The effect of facemask in patients with unilateral cleft lip and palate: a systematic review and meta-analysis

Assessment of the Mandibular Osseous Architecture in Cleft Lip and Palate Using Fractal Dimension Analysis: A Pilot Study

Background/Objectives: Although there has been extensive research on the orofacial morphologic effects of cleft lip and palate (CLP), the effects of CLP on mandibular structures remain largely unknown. The aim of this study was to investigate the trabeculation differences in the mandibular osseous architecture of patients with bilateral CLP (BCLP) and left-sided unilateral CLP (UCLP) using fractal dimension (FD) analysis and to compare these findings with healthy controls without CLP. Methods: A total of 63 patients (27 females, 36 males) with a mean age of 9.69 ± 1.5 years in the pre-peak growth stage were divided into three groups (n = 21 per group): the control group (CG), the BCLP group, and the UCLP group. The FD analysis was conducted on selected regions of interest (ROIs) from the mandibular condyle, angulus, corpus, and coronoid areas in TIFF-formatted panoramic radiographs. Statistical analyses were performed using the paired t-test and ANOVA for parametric data, and the Wilcoxon and Kruskal-Wallis tests for nonparametric data. Statistical significance was set at p < 0.05. Results: The FD values obtained from the ROIs of the right condyle were found to be significantly lower in the BCLP group compared to the CG and UCLP groups (p < 0.05). Conversely, the FD values for the left condyle were significantly higher in the CG group (p < 0.05), while no significant differences were observed between the BCLP and UCLP groups (p > 0.05). The FD value of the left condyle in the UCLP group was found to be significantly lower than that of the right condyle (p < 0.05). In the CG group, the FD values for both the right and left mandibular condyle and corpus were significantly higher than those for the angulus and coronoid regions; in the UCLP group, only the FD values of the right mandibular condyle and corpus were significantly higher than those for the same regions (p < 0.05). Conclusions: The reduced FD values in the mandibular condyle of CLP patients during the pre-peak growth stage suggest a loss of trabeculation and lower metabolic activity, while similarly, reduced FD values in the corpus region contribute to delayed tooth eruption timing, likely due to decreased masticatory forces during the intercuspal position and altered occlusal relationships. Clinical Relevance: In treating CLP patients, particularly with orthopedic face masks, the reduction in metabolic activities in these areas should be considered to achieve the optimal mandibular growth and development, and dental eruptions during the distribution of force from the chin to the corpus and condyle.

Evidence Mapping and Quality Analysis of Systematic Reviews on Various Aspects Related to Cleft Lip and Palate

BACKGROUND

Management of cleft lip and palate is interdisciplinary. An evidence-mapping approach was envisaged to highlight the existing gaps in this field, using only the highest level of evidence.

OBJECTIVES

To conduct evidence mapping and quality analysis of systematic reviews and meta-analyses related to any aspect of cleft lip and palate.

SEARCH METHODS

The cleft lip and palate field was divided into 9 domains and 50 subdomains and a method of categorization of systematic reviews was established. A comprehensive search strategy was carried out in seven databases along with the search of gray literature and references of included articles.

SELECTION CRITERIA

Systematic reviews related to any aspect of cleft lip and palate, conducted by a minimum of two reviewers, with a comprehensive search strategy and adequate quality analysis were included.

DATA COLLECTION AND ANALYSIS

A self-designed, pre-piloted data-extraction sheet was used to collect information that was analyzed through an expert group discussion. Quality analysis was performed using ROBIS-I, AMSTAR 2, and the PRISMA checklist.

RESULTS

A total of 144 systematic reviews published between 2008 and 2022 were included. The largest number of these could be categorized in the therapeutic domain (n = 58). A total of 27% of the studies were categorized as inconclusive, 40% as partially conclusive, and 33% as conclusive. As per ROBIS-I, 77% of reviews had high risk of bias while 58% were graded as critically low in quality as per AMSTAR 2. The majority of systematic reviews showed low reporting errors.

CONCLUSIONS

The majority of systematic reviews related to cleft lip and palate relate to therapeutic and prognostic domains and show high risk of bias and critically low quality regardless of the source journal. The results of this paper might serve as a starting point encouraging authors to carry out high-quality research where evidence is lacking.

REGISTRATION

A multidisciplinary expert-group formulated an a priori protocol, registered in Open Science Framework (DOI 10.17605/OSF.IO/NQDV2).

Efficacy of Different Methods of Bone-Anchored Maxillary Protraction in Cleft Lip and Palate Children: A Systematic Review and Meta-Analysis

INTRODUCTION

Bone-anchored maxillary protraction (BAMP) is an effective option for adolescent cleft patients with maxillary hypoplasia. Hence, this study was conducted to access the effectiveness of the many techniques of BAMP in cleft lip and palate patients.

METHODS AND MATERIALS

Data was compiled through a global search of random and nonrandom studies that investigated the efficacy of various techniques of BAMP in cleft lip and palate patients. The searches were conducted in ISI Web of Science, EMBASE, Scopus, Medline, and Cochrane Central Register of Controlled Trials from the beginning until October 12, 2021. The pertinent data of the comprised studies were extracted using predetermined extraction forms. Meta-analysis results were obtained by using inverse-variance to calculate the pooled results of the outcome measures.

RESULTS

Five studies were submitted for meta-analysis. The BAMP therapeutic methods investigated in the studies were facemask attached to miniplates (FM-MP) and class III elastics attached to maxillary and mandibular miniplates (C3-IE: class III intermaxillary elastic). The mean differences of A-VRP, A-N Prep., ANB, wits, overjet, and SNA landmarks indicated posttreatment was encouraging, showing maxillary protrusion, and correction of class III malocclusion. SNB landmark showed no statistically significant alterations posttreatment. Subgroup analysis of the C3-IE and FM-MP subgroups indicated that the changes in ANB, SNA, and overjet parameters in the FM-MP subgroup were more pronounced than in the C3-IE subgroup. No statistically significant differences were found when the results of these 2-treatment method were compared, except for in the overjet subgroup.

CONCLUSION

After undergoing BAMP treatment, the maxilla showed a more horizontal growth, but no changes in the vertical dimension were observed and the mandible did not rotate clockwise. In addition, using facemask-miniplates was more effective in increasing overjet compared with using class III elastics with bone anchors. In conclusion, BAMP treatment is a suitable alternative for adolescents with cleft lip and palate malformation.

Impact of bone-anchored maxillary protraction on the quality of life of subjects with complete unilateral cleft lip and palate

INTRODUCTION

This study aimed to evaluate the influence of bone-anchored maxillary protraction (BAMP) on the oral health-related quality of life (OHRQOL) in subjects with complete unilateral cleft lip and palate (UCLP) and moderate-to-severe maxillary deficiency.

METHODS

A longitudinal observational study was conducted with a sample of 20 patients (13 males, 7 females) aged 10-14 years (mean age, 11.8 years) with Goslon 3, 4, and 5. To assess the patient's perception of their OHRQOL, the Quality of Life Questionnaire for Orthosurgical Patients was administered in 2 stages: after the installation of the protraction plates (T1) and 18 months after the protraction therapy started (T2). The questionnaire was composed of 4 domains, distributed over 22 questions: social aspects, facial esthetics, oral function, and awareness of facial deformity.

RESULTS

The treatment protocol improved the OHRQOL in 75% of the patients who presented UCLP. The domain social aspects of the deformity were the only one that showed a significant difference from T1 to T2 and indicated an improvement in self-esteem. The girls had worse OHRQOL than boys at T1, which was statistically significant only for the domains of social aspects of deformity and awareness of deformity. After BAMP therapy, the effect size indicated a larger change in OHRQOL in girls than in boys.

CONCLUSIONS

BAMP therapy positively impacted the OHRQOL and self-esteem of patients with UCLP during adolescence.

Orthodontic treatment protocols in patients with alveolar clefting: a survey of ACPA-approved cleft teams in the United States

OBJECTIVES

To describe pre- and post-alveolar bone graft (ABG) practice protocols of orthodontists associated with American Cleft Palate-Craniofacial Association-approved cleft and cleft/craniofacial teams.

MATERIALS AND METHODS

Electronic survey responses from team orthodontists were evaluated regarding pre-ABG orthodontic treatment type(s), timing of post-ABG imaging and post-ABG orthodontic treatment, and craniofacial orthodontic fellowship training status of the team orthodontists. A P value of <.05 was considered significant.

RESULTS

Of 31 responding orthodontists, 54.8% had fellowship training and 45.2% did not. Pre-ABG orthodontic preparation ranged from solely maxillary expansion for alveolar segment alignment (35.5%) to a combination of maxillary expansion for both alveolar segment alignment and posterior crossbite correction, anterior tooth alignment, and anterior crossbite correction (19.4%). Most captured post-ABG radiographs prior to orthodontic tooth movement (90.3%). Orthodontists began treatment at least 6 months (35.5%), 2-4 months (32.3%), or 4-6 months (29%) post-ABG. No significant differences were found when comparing fellowship subgroups. In addition, 47.1% of fellowship-trained orthodontists deferred post-ABG orthodontic treatment to at least 6 months post-operatively, vs 21.4% of non-fellowship trained orthodontists (P = .14).

CONCLUSIONS

A large variation in approaches is evident in pre-ABG orthodontic treatment types and timing of post-ABG treatment. Post-operative imaging is pursued by most orthodontists to assess graft status prior to initiating orthodontic treatment. Additional clinical research is needed to support providers in their decision-making with regard to evidence-based approaches.

Cleft Orthodontic Care in Europe: A Cross-Sectional Survey

(1) Background: Orthodontists have an important role in cleft care. Over the two decades since the Eurocleft studies, a significant improvement in healthcare systems has been achieved but there has been no critical assessment regarding the establishment of proposed standard protocols. This study aimed to describe the current provider characteristics, orthodontic appliances, services offered, orthodontic complications, and cost analysis of cleft treatment in Europe. (2) Methods: A cross-sectional 22-question online survey, accessible from January 2021 to July 2021, was sent to 214 practitioners, pertaining to provider characteristics, orthodontic appliances, services offered, orthodontic complications, and cost analysis. Descriptive statistics were calculated for each question. Fisher’s exact test was used to assess the association between categorical variables. (3) Results: A total of 79 responses from 23 European countries completed the survey (response rate = 37%), with 69 surveys being assessed after the exclusion of incomplete surveys. Rapid maxillary expansion was the preferred expansion protocol (45%). Distraction osteogenesis was the most reported alternative treatment to secondary bone grafts (19%), with private practitioners being less likely to perform these treatments (Fisher’s exact test, p = 0.001). Orthodontic services offered were, however, rather similar in the various locations of provision (hospital and/or university, private). Compromised oral hygiene (77%) was the most reported orthodontic complication. The National Health Services support the majority of cleft orthodontic care (67%) in Europe. (4) Conclusion: An apparent improvement in orthodontic healthcare provision has been achieved within Europe in the last two decades, but there are several discrepancies, namely regarding treatment timing and the appliances offered.

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.