palatal expander (distractor) with a maxillary osteotomy in the treatment of narrowed maxillae in treated cleft palate patients. Few articles in the literature isolated the effects of transpalatal distraction in cleft patients and most either excluded cleft patients or grouped them with non-cleft patients. The hypothesis is that the use of a bone-borne palatal expander in conjunction with a maxillary osteotomy would improve the amount of maxillary expansion at the anterior segment with less tipping of the segments and provide a harmonious arch form.

METHODS

We studied four patients above 14 years of age with repaired cleft palate and progressive anterior constriction of the arch. All patients received a bone-borne distractor (UNI-Smile Distractor, Titamed, Belgium) combined with a LeFort I level osteotomy without pterygomaxillary disjunction. Dental models and CBCT measurements were used to analyze the skeletal and dental effects of the intervention.

RESULT

All the patients who completed the trial had satisfactory expansion and normalization of the maxillary arch form. The average increase in the intercanine distance was 12.9 mm while the average increase in the intermolar distance was 7.2 mm. No significant change in molar inclination or buccal bone thickness was observed.

CONCLUSION

The use of bone-borne palatal expanders aided by a maxillary osteotomy (transpalatal distraction) in treated cleft palate patients can provide a harmonious arch form in adolescent and adult patients. This trial was registered in the clinical trials registry with the ID NCT03837652 on February 12, 2019.

Prospective cohort 3D study of dental arches in children with bilateral orofacial cleft: Assessment of volume and superimposition

BACKGROUND

Cohort studies have evaluated dental arches of children.

AIM

To evaluate the volumetric, linear, palatal surface area, and the dental arch superimposition of participants with bilateral complete cleft lip (BCL) and bilateral cleft lip and palate (BCLP) surgically treated in a specialized hospital.

DESIGN

One hundred and thirty six digitized dental models evaluated before cheiloplasty (T1), after cheiloplasty (T2), and after palatoplasty (T3). The stereophotogrammetry software analysed the volume, palate superimposition, linear, and area measurements.

RESULTS

In BCL group, at T2, C-C', T-T', area, and volume significantly increased (P = .000, P < .000, P = .010 e P = .003, respectively). In BCLP group, the comparison T3 × T1 showed that C-C' decreased, whereas T-T' and the area increased (P < .000, P < .000, P = .000). The volume increased at T2, but decreased at T3 (P < .000) in participants with BCLP. The intergroup analysis revealed that C-C', T-T', I-C', and I-C were significantly smaller in participants with BCLP (P < .000, P = .016, P = .001 e P = .020, respectively), whereas the volume, superimposition, and area were statistically similar between groups (P > .05).

CONCLUSION

The comparison between bilateral orofacial clefts showed reduction in the transversal and anteroposterior linear measurements, but not in the area and volume, which was confirmed by the superimposition of the dental arches.

Dental arch changes comparison between expander with differential opening and fan-type expander: a randomized controlled trial

OBJECTIVES

To compare posterior crossbite correction frequency and dentoalveolar changes of the expander with differential opening (EDO) and the fan-type expander (FE).

TRIAL DESIGN

Two-arm parallel randomized controlled trial.

METHODS

Forty-eight patients from 7 to 11 years of age were allocated into two groups. Twenty-four patients were treated with the EDO and 24 patients were treated with the FE. Block randomization was performed. The study was single blind. Digital dental models were acquired before treatment and 6 months after rapid maxillary expansion. The primary outcomes were crossbite correction rate and maxillary arch width changes. Secondary outcomes were interincisal diastema, arch perimeter, length, size and shape, and mandibular dental arch changes.

RESULTS

The final sample comprised 24 patients (13 female and 11 male; mean initial age of 7.62 years) in the EDO group and 24 patients (14 female and 10 male; mean initial age of 7.83 years) in the FE group. The crossbites were corrected in 100 per cent of subjects from EDO group and in 75 per cent of patients in FE group. EDO showed greater increases in maxillary intermolar region (P < 0.001), while the FE demonstrated greater increases in the intercanine distance (P = 0.008). Increase in mandibular inter-first permanent molar distance was slightly greater in the EDO group (mean difference of 0.8 mm). Changes in arch length and perimeter were similar in both groups. Both expanders changed the maxillary arch shape. The post-treatment arch shape was larger in the anterior region for FE and in the posterior region in the EDO group.

HARMS

Discomfort during activation was reported by 54 per cent of the participants. A temporary change in the nasal bridge was reported by one patient from FE group.

CONCLUSIONS

Maxillary arch width and shape changes were distinct between the EDO and the FE. Greater transversal increases of the anterior and posterior regions were observed for the FE and the EDO, respectively. A slightly greater mandibular spontaneous expansion was observed for the EDO only at the molar region.

TRIAL REGISTRATION

NCT03705871.

Frequency of Additional Congenital Dental Anomalies in Children with Cleft Lip, Alveolar and Palate

The aim of the study was to assess the risk of incidence of additional congenital dental anomalies in children with nonsyndromic cleft lip, alveolar and/without palate (CL/P). Hypodontia, hyperdontia and canines impaction was recognized. From patients with CL/P treated at the Clinic of Congenital Facial Deformities in Chair and Department of Jaw Orthopedics Medical University of Lublin, 56 subjects were randomly selected. On the panoramic radiographs taken at the age of 8-12 years, the angle of upper unerupted canines was measured using Westerlund's recommendations. The supernumerary teeth and hypodontia were checked. The procedures: maxillary expansion, secondary alveolar bone graft (SABG) and extraction of primary canines were noted. The frequency of canines impaction was 5.36%. Hypodontia was found in 37.5% of patients; hyperdontia was present in 23.21% of patients. No influence of procedures (expansion of the maxilla, SABG, deciduous canines extraction) on permanent maxillary canine eruption was proved. Patients with CL/P are exposed to the unfavorable position of unerupted maxillary canines most frequently in the cleft area of complete cleft. Maxillary lateral incisor on the cleft side is most frequently affected with congenital anomaly. Hypodontia and hyperdontia do not influence maxillary canine impaction. Good clinical result was achieved with an applied approach, which should be widely introduced.

Dental arch size and shape after maxillary expansion in bilateral complete cleft palate: A comparison of three expander designs

OBJECTIVE

The objective of this study was to compare the effects on upper dental arch size and shape after maxillary expansion with Hyrax, Quad-helix, and a differential opening expander in bilateral cleft lip and palate (BCLP) patients.

MATERIALS AND METHODS

Seventy-five BCLP patients were divided into three groups: Hyrax (H), Quad-helix (QH), and Expander with differential opening (EDO). Digital models were obtained before (T1) and after 6 months (T2) of maxillary expansion. Twelve landmarks were placed by one investigator on T1 and T2 dental models of each group, and x,y coordinates for each landmark were collected. For dental arch size analysis, centroid size of each dental arch at T1 and T2 was calculated from raw coordinates and was used as the measure of size. Procrustes Analysis was performed for dental arch shape analysis. Analysis of variance was used to compare the groups for size and shape differences (P < .05).

RESULTS

There were no significant dental arch size differences among the expanders at T1 or T2. Differences in arch shape were found between all groups at T2. Intragroup arch shape showed a significant variation for the QH and EDO groups. while it remained stable in the H group.

CONCLUSIONS

Both the QH and the EDO create dental arch shape changes with greater intercanine than intermolar increase. The H does not change the dental arch shape.

Cephalometric evaluation of rapid and slow maxillary expansion in patients with BCLP: Secondary data analysis from a randomized clinical trial

OBJECTIVE

To compare the dentoskeletal effects of rapid (RME) and slow (SME) maxillary expansion in patients with bilateral complete cleft lip and palate (BCLP).

MATERIALS AND METHODS

This was a secondary analysis of a previous randomized controlled trial (RCT). Forty-six patients (34 male, 12 female) with BCLP and posterior crossbite (mean age of 9.2 years) were randomly assigned to two study groups. Group RME comprised subjects treated with Haas/Hyrax expander. Group SME included patients treated with quad-helix appliance. Cone-beam computed tomography (CBCT) was performed before expansion (T1) and after appliance removal at the end of a 6-month retention period (T2) for a previous RCT that compared the transverse skeletal effects of RME and SME. CBCT-derived cephalometric images were generated and cephalometric analysis was performed using Dolphin Imaging Software (Chatsworth, Calif). Intergroup comparisons were performed using t tests (P < .05).

RESULTS

Baseline forms were similar between groups. No significant differences between RME and SME groups were found.

CONCLUSIONS

Rapid and slow maxillary expansion produced similar sagittal and vertical changes in patients with BCLP. Both Haas/Hyrax and quad-helix appliances can be used in patients with vertical facial pattern. Clinical relevance: RME and SME can be equally indicated in the treatment of maxillary arch constriction in patients with BCLP.

The Difference in Cervical Vertebral Skeletal Maturation between Cleft Lip/Palate and Non-Cleft Lip/Palate Orthodontic Patients

Objective

The aim was to evaluate differences in the cervical vertebral skeletal maturity of unilateral cleft lip and palate (UCLP) and non-cleft lip/palate (non-CLP) Saudi male orthodontic patients.

Method

This cross-sectional multicenter study took place at the dental school, King Saud University and King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between October 2014 and September 2015. The records of Saudi male orthodontic patients with UCLP (n = 69) were collected. Cervical vertebral maturation was assessed using their cephalometric radiographs. The records of 138 age-matched non-CLP Saudi male orthodontic patients served as controls.

Results

There was a significant difference in skeletal maturity between the UCLP and non-CLP groups, as evident in the delayed skeletal development among the UCLP participants. Moreover, pubertal growth spurt onset was significantly earlier in the non-cleft participants in comparison with the UCLP participants (p = 0.009).

Conclusions

There is delayed skeletal maturity among the UCLP Saudi male population in comparison with their non-CLP age-matched peers.

Plaque index and gingival index during rapid maxillary expansion of patients with unilateral cleft lip and palate

OBJECTIVE

To assess, during rapid maxillary expansion, the plaque index (PI) and the gingival index (GI) of patients with unilateral cleft lip and palate(UCLP) using Hyrax (HX) or inverted mini-Hyrax (IMHX) rapid maxillary expanders (RME) considering patients' sex and age.

METHODS

PI (Quigley Index modified by Turesky et al) and GI (Löe and Silness) of 28 UCLP (11 females; 17 males: aged 8 to 15 years) submitted to daily RME activation were assessed before (T0) and 7 (T1), 28 (T2) and 90 (T3) days after activation. Log-linear models and Bonferroni correction were performed to analyze possible differences in PI and GI between RME, sexes or age groups over time.

RESULTS

Intra-group comparison revealed significant increases in PI of patients using HX (T0 < T2), IMHX (T0 < T3; T1< T3), males (T0 < T1; T0 < T2; T0 < T3) or aged 12-15 years (T0 < T1; T0 < T2; T0 < T3), and in GI of patients using IMHX (T0 < T3; T1 < T3), females (T1 < T3; T2 < T3) or aged 12-15 years (T0 < T3; T2 < T3). One inter-group difference in GI according to patients' age (8-11 < 12-15; T1) was observed.

CONCLUSIONS

Since a single difference between groups was encountered, the results of this study indicated that PI and GI during maxillary expansion were similar between HX and IMHX, sexes and the analyzed age groups. Therefore, orthodontists can use these RME in UCLP patients according to the patient's necessity or their preferences.

Early Craniofacial Morphology and Growth in Children with Bilateral Complete Cleft Lip and Palate

Purpose

Analysis of craniofacial morphology and growth in children with bilateral complete cleft lip and palate (BCCLP), compared with a control group with unilateral incomplete cleft lip (UICL), before any treatment as well as 20 months after lip closure.

Material

The children were drawn from a group representing all Danish children with cleft born 1976 to 1981. Sixty-four children were included in the study (19 BCCLP and 45 UICL). The ages were 2 and 22 months at examinations 1 and 2, respectively.

Method

The method of investigation was infant cephalometry in three projections. The craniofacial morphology was analyzed using linear, angular, and area variables. Growth was defined as the displacement vector from the coordinate of the corresponding landmark in the x-ray at examination 1 to its coordinate at examination 2, corrected for x-ray magnification. The growth of an anatomical region in a patient was assessed by investigating the growth pattern formed by a collection of individual growth vectors in that region.

Results

The BCCLP group differed significantly from the UICL group. The most striking findings in BCCLP were an extremely protruding premaxilla; markedly increased posterior maxillary width; increased width of the nasal cavity; short maxilla with reduced posterior height; short mandible; bimaxillary retrognathia; severe reduction in the size of the pharyngeal airway; and a more vertical facial growth pattern.

Conclusion

Our findings indicate that a facial type including a wide and posterior short maxilla, short mandible, and bimaxillary retrognathia might be a liability factor that increases the probability of developing cleft lip and palate.

Rapid Maxillary Expansion after Secondary Alveolar Bone Graft in a Patient with Bilateral Cleft Lip and Palate

Objective

To verify the effects of rapid maxillary expansion performed after secondary alveolar bone graft in one patient.

Setting

Department of Orthodontics of the Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo.

Patient(s)

The patient had bilateral cleft lip and palate, had already had a bone graft, and showed a relapsing maxillary constriction in need of correction.

Intervention

A fixed dental-mucous-bone-supported expander corrected the maxillary constriction.

Main Outcome Measure(s)

Measurements were obtained from dental casts, including transverse dimensions (intercanine distance [IC], interfirst premolar distance [IP], and interfirst molar distance [IM]) and measurements of the grafted area (interfirst premolar/central incisors [IPI] and interfirst premolar/canine [IPC]) to observe the changes. Clinical and radiographic analyses were done through direct view.

Results

The occlusal radiograph of the maxilla after expansion showed opening of the intermaxillary suture in the premaxillary area, which was clinically confirmed by the diastema between the maxillary central incisors. No radiographic alteration was observed in the grafted area. The transverse measurements of the dental casts (IC, IP, and IM) showed a significant increase. The measurements of the teeth adjacent to the grafted area, IPI and IPC, increased.

Conclusions

The orthopedic effect of rapid maxillary expansion after bone graft was verified. Nevertheless, additional studies are necessary to define any side effects in patients submitted to bone graft.

Dental Arch Relationships and Reverse Headgear Effects in Southern Chinese Patients with Unilateral Cleft Lip and Palate: A Retrospective Study

OBJECTIVE

To evaluate the severity of the dental arch relationships and the treatment outcomes of reverse headgear (RHG) in southern Chinese patients with unilateral cleft lip and palate (UCLP).

DESIGN

A retrospective study.

SETTING

Faculty of Dentistry, The University of Hong Kong.

PATIENTS

Thirty-eight UCLP patients with complete records. Among them, 14 were later treated with RHG (RHG group) and 24 were under review (non-RHG group) before definitive orthodontic or in conjunction with orthognathic surgery.

INTERVENTIONS

Study models at T1 (aged 9.4 ± 0.4 years old), prebone grafting and before any orthodontic treatment started; T2 (aged 11.3 ± 0.6 years old), after bone grafting, and RHG treatment (RHG group) or under review (non-RHG group); and T3 (aged 15.3 ± 3.2 years old), pretreatment of definitive orthodontic or in conjunction with orthognathic surgery.

MAIN OUTCOME MEASURES

With satisfactory intra- and interexaminer agreement proven by the kappa value, the dental arch relationships of the study models at T1, T2, and T3 were assessed by a solo calibrated examiner using the GOSLON Yardstick.

RESULTS

The median GOSLON score for southern Chinese patients with UCLP at T1 was 4.0. Sixty percent of the patients were categorized as "poor" at T1. RHG significantly improved dental arch relationships from T1 to T2, and the improvement was maintained until T3 assessed by the GOSLON Yardstick.

CONCLUSIONS

The dental arch relationships in southern Chinese UCLP patients at 8 to 10 years old are unfavorable. RHG treatment shows positive effects in improving the dental arch relationships in UCLP patients, as assessed by the GOSLON Yardstick.

Dentoskeletal outcomes of a rapid maxillary expander with differential opening in patients with bilateral cleft lip and palate: A prospective clinical trial

INTRODUCTION

The purpose of this 2-arm parallel study was to evaluate the dentoskeletal effects of rapid maxillary expansion with differential opening (EDO) compared with the hyrax expander in patients with complete bilateral cleft lip and palate.

METHODS

A sample of patients with complete bilateral cleft lip and palate was prospectively and consecutively recruited. Eligibility criteria included participants in the mixed dentition with lip and palate repair performed during early childhood and maxillary arch constriction with a need for maxillary expansion before the alveolar bone graft procedure. The participants were consecutively divided into 2 study groups. The experimental and control groups comprised patients treated with rapid maxillary expansion using EDO and the hyrax expander, respectively. Cone-beam computed tomography examinations and digital dental models of the maxillary dental arches were obtained before expansion and 6 months postexpansion. Standardized cone-beam computed tomography coronal sections were used for measuring maxillary transverse dimensions and posterior tooth inclinations. Digital dental models were used for assessing maxillary dental arch widths, arch perimeters, arch lengths, palatal depths, and posterior tooth inclinations. Blinding was used only during outcome assessment. The chi-square test was used to compare the sex ratios between groups (P <0.05). Intergroup comparisons were performed using independent t tests with the Bonferroni correction for multiple tests.

RESULTS

Fifty patients were recruited and analyzed in their respective groups. The experimental group comprised 25 patients (mean age, 8.8 years), and the control group comprised 25 patients (mean age, 8.6 years). No intergroup significant differences were found for age, sex ratio, and dentoskeletal variables before expansion. No significant differences were found between the EDO and the hyrax expander groups regarding skeletal changes. The EDO promoted significantly greater increases of intercanine width (difference, 3.63 mm) and smaller increases in canine buccal tipping than the conventional hyrax expander. No serious harm was observed other than transitory variable pressure sensations on the maxillary alveolar process in both groups.

CONCLUSIONS

The EDO produced skeletal changes similar to the conventional hyrax expander. The differential expander is an adequate alternative to conventional rapid maxillary expanders when there is need for greater expansion in the maxillary dental arch anterior region.

REGISTRATION

This trial was not registered.

PROTOCOL

The protocol was not published before trial commencement.

FUNDING

This study received financial support from FAPESP (process number 2009/17622-9). As a possible conflict of interest, a patent with an EDO was submitted in March 2011 to the National Institute of Industry Property and is still in process. However, we believe that this is a natural step of translational research (bench-to-bedside), and we guarantee that the scientific results are true.

Slow versus rapid maxillary expansion in bilateral cleft lip and palate: a CBCT randomized clinical trial

OBJECTIVES

The purpose of this "two-arm parallel" trial was to compare the orthopedic, dental, and alveolar bone plate changes of slow (SME) and rapid (RME) maxillary expansions in patients with complete bilateral cleft lip and palate (BCLP).

MATERIAL AND METHODS

Forty-six patients with BCLP and maxillary arch constriction in the late mixed dentition were randomly and equally allocated into two groups. Computer-generated randomization was used. Allocation was concealed with sequentially, numbered, sealed, opaque envelopes. The SME and RME groups comprised patients treated with quad-helix and Haas/Hyrax-type expanders, respectively. Cone-beam computed tomography (CBCT) exams were performed before expansion and 4 to 6 months post-expansion. Nasal cavity width, maxillary width, alveolar crest width, arch width, palatal cleft width, inclination of posterior teeth, alveolar crest level, and buccal and lingual bone plate thickness were assessed. Blinding was applicable for outcome assessment only. Interphase and intergroup comparisons were performed using paired t tests and t tests, respectively (p < 0.05).

RESULTS

SME and RME similarly promoted significant increase in all the maxillary transverse dimensions at molar and premolar regions with a decreasing expanding effect from the dental arch to the nasal cavity. Palatal cleft width had a significant increase in both groups. Significant buccal inclination of posterior teeth was only observed for RME. Additionally, both expansion procedures promoted a slight reduction of the alveolar crest level and the buccal bone plate thickness.

CONCLUSIONS

No difference was found between the orthopedic, dental, and alveolar bone plate changes of SME and RME in children with BCLP. Both appliances produced significant skeletal transverse gains with negligible periodontal bone changes. Treatment time for SME, however, was longer than the observed for RME.

CLINICAL RELEVANCE

SME and RME can be similarly indicated to correct maxillary arch constriction in patients with BCLP in the mixed dentition.

An alternative clinical approach to achieve greater anterior than posterior maxillary expansion in cleft lip and palate patients

Cleft lip and palate patients commonly present maxillary constriction, particularly in the anterior region. The aim of this case report was to describe an alternative clinical approach that used a smaller Hyrax screw unconventionally positioned to achieve greater anterior than posterior expansion in patients with complete unilateral cleft lip and palate. The idea presented here is to take advantage of a reduced dimension screw to position it anteriorly. When only anterior expansion was needed (patient 1), the appliance was soldered to the first premolar bands and associated to a transpalatal arch cemented to the first molars. However, when overall expansion was required (patient 2), the screw was positioned anteriorly, but soldered to the first molar bands. Intercanine, premolar, and first molar widths were measured on dental casts with a digital caliper. Pre-expansion and postexpansion radiographs and tomographies were also evaluated. A significant anterior expansion and no intermolar width increase were registered in the first patient. Although patient 2 also presented a greater anterior than posterior expansion, a noteworthy expansion occurred at the molar region. The alternative approach to expand the maxilla in cleft patients reported here caused greater anterior than posterior expansion when the Mini-Hyrax was associated to a transpalatal arch, and its reduced dimension also minimized discomfort and facilitated hygiene.

Alteration of maxillary and mandibular growth of adult patients with unoperated isolated cleft palate

OBJECTIVE

The objective of this study was to investigate the effects of cleft palate itself on the growth of maxilla and mandible.

PATIENTS AND METHODS

Fifty-two adult female patients with unoperated isolated cleft palate and 52 adult female individuals with normal occlusion were included in our study. Computer software was used for lateral cephalometry measurement. Manual measurement was performed for dental cast measurements, and sample t test analysis was applied to analyze the differences between the 2 groups using SPSS 17.0.

RESULTS

The sella-nasion-subspinale point angle, subspinale-nasion-supramentale point angle, and maxillary arch length of the cleft group were significantly smaller than those of the control group (P < 0.01). Both maxillary and mandibular posterior dental arch widths of the cleft group were significantly larger compared with the control group (P < 0.01), whereas the sella-nasion-supramentale point angle, mandible arch length, palate height, and palate shelf inclination did not differ between the 2 groups. The measurements did not differ between the submucosal cleft and the overt cleft patients.

CONCLUSIONS

Cleft palate itself has adverse effects on the maxilla growth with shorter maxillary arch length and wider posterior dental arch width.

Exploratory genotype-phenotype correlations of facial form and asymmetry in unaffected relatives of children with non-syndromic cleft lip and/or palate

Family relatives of children with nonsyndromic cleft lip with or without cleft palate (NSCL/P) who presumably carry a genetic risk yet do not manifest overt oral clefts, often present with distinct facial morphology of unknown genetic etiology. This study investigates distinct facial morphology among unaffected relatives and examines whether candidate genes previously associated with overt NSCL/P and left-right body patterning are correlated with such facial morphology. Cases were unaffected relatives of individuals with NSCL/P (n = 188) and controls (n = 194) were individuals without family history of NSCL/P. Cases and controls were genotyped for 20 SNPs across 13 candidate genes for NSCL/P (PAX7, ABCA4-ARHGAP29, IRF6, MSX1, PITX2, 8q24, FOXE1, TGFB3 and MAFB) and left-right body patterning (LEFTY1, LEFTY2, ISL1 and SNAI1). Facial shape and asymmetry phenotypes were obtained via principal component analyses and Procrustes analysis of variance from 32 coordinate landmarks, digitized on 3D facial images. Case-control comparisons of phenotypes obtained were performed via multivariate regression adjusting for age and gender. Phenotypes that differed significantly (P < 0.05) between cases and controls were regressed on the SNPs one at a time. Cases had significantly (P < 0.05) more profile concavity with upper face retrusion, upturned noses with obtuse nasolabial angles, more protrusive chins, increased lower facial heights, thinner and more retrusive lips and more protrusive foreheads. Furthermore, cases showed significantly more directional asymmetry compared to controls. Several of these phenotypes were significantly associated with genetic variants (P < 0.05). Facial height and width were associated with SNAI1. Midface antero-posterior (AP) projection was associated with LEFTY1. The AP position of the chin was related to SNAI1, IRF6, MSX1 and MAFB. The AP position of the forehead and the width of the mouth were associated with ABCA4-ARHGAP29 and MAFB. Lastly, facial asymmetry was related to LEFTY1, LEFTY2 and SNAI1. This study demonstrates that, genes underlying lip and palate formation and left-right patterning also contribute to facial features characteristic of the NSCL/P spectrum.

Clinical and Radiographic Assessment of Secondary Bone Graft Outcomes in Cleft Lip and Palate Patients

Purpose. To compare the results of secondary alveolar bone grafts in patients with complete cleft lip and cleft lip and palate using 2 radiographic scales and according to the rate of canine eruption through the newly formed bone. Materials and Methods. We analyzed pre- and postoperative radiographs of 36 patients for the amount of bone in the cleft site according to the Bergland and Chelsea scales. The associations between the variables and the correlation between the scales were measured. Results. A total of 54.2% and 20.8% of cases were classified as type I and type II, respectively, using the Bergland scale, whereas 50% and 22.5% were classified as types A and C, respectively, using the Chelsea scale. A positive correlation between the 2 scales was observed. In 33.3% of males, 58.3% of females, 54.5% of unilateral cleft cases, and 12.5% of bilateral cleft cases, the permanent canines had erupted. Bone grafts performed prior to canine eruption achieved more satisfactory results. Conclusions. Our results suggest that both radiographic scales are important tools for the evaluation of bone grafts. Additionally, longer time periods of evaluation were associated with improved results for patients with secondary alveolar bone grafts.

What operative or anatomic factors affect dental arch development in the cleft patient?

PURPOSE

There has been dispute about the exact factors influencing dental arch development in adult cleft palate patients, so we designed this study to investigate the effects of operative and anatomic factors on the development of dental arch morphology.

PATIENTS AND METHODS

A retrospective cohort study was conducted among 3 groups of patients (operated, unoperated, and normal) from West China College of Stomatology, Sichuan University, Chengdu, China. The differences in dental arch morphology, including length and width of the upper and lower dental arches, inclination of the palatal shelf, and palatal height, were analyzed by variance analysis with SPSS software, version 13.0 (IBM, Armonk, NY).

RESULTS

We enrolled 90 individuals: 30 unoperated adults with bilateral cleft lip and palate, 30 adults with operated bilateral cleft lip and palate, and 30 normal adults. The widths of all upper and posterior lower arches, lengths of the anterior upper arch, palatal height, and palatal shelf inclination in the operated group were smaller than those in the unoperated group; the lengths and widths of the anterior upper arch were smaller whereas the widths of the posterior upper and lower arches, palatal height, and palatal shelf inclination were greater in the unoperated group compared with the normal group.

CONCLUSIONS

Operated cleft patients show the most severe deformation of the maxillary arch, especially in the anterior part. There is an intrinsic palatal tissue deficiency in cleft patients, whereas the maxillary arch deformation in unoperated cleft patients is limited to the anterior region only.

Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies-USP (HRAC-USP)--part 2: pediatric dentistry and orthodontics

The aim of this article is to present the pediatric dentistry and orthodontic treatment protocol of rehabilitation of cleft lip and palate patients performed at the Hospital for Rehabilitation of Craniofacial Anomalies-University of São Paulo (HRAC-USP). Pediatric dentistry provides oral health information and should be able to follow the child with cleft lip and palate since the first months of life until establishment of the mixed dentition, craniofacial growth and dentition development. Orthodontic intervention starts in the mixed dentition, at 8-9 years of age, for preparing the maxillary arch for secondary bone graft procedure (SBGP). At this stage, rapid maxillary expansion is performed and a fixed palatal retainer is delivered before SBGP. When the permanent dentition is completed, comprehensive orthodontic treatment is initiated aiming tooth alignment and space closure. Maxillary permanent canines are commonly moved mesially in order to substitute absent maxillary lateral incisors. Patients with complete cleft lip and palate and poor midface growth will require orthognatic surgery for reaching adequate anteroposterior interarch relationship and good facial esthetics.

Dentoalveolar relationships of Malay children with unilateral cleft lip and palate

OBJECTIVE

To determine the treatment outcome based on dentoalveolar relationships among Malay children born with nonsyndromic complete unilateral cleft lip and palate (UCLP).

DESIGN

Retrospective cohort study.

SETTING AND SAMPLE POPULATION

The Department of Orthodontics at the School of Dental Science and the Reconstructive Sciences Unit, School of Medical Science, Universiti Sains Malaysia. Dental study models of 82 UCLP Malay children aged 8 to 10 years were evaluated. All subjects had their cleft lip and palate repaired, but no alveolar bone graft or any orthodontic treatment was performed.

OUTCOME MEASURE

The outcome of dental arch relationships was assessed using the Goslon Yardstick Index: a dental measure with outcomes ranked on a scale ranging from 1 to 5. Agreement of rating was assessed with weighted kappa statistics; both intraexaminer and interexaminer agreements were high, indicating good reproducibility.

RESULTS

A total of 2.4% of the sample was in grade 1, 24.4% in grade 2, 35.4% in grade 3, 31.7% in grade 4, and 6.1% in grade 5. The mean Goslon index score was 3.15.

CONCLUSION

Dentoalveolar relationship outcomes of UCLP Malay children are intermediate according to the Goslon Yardstick. Interpretation of results should consider the ethnic differences in the craniofacial complex.

Rapid Maxillary Expansion after Secondary Alveolar Bone Grafting in Patients with Alveolar Cleft

Objective:

To test the hypothesis that it is possible to perform rapid maxillary expansion (RME) after alveolar bone grafting in patients with clefts of the lip and palate (CLP) without compromising the final result of the bone graft.

Design:

Occlusal and periapical radiographs of the grafted area of 17 unilateral and 11 bilateral patients with CLP (n  =  28) were obtained before and after RME.

Setting and sample population:

Hospital for Rehabilitation of Craniofacial Anomalies (HRAC), University of São Paulo. Twenty-eighty patients with CLP who had undergone RME.

Interventions:

RME was performed in patients with CLP who had already undergone RME before secondary bone grafting but with relapse of the maxillary dental arch constriction, as well as in patients with CLP who had never undergone expansion before bone grafting.

Outcome measure:

Qualitative evaluation in occlusal and periapical radiographs after alveolar bone grafting.

Results:

Findings showed opening of the midpalatal suture in 42.8% of patients in this study. Regardless of the success rate of RME, the alveolar bone grafting was not affected when the procedures were inverted.

Conclusion:

The hypothesis was accepted. RME can be performed after secondary alveolar bone grafting without affecting it.

Dental Arch Width Stability after Quadhelix and Edgewise Treatment in Complete Unilateral Cleft Lip and Palate

Objective: To evaluate the transverse stability of the dental arch in unilateral cleft lip and palate (UCLP) patients after orthodontic treatment with quadhelix and edgewise appliances.

Materials and Methods: Twenty repaired complete UCLP patients with posterior crossbites were chosen as the study subjects. All had ceased retention at least 15 months previously. Measurements were carried out directly on the pretreatment, posttreatment, and postretention study models using a three-dimensional dental cast analyzer. The interdental widths were measured for the canines, first premolars, second premolars, first molars, basal bone, and the alveolar arch. Two-way analysis of variance and Fisher's LSD was performed in comparing the difference between intervals.

Results: Lower inter-first-premolar width and upper arch widths of each region increased significantly (P &lt; .05) after orthodontic treatment. The expansion was greater in the anterior than the posterior region in the upper arch, and the greatest increase was in the upper first premolar region. The upper arch width decreased after retention, with the decrease of the arch width in the upper canine (1.3 ± 0.8 mm) and first premolar (1.5 ± 0.8 mm) regions being statistically significant. The increased upper arch width in each region and the lower inter-first-premolar width maintained significant expansion after retention.

Conclusions: The widths of the dental arch increased significantly after expansion with a quadhelix followed by preadjusted edgewise treatment. Relapse occurred, especially in the upper canine and first premolar region, but most of the treatment effect on the upper arch remained after retention.

A influência da queiloplastia realizada em tempo único e em dois tempos cirúrgicos no padrão oclusal de crianças com fissura bilateral completa de lábio e palato

OBJETIVO: analisar a influência da queiloplastia realizada em tempo único e em dois tempos cirúrgicos no padrão oclusal de cirnaças com fissuras bilateral completa de lábio e palato. METODOLOGIA: a relação oclusal, de acordo com o índice Bauru, para a fissura bilateral completa de lábio e palato, foi estudada em uma amostra de 91 crianças nos estágios de dentadura decídua e mista. As crianças apresentavam fissura bilateral completa de lábio e palato e encontravam-se distribuídas na faixa etária compreendida entre 4 anos e 3 meses e 11 anos no momento do exame oclusal. Todas as crianças foram operadas na infância, no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP), obedecendo dois protocolos de queiloplastia primária: 53 crianças foram submetidas à queiloplastia em tempo único (G1) e 38 crianças foram submetidas à queiloplastia em dois tempos cirúrgicos (G2). RESULTADOS E CONCLUSÕES: o padrão oclusal, mensurado com base numa escala de 1 a 5, de acordo com o índice Bauru para fissura bilateral completa de lábio e palato, obteve média de 2,28 e 2,51 para a queiloplastia realizada em tempo único e em dois tempos cirúrgicos, respectivamente. Os resultados permitem concluir que as cirurgias plásticas primárias comprometem a oclusão na dentadura decídua e mista, independentemente do número de etapas para a realização da queiloplastia.

Maxillary growth of adult patients with unoperated cleft: answers to the debates

Maxillary growth of adult patients with unoperated cleft has long been studied, but results varied between different studies. The objectives of this study were to determine the growth potential of adult patients with unoperated clefts compared to the normal population and to differentiate the growth potential among types of clefts.

METHODS

Subjects were from the same ethnic group, were more than 16 years of age with non-syndromic cleft and no associated anomalies. The types of cleft included unilateral complete cleft lip and palate (UCLP), bilateral complete cleft lip and palate (BCLP), unilateral cleft lip (UCL) and isolated cleft palate (CP). The sella-nasion-A point (SNA) angle from the cephalometry was measured, and a dental cast study using a three-dimensional imaging system was performed.

RESULTS

SNA measurements showed significant differences among different groups, the BCLP group having larger values and the CP group having smaller values when compared with normal values. Dental cast analysis measuring palatal surface area showed a significantly smaller area in patients with cleft as compared to normal controls, but no difference among the different types of cleft. From the linear measurement it was found that the interdental distance was significantly more narrow in the anterior part up to the first premolar region as compared to the control group, especially in the complete cleft groups (UCLP and BCLP). Dentoalveolar arch was also deeper and longer in these complete cleft groups.

CONCLUSION

There is an intrinsic tissue deficiency in all groups of patients with cleft; however, the sagittal development is still comparable to that of a normal population. Tissue deficiency mostly occurs in the anterior part. There is no difference in terms of the deficiencies among the different groups of cleft.

Influence of lip repair on craniofacial morphology of patients with complete bilateral cleft lip and palate

OBJECTIVE

The aim of this study was to compare two groups of adult male patients with complete bilateral cleft lip and palate (BCLP) on the basis of lateral cephalometric radiographs.

PATIENTS

The first group of adult male patients with complete BCLP was comprised of 13 unoperated patients with an average age of 21 years. The second group was comprised of 14 patients with an average age of 21 years 7 months, who had been operated only on the lip prior to 2 years of age.

DESIGN

The following measurements were evaluated: angle and length of cranial base; maxillary spatial positioning and length; mandibular spatial positioning; morphology and length; maxillomandibular relationship; vertical facial length; dental positioning; interdental arch relationship; and soft profile.

RESULTS

The results suggest that lip repair has a significant influence on certain areas of the craniofacial complex, mainly the premaxilla and the upper incisors.

CONCLUSIONS

The most significant findings consequent to lip repair consisted of reduction of the premaxillary anterior projection and lingual tipping of the upper incisors. Retropositioning of the premaxilla, especially in the alveolar part, is a desired effect of lip repair in complete BCLP. Such effect on the projected premaxilla is usually beneficial, except when the exceedingly severe lip pressure, unfavorable growth pattern, or both retropositions the midface profile beyond acceptable sagittal limits.

Bilateral superiorly based full-thickness nasolabial island flaps for closure of residual anterior palatal fistulas in an unoperated elderly patient

OBJECTIVE

Unoperated bilateral complete cleft lip and palate in an adult or elderly patient is seen rarely, and the existence of unoperated clefts is a result of unfavorable economic and social circumstances. We report an unoperated 65-year-old patient with bilateral complete cleft lip and palate and present our preference for the surgical management.

INTERVENTIONS

Repair of the bilateral complete cleft lip and palate was successfully carried out using straight-line closure for the bilateral cleft lip and two-flap pushback palatoplasty with superiorly based lateral port control pharyngeal flap for the wide cleft palate at the first stage, and large residual anterior palatal fistulas were closed using bilateral superiorly based (retrograde flow) full-thickness nasolabial island flaps at the second stage.

CONCLUSIONS

To our knowledge based on a review of the literature, this is the first report of an elderly patient with bilateral complete cleft lip and palate and the first application of bilateral superiorly based (retrograde flow) full-thickness nasolabial island flaps for closure of large residual anterior palatal fistulas or alveolar clefts. The bilateral superiorly based (retrograde flow) full-thickness nasolabial island flap may be a good solution in large anterior palatal defects using unilaterally or bilaterally in a single stage with minimal donor site morbidity, in which there is not enough tissue for local repair or if previous attempts are unsuccessful.