The psychosocial effects of cleft lip and palate: a systematic review

Beyond the Chest Wall: Examining the Relationship between Morphological Features and Psychosocial Distress in Pectus Excavatum Patients

INTRODUCTION

 Pectus excavatum patients frequently experience psychosocial distress, yet the relationship with morphological features of the deformity remains unexplored. We hypothesize that certain morphological features analyzed by 3D optical surface imaging contribute more prominently to the distress experienced by pectus excavatum patients as they impact the visible severity of the deformity.

MATERIALS AND METHODS

 Consecutive pectus excavatum patients who received three-dimensional optical surface imaging between August 2019 and November 2022 were included. Logistic regression analysis assessed the association between morphological features and psychosocial distress in which the distress was scored as a binary variable, based on a self-reported assessment.

RESULTS

 Among 215 patients, 55% reported psychosocial distress with multivariable analyses revealing greater depth and length of the deformity being significantly correlated with psychosocial distress. However, this prediction model demonstrated a moderate discriminative ability with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI], 0.59-0.73) for pectus depth and 0.58 (95% CI, 0.51-0.66) for pectus length.

CONCLUSIONS

 The morphological features of length and depth of the deformity are correlated with psychosocial distress. Nonetheless, these individual features are weak predictors due to their moderate discriminative ability. This underscores that other patient-related factors, such as personality traits, neuropsychological conditions, and other psychosocial influences, are likely to play a role in the occurrence of psychosocial distress. Future studies should investigate these variables alongside the incorporation of standardized instruments for measuring psychosocial distress to better understand and address the distress in this population.

Psychosocial Status and Self-Perception in Patients with Cleft Lip and/or Palate

ObjectiveTo describe how the psychosocial status of patients with cleft lip and/or palate (CL/P) relates to patient-reported outcomes (PROs).DesignCross-sectional retrospective chart review.SettingTertiary care pediatric hospital.Patients/ParticipantsPatients aged 8 to 29 years attending cleft team evaluations during a 1-year period.Main Outcome MeasuresCLEFT-Q.ResultsPatients (N = 158) with isolated or syndromic CL/P and mean age 13.4 ± 3.0 years were included. Fifteen (9%) patients had siblings who also had CL/P. Of 104 patients who met with the team psychologist, psychosocial concerns were identified in 49 (47%) patients, including 25 (24%) with Attention-Deficit/Hyperactivity Disorder or behavior concerns, 28 (27%) with anxiety, and 14 (13%) with depression or mood concerns. Younger age and having siblings with cleft were associated with better PROs, while psychosocial concerns were associated with worse PROs on Speech, Psychosocial, and Face Appearance scales.ConclusionsPatient perception of cleft outcomes is linked to psychosocial factors.

Validity of the Cleft Aesthetic Rating Scale Does Not Improve with Inclusion of Fixed Scores for Atypical Outcomes

ObjectiveThe Cleft Aesthetic Rating Scale (CARS) is a valid tool to assess the aesthetic outcome after unilateral cleft lip and palate (UCLP) repair. The goal of this study was to investigate whether the reliability of CARS increases by including fixed rates for atypical outcomes such as a smaller nostril, lower vermillion border or whistling deformity.Design197 patients with UCLP who underwent cleft repair were included. Three cleft experts rated the post-operative photos using the original CARS, followed by a second assessment employing the modified CARS.SettingMedisch Centrum Leeuwarden, Universitair Medisch Centrum Groningen, Radboud Universitair Medisch Centrum and Amsterdam University Medical Center.PatientsPhotographs of 16- to 25-year-old patients with repaired UCLP.InterventionsTwo separate assessments using the original and modified CARS.Main outcome measuresThe Intraclass Correlation Coefficient (ICC) was used to test inter-rater reliability of the original and modified version of the CARS.ResultsThe reported ICC for the nose scored by means of the original and modified CARS were 0.68 (95% CI 0.62-0.74) and 0.66 (95% CI 0.59-0.72) respectively. The reported ICC for the lip assessed with the original and modified CARS were 0.53 (95% CI 0.33-0.67) and 0.57 (95% CI 0.34-0.72) respectively.ConclusionsNo significant difference was found between the original and modified ICC of the nose and lip. The implementation of the fixed rates did not result in an increased reliability of the CARS. Therefore, we recommend the utilization of the original CARS.

Satisfaction of Caregivers of Patients With Cleft Lip-Palate at the Khoula Hospital Cleft Center

Existing literature has explored the perspectives of parents of children with cleft lip and/or palate; however, there is a lack of studies addressing parental satisfaction within the Khoula Hospital health care system. The aim of this study was to assess caregiver satisfaction with the cleft care services at Khoula Hospital. A qualitative, questionnaire-based study was distributed to caregivers of children born with cleft lip and/or palate who underwent surgical repair between 2010 and 2024. The study was conducted at the comprehensive cleft center at Khoula Hospital. A total of 797 caregivers participated in the study. Participants reported overall satisfaction with the general cleft care services, although many expressed a desire for the establishment of a combined clinic. Although most caregivers of children with cleft lip and/or palate expressed satisfaction with their children's care, those who were dissatisfied suggested feasible improvements that could enhance the involvement of parents as integral members of the craniofacial team, fostering a more constructive and positive partnership.

Impact of Cheiloplasty and Palatoplasty on the Quality of Life of Children With Cleft Lip and Palate

ObjectiveTo assess the quality of life of parents of patients with cleft lip and/or palate (CL/P) undergoing cheiloplasty or palatoplasty in the pre and/or postoperative periods.DesignThis is a mixed method study. The sample consisted of parents/guardians of non-syndromic patients with CL/P undergoing treatment in the University Hospital of Western Paraná in Brazil. Data were collected from February 2022 to December 2023 and included demographic information, the Impact on Family Scale (33 items) to assess quality of life, and semi-structured interviews, followed by content analysis.ResultsCaregivers' (N = 116) quality of life was generally in the middle to high range and similar across pre and postoperative time points. The most frequent topics identified in interviews were financial difficulties, time required for childcare, esthetic concerns, feeding, phonation, and integration of children into social environments with improvements reported after surgeries.ConclusionQuality of life of caregivers was similar across pre and postoperative periods and content analysis highlighted improvements in psychosocial and functional aspects. Early follow-up with specialized services is recommended to improve the quality of life of caregivers of children with CL/P.

Psychological Screening Indicates That 1 in 4 Children With Cleft Lip and Palate Require Psychological Support

Children with cleft lip and/or palate (CL/P) often experience developmental issues, including language delay, learning difficulties, and attention issues. The aim of the study was to assess potential difficulties in children with CL/P and to determine the necessity of ongoing psychological support. Eighty-two children treated for CL/P, 29 5-year-olds and 53 10-year-olds, participated together with their parents in the study. The Strengths and Difficulties Questionnaire (SDQ) was used to assess difficulties and strengths. Proxy reports were used for the 5-year-olds, while self-reports and proxy reports were utilized for the 10-year-olds. Patients who were identified as requiring further support were offered psychological interventions. Parents of 5-year-olds and 10-year-olds with CL/P estimated significantly more difficulties compared with parents of children in the normal population. Thirty-nine percent of the parents estimated that their child had minor, moderate or severe difficulties. However, 10-year-olds with CL/P didn't perceive any difference in difficulties compared with preadolescents in the normal population. The 10-year-olds estimated significantly less emotional difficulties than children in the normal population. Nevertheless, 41% of the 10-year-olds reported that they overall had difficulties, either minor or severe, in one or more areas. There were significantly moderate correlations between parental and child reports on SDQ. According to the results of the standardized psychological screenings, 25.6% of children with CL/P required additional psychological support. One in 4 children with CL/P needs psychological support. Standardized psychological interview-based follow-ups for patients with CL/P can contribute to more information regarding the patient's needs rather than only using a questionnaire.

A Review and Meta-Analysis on Altered Brain Structure in Patients Born with Non-Syndromic Cleft Lip and/or Palate

ObjectiveTo determine if there is evidence for a relationship between the presence of a non-syndromic cleft lip and/or palate (NSCL/P) and altered brain structure in cleft affected individuals.DesignElectronic database (MEDLINE; EMBASE; Cochrane library) and manual searches were performed and were limited to English language texts published between 1st of January 1969 until 1st of June 2024. Data extraction and risk of bias assessment were carried out independently by two reviewers. A meta-analysis on 9 publications was performed using a random effects model.Main outcome measureComparison of brain structure between patients born with cleft lip and/or palate and unaffected healthy individuals.ResultsThe review identified 11 studies, of which 9 were included in the meta-analysis. The latter comprised 398 individuals with NSCL/P compared to 458 unaffected controls. There was statistical evidence to suggest a reduction in the overall intracranial volume and the total cerebellar volume in the NSCL/P cases compared to the controls (Hedges' g and 95% confidence intervals: -0.36 [95% CI: -0.65, -0.08] and -0.69 [95% CI: -0.84, -0.53], respectively). For the cortical gray matter, straight gyrus, and total cerebral volume, there was no statistical evidence to suggest a difference between the NSCL/P cases and the controls.ConclusionIn individuals with NSCL/P, the overall intracranial volume and the total cerebellar volume were both smaller than in unaffected controls.

Buccal Fat Pad in Primary and Secondary Cleft Palate Repair: A Systematic Review of the Literature

ObjectiveTo review the evidence supporting the use of buccal fat pad (BFP) in primary and secondary cleft palate repair and its short- and long- term clinical outcomes.DesignSystematic review conducted by 2 independent reviewers following PRISMA guidelines.Setting: None ParticipantsArticles were identified from three databases (Pubmed/Medline, Embase and Web of Science). Search terms included "cleft palate", "palatoplasty", "palate repair", "buccal fat pad".InterventionsUse of BFP in primary and secondary cleft palatoplasty.Main Outcome MeasuresPrimary outcomes were immediate postoperative complications, postoperative fistula, and maxillary growth. Secondary outcomes were palatal length, speech, and donor site morbidity.ResultsNinety-one reports were retrieved after excluding duplicates. Twenty-three studies were included (13 case series and 10 comparative studies). Overall level of evidence was low. Randomized and non-randomized studies had a high risk of bias. In primary palatoplasty, BFP was more frequently used filling lateral relaxing incisions(57.4%), or in the hard-soft palate junction and covering mucosal defects(30.1%). In these patients, post operative fistula incidence was 2.8%. Two studies found wider transverse maxillary dimensions after BFP use. No higher incidence of bleeding, infection, dehiscence, or flap necrosis was reported. In secondary palatoplasty, no recurrent fistulas were reported for patients undergoing BFP for fistula repair.ConclusionsBFP appears to be associated with a favorable impact in fistula prevention and management, as well as in transverse maxillary growth. However, there is a high heterogeneity among studies, high risk of bias and overall low quality of evidence. More high-quality research with long-term follow-up is warranted.

Is the Future of Cleft Care Financially Sustainable? An Economic Analysis of Inflation-Adjusted Reimbursements

OBJECTIVE

As Medicaid continues to expand, it remains unclear if reimbursement rates for cleft care are keeping up with the national economy. The purpose of this study is to determine how financial trends in cleft lip and palate repair reimbursements compare to annual changes in the U.S. economy.

DESIGN

Current Procedural Terminology (CPT) codes for cleft lip and palate repair were retrospectively reviewed between 2018 and 2023. Reimbursements were adjusted for inflation to 2023 U.S. dollars using Medicaid physician fee schedules. Annual percentage changes in inflation-adjusted reimbursements, and reimbursement Compounded Annual Growth Rate (CAGR) were compared to the annual change in the U.S. Consumer Price Index (CPI).

SETTING

Multi-state, Medicaid.

PARTICIPANTS

Medicaid reimbursements of 6 U.S. states, 5 with highest birthrates: California, Texas, Florida, New York, and Pennsylvania. Colorado, the study institution, was evaluated.

MAIN OUTCOME(S)

Primary outcomes included annual changes in overall and inflation-adjusted reimbursement rates for cleft lip and palate surgical procedures as compared to annual changes in CPI.

RESULTS

The U.S. CPI increased by 20.9% from 2018 to 2023, while the overall total percentage change in reimbursement rates for all cleft lip and palate procedures increased by 7.23%. The inflation-adjusted overall percent change in reimbursements for all procedures decreased by -12.81%. For all procedures, the average CAGR was -2.66%.

CONCLUSIONS

Inflation-adjusted reimbursement rates for cleft lip and palate repair have significantly decreased in contrast to the annual growth in U.S. CPI. These findings show a potential lack of financial sustainability for surgical cleft care, indicating the need for healthcare policy reform.

Effects of malocclusion and orthodontic treatment on quality of life among orthodontic patients with craniofacial disorder compared to healthy controls : A cross-sectional study

PURPOSE

Craniofacial disorders (CD) affect the Oral Health Impact Profile (OHIP). Therefore, this study evaluates the OHIP in orthodontic patients with cleft lip and/or palate or Robin sequence compared to healthy controls (C).

METHODS

A prospective, cross-sectional study was conducted. Oral health-related quality of life (OHRQoL) was assessed using the OHIP-14 questionnaire, with responses categorized into functional and psychological well-being items. In addition, the study considered the influence of crossbite, orthodontic appliance type, oral hygiene, and speech therapy. A high OHIP score represents a good quality of life. The Mann-Whitney test was used for nonparametric quantitative variables; statistical significance was set at p < 0.05.

RESULTS

The study included 119 participants (ages 7-21 years; 61 male, 58 female), divided into a CD group consisting of patients with cleft lip and/or palate or Robin sequence (n = 42) and a control group (C; n = 77; mean age 13.5 ± 5.2 and 14.3 ± 3.3 years, respectively). Both groups showed comparable OHIP-14 scores. The CD group reported significantly higher satisfaction regarding nutritional intake (p = 0.03), while the social and psychological dimensions were reduced (p = 0.04). Factors like crossbite, orthodontic appliance and speech therapy did not have a significant impact on OHIP. CD patients with good oral hygiene showed significantly superior self-reported psychological OHIP (p = 0.04).

CONCLUSION

Patients with cleft lip and/or palate or with Robin sequence exhibited OHIP scores comparable to healthy individuals despite their underlying condition. Early guidance on dental care and tooth-friendly nutrition has the potential to improve OHRQoL. Additionally, providing supplemental psychological support during orthodontic treatment is advisable.

Lives of Irish Adolescents Who Were Born With a Cleft (LIA-Cleft)

ObjectiveThe objective was to describe the lives of adolescents, who were born with cleft lip and palate (CL/P), in comparison to the general population as recorded in Growing up in Ireland (GUI), the national longitudinal study of children and youth.DesignThis was a cross-sectional study.Setting: The study was performed in a cleft center at a university teaching hospital.Participants: Adolescents born with CL/P in the years 2007 to 2009.Interventions: Growing up in Ireland questionnaires, which assessed demographics, health and experience of friendship, school, leisure, and social life, were adapted and administered to adolescents and their parents/guardians, who were identified from a prospectively maintained cleft database. Data were compared to that of GUI Cohort '08.Main Outcome Measures: Outcome measures comprised primary caregiver and young person self-report items. Mental health and psychological well-being were assessed using validated instruments including the Strengths and Difficulties Questionnaire.ResultsThirty adolescents (10 female, 20 male) participated in the LIA-Cleft group. LIA-Cleft respondents indicated poorer ratings of both medical and dental health than the GUI group. Responses to questions regarding friendship, bullying, physical activity, social media, and screen time were similar in the GUI and LIA-Cleft groups. The LIA-Cleft group were less satisfied with their lives and exhibited lower self-esteem than the GUI group, but did not differ in measures of mental health and well-being or socioemotional well-being.ConclusionsIn spite of reporting poorer medical and dental health, young people who were born with CL/P in Ireland lead lives that are broadly similar to their peers in the general population.

Does Palatoplasty Technique Impact Resolution of Eustachian Tube Dysfunction?

ObjectiveTo determine whether palatoplasty technique affects the resolution of eustachian tube dysfunction and postoperative speech outcomes in children with cleft palate (CP).DesignRetrospective cohort.SettingMultidisciplinary cleft and craniofacial clinic at a tertiary care center.PatientsSeventy-three patients with nonsyndromic CP who underwent palatoplasty between 2005 and 2019. Inclusion criteria included soft palate repair with Furlow technique or intravelar veloplasty (IVV) and Veau classifications I-III.InterventionsEither Furlow or IVV repair was performed based on the surgeon's clinical judgment. All patients had bilateral ear tubes placed prior to or at the time of palate repair, with postpalatoplasty ear tubes placed at the ENT surgeon's discretion. Patients received routine follow-up care for over 5 years. Data were analyzed with Wilcoxon tests, χ2 tests, and negative binomial regression.Main Outcome MeasuresNumber of postpalatoplasty ear tubes placed, rates of velopharyngeal insufficiency, and speech surgery after palatoplasty in each group.ResultsFurlow repair patients required a similar number of postpalatoplasty ear tubes (P = .321) and underwent additional sets at similar rates compared to those who underwent IVV repair. Negative binomial regression found no covariates (age, race, Veau, repair type, speech surgery, fistula repair) that predicted additional ear tube requirements.ConclusionFurlow repair patients required postpalatoplasty ear tubes at a similar rate compared to IVV repair patients. While the palatoplasty techniques differ, patients may still need the same amount of time for resolution of their eustachian tube dysfunction.

Appearance-related distress impacts psychological symptoms in Chinese patients with cleft lip

Background

This study aimed to explore the characteristics of appearance-related distress and the relationship between appearance-related distress, anxiety and depression symptoms in Chinese patients with cleft lip (CL).

Methods

The Derriford Appearance Scale 59 (DAS-59), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) were used to screen for appearance-related distress, anxiety, and depression symptoms in Chinese patients with CL, respectively.

Results

A total of 63 patients with CL, comprising 43 unilateral and 20 bilateral cases, and 64 individuals without CL in the control group were included in the study. Appearance-related distress was compared between patients with CL and non-cleft individuals. The relationship between appearance-related distress and two psychological symptoms was estimated. The DAS-59 scores in patients with CL were significantly higher than those in non-cleft individuals. The DAS-59 scores in patients with CL who had anxiety or depression symptoms were significantly higher than those without symptoms, and the DAS-59 scores were correlated with GAD-7 and PHQ-9 scores. After adjustment for demographic variables, the DAS-59 scores were also positively associated with GAD-7 and PHQ-9 scores in patients with CL.

Conclusion

More significant appearance-related distress was observed in Chinese patients with CL compared to the control group, but it did not exhibit a correlation with the patients' diagnosis (unilateral or bilateral), sex, age, or other demographic characteristics. Furthermore, appearance-related distress plays a significant role in psychological symptoms and may serve as a predictor of anxiety and depressive symptoms.

Primary Rhinoplasty for Unilateral Cleft Lip: A Long-Term Cohort Assessment of Aesthetic and Anthropometric Outcomes

The decision to undertake rhinoplasty maneuvers during cleft lip repair remains controversial. Little data compare long-term outcomes with and without primary rhinoplasty (PR). This study compared nasolabial outcomes in cohorts with unilateral cleft lip (UCL) treated with and without PR at the Children's Hospital of Philadelphia using standardized aesthetic and anthropometric assessments.

Retrospective cohort study.

Tertiary care pediatric hospital.

Patients who underwent lip repair for UCL.

Cleft lip repair with and without PR.

Anthropometric analyses and crowdsourced aesthetic assessments using Americleft nasolabial appearance reference scales and pairwise comparisons.

Among 208 patients, 155 (74.5%) and 53 (25.5%) underwent lip repair with and without PR at 4.5 ± 1.1 months. Primary rhinoplasty (β = 0.345, P = .037) and a lower Cleft Lip Severity Index (β = -0.341, P < .001) predicted superior pairwise rank at 4.9 ± 1.9 years of age. History of PR predicted decreased columellar deviation angle (CDA) (β = -2.375, P = .019) and improved nostril symmetry (β = 0.111, P = .038). Increased columellar-labial angle (r = 0.27, P = .002), improved nostril symmetry (r = -0.23, P = .01), and decreased CDA (r = -0.45, P < .001) correlated with superior ratings. Patients with ˂20 days of postoperative nasal stenting had inferior lateral ratings (2.4 ± 0.6 vs 2.1 ± 0.5, P = .005). Those who underwent surgery at ˂5.3 months had inferior nasal projection (Goode's ratio 0.56 ± 0.09 vs 0.62 ± 0.08, P = .006).

Primary rhinoplasty for UCL offers superior aesthetic results in early childhood by layperson and anthropometric assessments. Specific improved characteristics from PR-CDA and nostril symmetry-most greatly influence layperson perception of nasal appearance. Older age at surgery predicted increased nasal projection, while prolonged nasal stenting predicted superior profile appearance.

Rethinking speech sound disorder (SSD) in non-syndromic cleft lip and palate: The importance of recognizing phonological and language difficulties

BACKGROUND

Children born with cleft palate ± lip (CP ± L) are at risk of speech sound disorder (SSD). Up to 40% continue to have SSD at age 5-6 years. These difficulties are typically described as articulatory in nature and often include cleft speech characteristics (CSC) hypothesized to result from structural differences. In non-CP ± L SSD comorbidity with language difficulties is often reported. There is growing evidence of concomitant language difficulties in children with CP ± L and of a higher prevalence of developmental speech errors in children compared with non-CP ± L peers. The impact of underlying phonological and language skills on speech production in children with CP ± L is poorly understood.

AIMS

To investigate language outcomes in children with CP ± L and the relationship to speech production, by answering the following research questions: (1) Does the profile of language skills in children with CP ± L differ from normative samples? (2) Do children with CP ± L and SSD have poorer language skills than those with typically developing speech? (3) Is there an association between language skills and speech profile in children with CP ± L at age 5-8 years?

METHODS & PROCEDURES

In this prospective cross-sectional, observational study, 95 participants were recruited from regional cleft lip and palate services in the UK. They were aged 5;0-7;11 with non-syndromic CP ± L. Those with a syndromic diagnosis, global learning disability, sensorineural hearing loss and first language other than English were excluded. Assessments of speech (Diagnostic Evaluation of Articulation and Phonology-DEAP) and language (Clinical Evaluation of Language Fundamentals-5th UK edition-CELF) were completed. Language outcomes were analysed and compared with normative samples and according to speech error analysis.

OUTCOMES & RESULTS

Average language scores were within the expected range. For those presenting with SSD, language scores were significantly lower than those with typically developing speech. Analysis of speech errors showed four distinct speech profiles: typical speech, CSC only, developmental speech characteristics (DSC), and combined CSC + DSC. Language scores were lower for participants with DSC (±CSC). A significant association was found between the presence of CSC + DSC and expressive language outcomes (odds ratio (OR) = 10.82; 95% confidence interval (CI) = 2.42, 48.32, p = 0.002).

CONCLUSIONS & IMPLICATIONS

An association between language skills and speech production was observed. The distribution of speech errors in children with CP ± L varied with a high level of DSC as well as CSC. Those with CSC + DSC had significantly lower language scores than those with typically developing speech or CSC only. Speech and language therapists working with this caseload should be alerted to potential ongoing phonological and language difficulties in children presenting with this profile.

WHAT THIS PAPER ADDS

What is already known on this subject Children born with CP ± L are known to be at risk of SSD. There is also evidence of language delay in the early years. Evidence for persistent language difficulties is equivocal but some studies have shown a higher than average prevalence of developmental phonological errors in addition to cleft articulation errors in speech production. What this paper adds to the existing knowledge This study investigates links between speech development and language skills in children aged 5-8 years with non-syndromic CP ± L. It adds to our understanding of the nature of SSD in children with CP ± L and in particular the relationship between language skills and speech production. It shows that children with CP ± L have varied speech profiles and that those presenting with delayed phonological processes are also at risk of language difficulties. What are the potential or actual clinical implications of this work? Speech and language therapists working with children with CP ± L should be aware of the varied nature of SSD in this population. They should be alert to the need for additional assessment of language for those presenting with delayed phonological processes and the implications this has for educational attainment.

Evaluating quality of life changes in patients with cleft lip or palate: a mixed method pre- and postsurgical analysis in Karachi

BACKGROUND

Cleft lip and/or palate (CLP) is the most common orofacial congenital disability, presenting significant medical, psychological, and social challenges. In Pakistan, the incidence of CLP is high, estimated at one in 523 live births, but accurate data are lacking due to the absence of a birth registry. Early diagnosis and intervention are crucial for improving outcomes. This study evaluated the impact of CLP on patients' quality of life in Karachi, comparing pre- and post-surgical phases.

METHODS

A sequential exploratory quantitative-qualitative mixed-methods study was conducted at two tertiary care hospitals in Karachi. In the quantitative phase, 280 patients with CLP, either awaiting or post-surgery, completed the Oral Health Impact Profile (OHIP-14) questionnaire to assess oral health-related quality of life (OHRQoL). Based on questionnaire responses, 30 participants were purposively selected for in-depth, semi-structured interviews exploring their experiences. Quantitative data were analyzed using SPSS version 25; qualitative data were analyzed thematically.

RESULTS

Quantitative findings revealed significant gender disparities in cleft types and correction status; females had a higher prevalence of unilateral cleft lip, while males had more cleft palate cases. Dental and oral health issues significantly affected daily activities, with higher impacts in cleft palate patients. OHRQoL varied by gender, cleft type, and correction status, with those post-surgery reporting poorer OHRQoL. Qualitative analysis identified six themes: Diagnosis and Early Treatment, Challenges and Impact, Postsurgical Experiences, Support Systems, Healthcare Experiences, and Future Perspectives. Inconsistencies in psychological support, accessibility and financial burdens were presented as significant issues. Sentiment analysis highlighted varied emotions, from despair to hope and gratitude.

CONCLUSIONS

CLP significantly affects patients' quality of life in Karachi across multiple dimensions. Early diagnosis and surgical intervention are essential but often hindered by financial and accessibility issues. Psychological effects, including low self-esteem and social isolation, highlight the need for integrated mental health support. Family and community support are critical for patient resilience. A comprehensive approach addressing medical, psychological, social, and systemic factors is necessary to improve outcomes for individuals with CLP.

Association of Clinical, Biomechanical, and Psychosocial Factors with Smile Dynamics in Unilateral Cleft Lip: A Multicenter Observational Study

OBJECTIVE

To investigate the association between clinical, biomechanical, and psychosocial factors and smiling behavior in individuals with treated unilateral cleft lip with or without cleft palate (UCL ± P) compared to non-cleft controls.

DESIGN

Multicenter observational study in New Zealand.

PARTICIPANTS

Individuals aged ≥15 (N = 42) comprised 2 study groups: a UCL ± P group (N = 21) and a non-cleft control group (N = 21).

METHODS

Participants viewed an amusing video while their facial expressions were recorded. Smile features were automatically detected via software. A clinical outcome, nasolabial esthetics, was scored using the Asher-McDade system. Perioral biomechanical properties were measured via myotonometry. Smile Esthetics-related Quality of Life (SERQoL), Orofacial Esthetics Scale (OES), and personality (IPIP-NEO-60) questionnaires were completed.

RESULTS

Smile features and personality traits did not differ between the groups. Participants with UCL ± P exhibited higher stiffness (+44.2%; Cohen's d = 1.6) and tone (+22.6%; Cohen's d = 1.9) at the cleft scar site, and higher decrement (or lower elasticity, +8.5%; Cohen's d = 0.8) adjacent to the scar. Nasolabial esthetics and elasticity of the scar correlated with the duration of smiles and relative smile time (-0.50 < R < -0.44; p < .05). Participants in the UCL ± P group had lower scores for the OES and higher impacts on SERQoL for social contacts and dental self-confidence.

CONCLUSIONS

Adolescents and adults with UCL ± P exhibit similar smile behavior as their cleft-free peers-at least in non-social settings. Nasolabial esthetics and perioral biomechanical properties are associated with propensity to smile. UCL ± P is negatively associated with smile-related quality of life and an individual's perception of their facial appearance.

Organotin exposure and DNA methylation in non-syndromic cleft lip and palate: Integrating findings from case-control studies and animal experiments

Human exposure to organotin is common but little is known about the adverse pregnancy outcomes. This study aimed to explore the association between organotin exposure and the risk of non-syndromic cleft lip with or without cleft palate (NSCL/P) and to explore the underlying mechanism. Placental samples (109 NSCL/P cases and 128 controls) were analyzed for 8 organotin concentrations, and subsequent animal experiments were conducted by administering tributyltin (TBT) during critical developmental periods. DNA methylation BeadChip analysis (12 NSCL/P and 12 controls), bisulfite Sequencing analysis (3 NSCL/P and 3 controls mice), and RNA sequencing were performed to explore epigenetic mechanisms. Logistic regression, LASSO regression, support vector machine, random forest, and mediation effect analysis were utilized to identify key genes related to TBT and NSCL/P. Only tributyltin met the detection criteria for further analysis among 8 compounds. The median levels of TBT in cases (8.93 ng/g) were statistically significantly higher than those in controls (5.33 ng/g). Excessive TBT exposure in maternal placenta was associated with an increased risk of NSCL/P (OR = 6.44, 95 % CI, 2.91-14.25) in humans, showing a dose-response relationship (p for trend <0.05). 288 differentially methylated CpG sites in 129 genes were identified between cases and controls. Tributyltin was associated with FGFR2 and SCD hypomethylation, which were identified as potential key genes associated with NSCL/P. Mediation analysis suggested that DNA methylation of FGFR2 and SCD may mediate the impact of TBT on NSCL/P occurrence. TBT exposure during the critical period in mice (GD8.5-GD15.5) can induce progeny NSCL/P. Altered FGFR2 and SCD hypomethylation and gene expression observed in response to TBT exposure in fetal mice. Excessive TBT exposure was associated with increased risks of human NSCL/P. TBT exposure can induce NSCL/P in fetal mice. FGFR2 and SCD were implicated in NSCL/P pathogenesis, potentially mediated by DNA methylation alterations.

Epidemiology of cleft lip and palate in Bhutan, 2015-2022

BACKGROUND

The epidemiology of cleft lip (CL) and cleft palate (CLP) has not previously been described in the context of the Bhutan and Bhutanese populations. Using National Birth Defects Surveillance Data and other vital statistics, we present the comprehensive epidemiology of the cleft lip and palate in Bhutan.

METHODOLOGY

The National Birth Defects Surveillance Data Registry from 2015 to 2022 is reviewed retrospectively, covering 8 years of birth defect surveillance in the country from records maintained with three referral hospitals in the country. The baseline prevalence and incidence of cleft lip and palate have been presented over the years. The incidence of cleft lip and palate was defined as the number of cases per 1000 live births. We used Poisson's regression to compute the incidence of cleft lip and palate. Pearson chi-square tests (χ2) were used to examine the associations of maternal and child characteristics with cleft lip and palate.

RESULTS

A total of 1401 newborns with various birth defects were born among the 89,078 live births from 2015 to 2022 in Bhutan. Of these, 122 (8.7%) constituted orofacial clefts. The prevalence of orofacial clefts tended to increase, with a period prevalence of 1.37 per 1000 live births. There were more cases in males (72) than in females (50). The incidence rate ratio ranged from 1.2 to 2.0 compared with the 2015 baseline year, indicating increased rates over time.

CONCLUSION

Orofacial clefts constituted 8.7% of total birth defects and 1.37 per 1000 live births over the years. The increasing prevalence trends and incidence rate ratios over the years underscore the importance of ongoing surveillance and interventions to address the burden of orofacial clefts in Bhutan.

CLINICAL TRIAL NUMBER

Not applicable.

The mediating role of life satisfaction in the effect of caregiving burden on mental well-being in parents of children diagnosed with cleft lip/palate

PURPOSE

This study aimed to examine the effect of caregiving burden on the mental well-being of parents of children with cleft lip/palate, with life satisfaction as a mediator.

DESIGN AND METHODS

This descriptive, cross-sectional study was conducted with a sample of 347 parents of children with cleft lip/palate. Data were collected through face-to-face interviews with the parents between March 18 and September 4, 2023. The data collection tools included a sociodemographic data form, the Zarit Burden Interview, the Warwick-Edinburgh Mental Well-Being Scale, and the Satisfaction with Life Scale.

RESULTS

It was found that parents with a higher caregiving burden had lower levels of life satisfaction. Additionally, parents with higher life satisfaction reported better mental well-being. The findings indicated that as the caregiving burden increased, the mental well-being of the parents decreased. The results suggest that life satisfaction mitigates the negative impact of caregiving burden on mental well-being.

CONCLUSION

These findings suggest that life satisfaction plays a significant mediating role in maintaining and supporting parents' mental health. Parents with higher life satisfaction appear to cope better with the challenges posed by caregiving burden, which in turn helps them maintain better mental well-being.

PRACTICE IMPLICATIONS

The findings show that as the caregiving burden increases, both life satisfaction and mental well-being decrease. Therefore, it is crucial to develop practical interventions to support these parents.

Psychosocial Outcomes in Children with Cleft Lip and/or Palate: Associations of Demographic, Cleft Morphologic, and Treatment-Related Variables

OBJECTIVE

To determine associations of demographic, morphologic, and treatment protocol parameters with quality of life (QoL), appearance/speech satisfaction, and psychological adjustment.

DESIGN

Observational study utilizing retrospective report of protocol variables and current outcome variables.

SETTING

Six North American cleft treatment clinics.

PARTICIPANTS

Children, ages 8.0-10.99 years, with Cleft Lip ± Alveolus, Cleft Palate, Cleft Lip and Palate, and parents (N = 284).

OUTCOME MEASURES

Pediatric QoL Inventory (PedsQL): Parent, Child, Family Impact Module (FIM); Patient Reported Outcome Measurement Information System (PROMIS); Child Behavior Checklist (CBCL); CLEFT-Q.

RESULTS

Outcome scores were average with few differences by cleft type. Multiple regression analyses yielded significant associations (Ps < .05) between socioeconomic status, race, and age at assessment and parent- and self-reported measures. Females had higher PROMIS Depression (β=.20) but lower CBCL Affective (β = -.16) and PROMIS Stigma scores (β= -.24). Incomplete cleft lip was associated with lower PROMIS Depression, and more positive ratings of CLEFT-Q: Nose, Nostril, Lip Scar; CBCL Competence scores, (βs = -.17 to .17). Younger Age at Lip Closure was associated with higher CBCL School Competence (β= -.18). Younger Age at Palate Closure was associated with higher Child PedsQL Total, Physical, Psychosocial QoL, and better CLEFT-Q Speech Function (βs = -.18 to -.15). Furlow Palatoplasty was associated with more CBCL Externalizing Problems (β = .17) higher CBCL Activities (β = .16). For all diagnoses, fewer Total Cleft-Related Surgeries was associated with lower PROMIS Stigma and higher CBCL Total Competence and Activities (βs = -.16 to .15).

CONCLUSIONS

Demographic characteristics, lip morphology, and treatment variables are related to later psychological functioning.

A National Assessment of Racial and Ethnic Disparities in Cleft Lip Repair

PURPOSE

The authors examined the effects of race and ethnicity on the likelihood of experiencing delays to surgery, postoperative surgical complications, and prolonged hospital length of stay (LOS) after primary cleft lip repair.

METHODS

Patients who underwent cleft lip repair were identified in the 2006 through 2012 Kids' Inpatient Database. Primary outcomes were defined as treatment after 6 months of age, any surgical complication, LOS greater than 1 day, and total hospital charges. Multivariable analyses were performed to adjust for sociodemographic and clinical characteristics that might account for differences in outcomes.

RESULTS

There were 5,927 eligible patients with cleft lip: 3,724 White, 1,316 Hispanic, 279 Black, 277 Asian or Pacific Islander, and 331 other (including American Indian or Alaska Native, multiple races, or races/ethnicities not specified within the dataset). Across all outcomes, there were significant unadjusted differences ( P < 0.001) by race and ethnicity, with White children having the lowest odds of delayed surgery, complications, and prolonged LOS, and the lowest charges. Multivariable analyses suggested that differences in baseline health status may account for much of this disparity in combination with factors such as income, insurance type, and location. Even after adjusting for covariates, significantly increased odds of delayed surgery and higher charges remained for Hispanic and Asian or Pacific Islander patients.

CONCLUSION

There are significant differences in the odds of delays, complications, prolonged hospital stays, and total charges among patients with cleft lip of different races or ethnicities. Advocacy efforts to ameliorate disparity in early infant health may subsequently improve equity in cleft outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Worth the Pain? Comparing Pain Scores in Primary Furlow Palatoplasty With and Without Buccal Flap Augmentation

OBJECTIVE

Pain following primary palatoplasty can adversely affect nutritional and quality of life following primary palatoplasty. The incorporation of buccal flaps during primary cleft palate (CP) repair provides additional tissue to reduce the risk of velopharyngeal insufficiency, though the additional donor site may alter pain levels in the postoperative period. This study sought to compare postoperative pain levels in patients undergoing primary CP repair with or without buccal flaps.

DESIGN

A single-institution, retrospective cohort study.

SETTING

An academic children's hospital with an affiliated comprehensive cleft care team.

PATIENTS

Patients age 18 months or less with cleft palate undergoing primary palatoplasty from 2016 to 2021 were included. Patients were stratified by the number of buccal flaps utilized during repair.

MAIN OUTCOME MEASURES

Primary outcome was 24-h postoperative pain score, measured using the FLACC pain scale. Secondary outcome was 24-h postoperative narcotic use, measured in morphine milligram equivalents (MME).

RESULTS

A total of 106 patients (53 without buccal flaps, 53 with 1 + buccal flaps) were included. There was no significant difference in postoperative pain scores between the groups (p > 0.9). Both groups had similar postoperative narcotic utilization (p = 0.8).

CONCLUSIONS

This study demonstrates no significant difference in postoperative pain levels or narcotic utilization between patients undergoing primary Furlow palatoplasty with or without buccal flaps. This information can help address parental concerns regarding pain in the context of a larger donor site for patients undergoing primary palatoplasty with buccal flaps. Larger, multi-institutional randomized trials are needed to confirm these findings.

Bullying in Swiss Youth Born with a Unilateral Cleft lip and Palate by Self- and Parent-Report

OBJECTIVE

This study aimed to gain a better understanding of bullying as victims and aggressors in youths born with unilateral cleft lip and palate (UCLP).

DESIGN

This is an observational study comparing youths with UCLP (ages 8-16) and their parents with a control group (CG) of children in state schools and their parents.

PARTICIPANTS

Forty-one youths (43% female; mean age 12.4 ± 2.3 years) and their parents (n = 40) composed the UCLP group and 56 youths (47% female; mean age 12.4 ± 1.2 years) and their parents (n = 33) were in the CG.

MAIN OUTCOME MEASURE

The Olweus Bully/Victim questionnaire self- and parent-report was used to assess victims and aggressors involved in bullying behaviors.

RESULTS

About 30% of all youths reported being a frequent victim of bullying at least 2-3 times a month and an additional 32.3% were bullied 1-2 times in the last 2-3 months. For the total sample, parents significantly (P < .05) underestimated any bullying, both as a victim (youths 62.5% vs parents 45.7%) and as an aggressor (youths 53.1% vs parents 37.1%). There were no significant group differences in experiencing any bullying between the youths with UCLP (52.5%) and the CG youths (69.6%) or in its perception by their parents (43.2% and 48.5%, respectively). There were no group differences between the combinations of victim and aggressor.

CONCLUSIONS

While there were no differences in bullying prevalence in our sample between youths with UCLP and their peers, this study highlights differences in bullying perceptions between parents and their children.

Simultaneous Furlow Palatoplasty and Tonsillectomy for the Treatment of Velopharyngeal Insufficiency and Tonsillar Hypertrophy

OBJECTIVE

To determine whether performing tonsillectomy at the time of Furlow palatoplasty for the treatment of cleft palate related velopharyngeal insufficiency (VPI) incurs increased surgical complications or compromises speech outcomes.

DESIGN

A retrospective review of patients who had Furlow palatoplasty and the outcomes of surgery in the treatment of cleft palate related VPI.

SETTING

A single academic center between January 2015 and January 2022.

PARTICIPANTS

Patients with submucous cleft (SMC) palate or patients with prior straight line primary palatoplasty presenting with VPI.

INTERVENTIONS

Simultaneous conversion Furlow palatoplasty and tonsillectomy.

MAIN OUTCOME MEASURE(S)

Primary outcome measures include preoperative and postoperative Modified Pittsburgh Weighted Speech Scale (mPWSS), and postoperative surgical complications.

RESULTS

Eight patients (25%) underwent Furlow palatoplasty and concomitant tonsillectomy, while 24 patients (75%) underwent Furlow palatoplasty alone. A significantly lower median postoperative mPWSS score, corresponding to better velopharyngeal function, was reported for patients in the Furlow-tonsillectomy group (0, IQR 0-0) compared to the Furlow only group (1, IQR 0-9, p  =  0.046). No surgical complications were encountered in either group. Five patients (20.8%) in the Furlow only group required subsequent surgery for persistent VPI. No patients in the Furlow-tonsillectomy group required additional surgical treatment for VPI (0%, p  =  0.16).

CONCLUSIONS

Tonsillectomy at time of Furlow palatoplasty is utilized in patients with both VPI and baseline tonsillar hypertrophy to lessen the risk of postoperative obstructive breathing. Tonsillectomy performed concurrently with Furlow palatoplasty is safe, without increased risk of surgical complications, and does not compromise post-Furlow palatoplasty speech outcomes.

Cleft Lip and/or Palate: Children's Experiences of Stigma in Colombia

OBJECTIVE

Given prior craniofacial research reporting higher risk for negative social interactions, this study aimed to explore experiences of stigma described by children with cleft lip and/or palate (CL/P).

DESIGN

Qualitative interviews were conducted with children in three sessions (totaling 90-180 min) using creative activities in their homes and/or and walking interviews in their neighborhood. Interview transcriptions were interpreted primarily with thematic analysis following theoretical frameworks of the stigmatization process and self-stigma concept.

SETTING

Participants were recruited through Operation Smile Colombia. Interviews took place at children's homes and neighborhoods within three Colombian regions (Boyacá, Bogotá and Cundinamarca).

PARTICIPANTS

Children (N = 12) with CL/P aged between 6-12 years were interviewed.

RESULTS

Themes fit within the stigmatization process, starting with labeling and stereotyping, such as a range of mockery, and group separation by peers highlighting their not belonging and being socially 'other'. Status loss themes included negative appraisals of cleft-related differences and being perceived as 'ill' and 'imperfect'. Social exclusion themes reflected limited social interactions and loneliness. Self-stigma themes included shame about speaking with peers and anticipation of negative social interactions.

CONCLUSIONS

The study results suggest that the process of stigmatization and self-stigma adversely affect social interactions for children with a cleft in multiple ways. Healthcare practitioners and policy makers can help address the potential consequences of stigma by implementing interventions at micro, meso and macro levels.

Psychosocial Issues Related to Speech and Hearing in Patients With Clefts

INTRODUCTION

Individuals with cleft lip and palate often face persistent challenges related to speech and hearing disorders, impacting various aspects of their lives. These challenges can lead to additional mental health issues such as attention-deficit/hyperactivity disorder, anxiety, and depression, as well as heightened psychosocial challenges, including appearance-related issues, bullying, workplace discrimination, and impaired social interactions. Children and adolescents with these disorders commonly experience loneliness, peer rejection, and challenges in forming friendships, particularly during adolescence, while voice disorders can diminish the quality of life in older individuals.

CASE DESCRIPTION

This case study focuses on a 17-year-old male with unilateral cleft lip and palate undergoing treatment in Medellin, Colombia, aiming to provide insights into the intricate psychosocial challenges linked to speech and hearing difficulties in individuals with cleft conditions.

DISCUSSION AND EVALUATION

Clinical evaluations identified significant challenges concerning speech difficulties and self-perception, influenced by the patient's cleft condition, which impacts his self-esteem, confidence, and social skills development. The interconnectedness between speech and hearing challenges underscores the necessity for comprehensive care to address the multifaceted psychosocial aspects experienced by individuals with cleft conditions.

CONCLUSIONS

This case study used as an example, indicates that speech difficulties and psychosocial challenges related to cleft conditions are experienced from childhood and may persist into adulthood. These challenges can have profound effects on various aspects of life, including school, social interactions, family dynamics, and even romantic relationships. Consequently, the lack of confidence, social isolation, and limited social skills may delay patients from reaching their fullest potential.

Beyond the face: An interdisciplinary evaluation of satisfaction with appearance in young people with orofacial clefts

Orofacial clefts are the most common congenital anomaly of the face, and they significantly affect appearance. The combined effects of demographics, psychology, neurophysiology, and cleft characteristics to explain satisfaction with appearance in young people with a cleft have not yet been comprehensively studied in an interdisciplinary manner. We found that interpersonal difficulties, age, and conscientiousness were significant explanatory factors for satisfaction with appearance (tinterpersonal difficulties = -3.022, p = 0.006; tage = -3.563, p = 0.016; tconscientiousness = 4.161, p = 0.003); the model explained 50% of variance in satisfaction with appearance (R2 Adjusted = 0.504, Fvs. constant = 4.05, p = 0.00117). Furthermore, frontal alpha asymmetry was complexly intertwined with other variables, affecting the overall accuracy of the model, but explaining only 10.5% of variance in satisfaction with appearance when used as a factor alone. The results show that an interdisciplinary approach can substantially expand our understanding of the factors influencing self-perception in young people with orofacial clefts.

Interpersonal impressions of cleft and non-cleft adolescents: A panel assessment study of peers, laypersons, and clinicians using 3dMD images

BACKGROUND

Patients with cleft lip and palate anomalies suffer from associated negative psychosocial effects despite undergoing reconstructive surgeries. Discrimination from others may be a contributing factor. We aim to understand whether people react differently to cleft and non-cleft subjects in questions regarding aesthetic appraisal and interpersonal impressions, as well as whether diverging opinions exist between people of different backgrounds.

MATERIALS AND METHODS

Using the 3dMD system, three-dimensional craniofacial images of cleft (n = 20) and non-cleft (n = 5) pediatric individuals were obtained and used to create a Likert scale-based questionnaire. Participants from three different backgrounds, including adolescent peers, adult laypersons, and plastic surgeons, were recruited to complete the assessment. The resulting data were transferred to a bar graph and analyzed with the item response theory-graded response model to estimate the latent traits and capability of each subject.

RESULTS

Non-cleft images obtained more positive responses than cleft images in questions of both aesthetic appraisal and interpersonal impressions. However, some of the cleft images were rated similarly, or even superior, to non-cleft images in questions regarding interpersonal impressions. Surgeons showed the greatest latent capability in differentiating between cleft and non-cleft images, followed by adult laypersons, and then adolescent peers.

CONCLUSIONS

Despite cleft patients experiencing drastic improvements in appearance post-repair, all subject groups responded differently to questions concerning aesthetic and social impressions of pediatric cleft and non-cleft images. Plastic surgeons were more critical than others. These findings may offer further insight to clinicians, educators, and caregivers into the social challenges faced by cleft individuals.

Psychopathology in Infants, Toddlers, and Preschool Children with Nonsyndromic Clefts of the Lip and/or Palate: A Case-Control Study

OBJECTIVE

The aim of this study is to assess psychopathology and maternal interactions in infants, toddlers, and preschool children with nonsyndromic clefts of the lip and/or palate (NSCLP) and association of psychopathology with cleft-related factors and maternal interactions.

DESIGN

Twenty-six children from 4 to 72 months of age with NSCLP, who were attending the Plastic, Reconstructive and Aesthetic Surgery Department were included as the case group. Fifty-two healthy children who were matched on age and sex with the case group were taken as controls. Children were assessed in aspects of psychiatric diagnosis, articulation, and development.

RESULTS

Speech and language disorders (SLD) ( P <0.001), disorders of affect (DA) ( P =0.005), feeding behavior disorder ( P =0.002), sleep-behavior disorder (SBD) ( P =0.038), and disordered mother-child relationship ( P <0.001) were more prevalent in children with NSCLP. Dental alignment ( P =0.024), number of operations ( P =0.006), and type of operations ( P =0.012) were associated with DA. The children in the case group, who had disordered relationship with their mothers had significantly more SLD ( P =0.036) and SBD ( P =0.039).

CONCLUSIONS

Children with NSCLP are at risk of developing psychopathology, especially SLD and DA. Maternal interactions and the above cleft-related factors and may be the target of interventions to prevent and treat psychiatric disorders in these children.

Individuals with Cleft Lip and/or Palate Demonstrated Improved Self-Reported Psychosocial Functioning Following the Onset of the COVID-19 Pandemic

Objective

To evaluate the impact of the COVID-19 pandemic on the psychosocial functioning of individuals with cleft lip and/or palate (CL/P).

Methods

Patients with CL/P ≥ 6 years old were prospectively recruited from the Cleft and Craniofacial Clinic of a tertiary children's hospital. From July-October 2021, eligible patients (or their parent/guardian) were sent a survey regarding their psychosocial functioning before and after the start of the pandemic.

Main Outcome Measure

The difference between prepandemic and intrapandemic patient-reported outcome scores.

Results

Thirty-six patients (20 female, age: 15.9 ± 9.8 years) responded. Most had cleft lip and palate (77.8%), responded online (69.4%), interacted remotely via both voice- and video-conferencing (62.9%), and wore masks routinely (77.1%). Similar numbers of patients responded independently (27.8%), responded with the help of a parent/guardian (36.1%), or had a parent/guardian respond on their behalf (36.1%). General social-emotional well-being (p = 0.004, r rb = 0.659) and satisfaction with facial appearance (p = 0.044, r rb = 0.610) significantly improved after the start of the pandemic. Compared to their general intrapandemic social-emotional well-being scores, patients reported higher scores while wearing a mask (r rb = 0.827) and lower scores while interacting remotely (r rb = 0.605), although all were still significantly improved compared to their prepandemic scores (p ≤ 0.010). Patients also reported significant improvement in social functioning while wearing a mask (p = 0.036, r rb = 0.519), whereas they did not when considering their general intrapandemic feelings/experiences (p = 0.269, r rb = 0.211).

Conclusion

Patients with CL/P demonstrated significant improvement in overall social-emotional well-being, satisfaction with facial appearance, and social functioning after the start of the COVID-19 pandemic, particularly when wearing a mask.

Disability Caused by Cleft Lip and Palate: A Systematic Review and Critical Valuation Appraisal

OBJECTIVE

Measuring disability as a concept of impaired global function enables beneficiaries of treatment, the impact of treatment, and targets of health system investment to be rigorously assessed. Measures of disability are not well established for cleft lip and palate. This study aims to systematically review disability weight (DW) studies pertaining to orofacial clefts (OFCs) and identify methodological strengths and shortcomings of each approach.

DESIGN

Systematic literature review of studies that met the following criteria: (1) peer-reviewed publication, (2) focus on disability valuation, (3) mention orofacial clefts, and (4) publication January 2001-December 2021.

SETTING

None.

PATIENTS/PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Disability weight method of valuation and the value itself.

RESULTS

The final search strategy yielded 1,067 studies. Seven manuscripts were ultimately included for data extraction. The disability weights used in our studies, including those newly generated or taken from the Global Burden of Disease Studies (GBD), ranged widely for isolated cleft lip (0.0-0.100) and cleft palate with or without cleft lip (0.0-0.269). The GBD studies limited their consideration of cleft sequelae informing disability weights to impact on appearance and speech-related concerns, while other studies accounted for comorbidities such as pain and social stigma.

CONCLUSIONS

Current measures of cleft disability are sparse, inadequately reflect the comprehensive impact of an OFC on function and socialization, and are limited in detail or supporting evidence. Use of a comprehensive health state description in evaluating disability weights offers a realistic means of accurately representing the diverse sequelae of an OFC.

Early Follow-up of Parents by a Specialized Cleft Nurse After the Birth of an Infant with Cleft lip and/or Palate

OBJECTIVE

To document the impact of early follow-up by specialized cleft nurses (SCNs) to families of infants with cleft lip and/or cleft palate (CL/P).

DESIGN

Prospective inclusion of a control group, which received standard care alone, followed by an intervention group, which in addition received early SCN follow-up.

SETTING

The cleft lip and palate team at a University hospital.

PARTICIPANTS

70 families (69 mothers and 57 fathers); control group (n = 38); intervention group (n = 32).

INTERVENTION

SCNs offered a consultation at the maternity ward and follow-ups by phone or face-to-face at one, three, eight weeks and six months after birth.

OUTCOME MEASURES

Use of Internet-Questionnaire, Quality of discharge teaching scale (QDTS), Post discharge coping difficulty scale (PDCDS), Response on follow-up by health professionals.

RESULTS

Infants in the intervention group were admitted less frequently to a Neonatal Intensive Care unit (NICU); 21.9% vs 51.4%, P = .012. Parents in the intervention group used internet for cleft-related reasons less frequently (74.6% vs 85.9%), P = .112 and the mothers benefitted less from cleft-related activity on the internet (P = .013). The intervention group reported higher mean score for satisfaction with total cleft care (P = .001). There were no significant group differences regarding mean total score for discharge teaching (P = .315) and coping difficulties (P = .919).

CONCLUSION

Early follow-up by a SCN with expertise in cleft care is highly valued by parents. Closer cooperation between the cleft team and health professionals at birth hospitals and Child health centers is necessary for optimal follow-up.

Characterizing Interventions and Family Assistance of a Nurse Navigation Program in Orofacial Cleft Care

OBJECTIVE

Characterize the interventions and assistance employed by a cleft nurse navigator (CNN) which have mediated improvement in care equity at our institution.

DESIGN

Retrospective study.

SETTING

Academic tertiary care center.

PATIENTS, PARTICIPANTS

Patients presenting with cleft lip and/or cleft palate presenting between August 2020 and August 2021 with exclusions for syndromic diagnosis, Pierre-Robin sequence, late (> 6 months) presentation, and prior cleft surgery at outside institutions.

INTERVENTIONS

Multidisciplinary cleft nurse navigator program.

MAIN OUTCOME MEASURE(S)

Family interactions with the CNN by phone, text, and email across the first year of life including feeding support, nasoalveolar molding (NAM) assistance, appointment scheduling, financial assistance, addressing perioperative concerns, and facilitating physician consults. Patient weight and surgical timing were also recorded.

RESULTS

Sixty-nine patients were included with a total of 639 interactions between the CNN and families. Scheduling support (30%), addressing perioperative concerns (22%), and feeding support (20%) were the most common interactions. Feeding support and NAM assistance were heavily distributed in the first 3 months of life compared to after 3 months (P < .001). Median age at first contact was 1 week (range: 22 weeks gestation-14 weeks). There was no difference in the proportion of families receiving feeding support, NAM assistance, or scheduling assistance based on insurance status or race (P > .05 for all).

CONCLUSIONS

Scheduling assistance, addressing perioperative concerns, and feeding support are the predominant methods by which the CNN interacts with and assists families of patients with cleft conditions. CNN service distribution is largely equitable between demographic groups.

Use of Hyaluronic Acid Filler in Patients with Secondary Cleft Lip Deformity

METHODS

Retrospective case note review was undertaken of all patients treated in the clinic over a two-year period.

RESULTS

20 patients underwent HA filler injections to the upper lip 26 times. Most were female (F:M = 3:1) and patients were aged 18-58 years. Most patients had a unilateral cleft lip +/- palate (n = 13, 65%). The most common indication was to address upper lip volume (n = 13, 65%). Other indications included vermillion notch (n = 5, 25%), cupid bow peak height asymmetry (n = 4, 20%), scar asymmetry (n = 1, 5%) and nasal sill flattening (n = 1, 5%). Small volumes of filler were used with an average of 0.34 ml (range 0.05-1.2 ml). There were no complications and one patient reported pruritis post procedure.

CONCLUSIONS

HA filler is a safe and reliable treatment for certain aspects of asymmetry following cleft lip repair. It can be used to address volume deficiency and asymmetry, cupid bow peak height discrepancies and a vermillion notch for patients who do not want surgery. Injection of HA to the lips can be performed easily, with appropriate training, in the outpatient setting.

Columbia-Suicide Severity Rating Scale (C-SSRS) Reveals High Rates of Suicidality in 602 Patients With Cleft and Craniofacial Conditions

INTRODUCTION

Little is known about rates of suicidal ideation and behavior among youth with cleft lip and/or palate (CLP) and other craniofacial conditions.

METHODS

Records of patients ages 6 and older who were administered the Columbia-Suicide Severity Rating Scale (C-SSRS) Lifetime Version during routine multidisciplinary cleft or craniofacial team visits between 2019 and 2023 were examined. Demographics information, C-SSRS data, and diagnoses were assessed with statistics including t tests, the Fisher exact test, and odds ratios.

RESULTS

A total of 1140 C-SSRS questionnaires across 602 (433 CLP and 169 craniofacial) patients with an average age of 11.2±3.7 years were included. Eighty-four (13.6%) patients endorsed lifetime suicidal ideation, 9 (1.5%) had at least one instance of suicidal behavior, 30 (5.0%) endorsed nonsuicidal self-injury, and 2 (0.3%) engaged in self-injurious behavior. Compared with CLP, those with other craniofacial conditions had similar odds of endorsing suicidal ideation and behavior ( P ≥0.05). Compared with those with isolated cleft palates, CLP had greater odds of endorsing suicidal ideation and behavior, though those differences were not significant ( P ≥0.05). Incidence of suicidality was unchanged before, during, and after the COVID-19 pandemic ( P ≥0.05). Dividing patients by sex or insurance type revealed no difference in suicidality ( P ≥0.05).

CONCLUSION

Patients with CLP and craniofacial conditions have a high incidence of suicidal ideation and behavior, though levels are similar between these groups. Suicidality in these patients was not negatively impacted by the COVID-19 pandemic. Early identification of safety risks and psychosocial challenges through regular screening can facilitate connection with appropriate clinical interventions.

Parental anxiety/incompliance and patients' complications during COVID-19 pandemic regarding nasoalveolar molding treatment of infants with cleft lip/palate

OBJECTIVES

The ideal time for nasoalveolar molding (NAM) of infants with cleft lip and/or palate (CLP) is the first weeks after birth. The burden and responsibility that this method of treatment imposes on parents may result in incompliance. The coronavirus (COVID-19) pandemic and the redirection of health resources can make the situation worse. Therefore, this study evaluated the anxiety, complications, and incompliance of parents undergoing NAM during the COVID-19 pandemic.

MATERIALS AND METHODS

Demographic data of 35 infants with CLP treated during the COVID-19 pandemic, compliance and level of anxiety of both parents in addition to their complications were reported. The association between different variables and incompliance was evaluated by simple and multiple logistic regressions. The level of significance was considered at P value less than 0.05.

RESULTS

The highest level of parental anxiety related to the NAM process was the delay in ending the treatment. Meanwhile, the reason for the highest level of anxiety related to attending the treatment sessions was the probability of the infant's COVID-19 infection. Fathers expressed lower levels of anxiety than mothers, significantly. The most prevalent NAM complication was skin irritation. Parents of younger infants (≤28 days) and those with a history of COVID-19 infection were more compliant.

CONCLUSIONS

COVID-19 pandemic caused a significant increase in the level of anxiety in both parents, mainly due to the delay in treatment ending and the possibility of infant's infection. Moreover, considering the importance of treatment time, parents of younger infants were more compliant with the NAM process.

Age at primary surgery among orofacial cleft individuals in Indonesia

OBJECTIVES

To observe the age at primary cleft surgery among charity organizations such as Smile Train in helping Indonesia manage patients with OFC.

MATERIALS AND METHODS

A retrospective analysis of medical records was conducted to identify patients with orofacial clefts who underwent primary surgery between 2001 and 2021. The age at the time of surgery was recorded for each patient. Descriptive statistics were used to analyse the data and determine the average age at primary surgery.

RESULTS

In the period between 2001 and 2021, a total of 34 239 individuals in Indonesia underwent primary lip surgery, while 16 768 individuals received primary palatal surgery, as recorded in the Smile Train database. Notably, a significant proportion of these surgeries were classified as delayed primary repairs. Approximately 65.3% of primary lip surgeries were performed beyond the recommended timeline of 6 months of age, indicating a delay in the surgical intervention. Similarly, 67% of primary palatal surgeries were also delayed, occurring after the recommended timeline of 18 months of life.

CONCLUSIONS

This study provides insights into the age at primary surgery among individuals with orofacial clefts in Indonesia. The findings highlight the need for timely intervention and the importance of considering individualized treatment plans based on the specific type of orofacial cleft. Further research is warranted to explore factors influencing the age at primary surgery and their impact on treatment outcomes and long-term functional outcomes in this population.

Geospatial and Socioeconomic Factors Interact to Predict Management and Outcomes in Cleft Lip and Palate Surgery: A Single Institution Study of 740 Patients

OBJECTIVE

Determine interactions between geospatial and socioeconomic factors influencing cleft lip and/or cleft palate (CL/P) management and outcomes.

DESIGN

Retrospective review and outcomes analysis (n = 740).

SETTING

Urban academic tertiary care center.

PATIENTS

740 patients undergoing primary (CL/P) surgery from 2009 to 2019.

MAIN OUTCOMES MEASURES

Prenatal evaluation by plastic surgery, nasoalveolar molding, cleft lip adhesion, and age at CL/P surgery.

RESULTS

Prenatal evaluation by plastic surgery was predicted by the interaction between higher patient median block group income and shorter patient distance from the care center (OR = 1.07, p = 0.022). Nasoalveolar molding was also predicted by the interaction between higher patient median block group income and shorter distance from the care center (OR = 1.28, p = 0.016), whereas cleft lip adhesion was predicted by higher patient median block group income alone (OR = 0.41, p < 0.001). Lower patient median block group income predicted later age at cleft lip (β = -67.25, p = 0.011) and cleft palate (β = -46.35, p = 0.050) repair surgery.

CONCLUSIONS

Distance from the care center and lower median income by block group interacted to significantly predict prenatal evaluation by plastic surgery and nasoalveolar molding for patients with CL/P at a large, urban, tertiary care center. Patients living farthest from the care center who received prenatal evaluation by plastic surgery or who underwent nasoalveolar molding had higher median block group income. Future work will determine mechanisms perpetuating these barriers to care.

Travel Distance and Spanish-Speaking are Associated with Delays in the Treatment of Cleft Palate

OBJECTIVE

Delayed repair of cleft palate is associated with worse speech outcomes. Social determinants of health may influence the timing of surgery; however, there are no population health investigations to evaluate factors such as travel distance, language barriers, and payer. This study sought to identify factors that may interfere with timely cleft palate repair.

DESIGN

Retrospective cohort.

SETTING

National/multi-center.

PATIENTS/PARTICIPANTS

All cleft palate repairs within California were extracted from 2000-2021.

MAIN OUTCOMES MEASURES

The primary outcome was age at surgical repair, which was modeled with linear regression. Covariates included race, primary language, distance from patient home to hospital, socioeconomic status, primary payer, and managed care enrollment status.

RESULTS

11 260 patients underwent surgical repair of a cleft palate. Black race was associated with delayed repair (22 additional days, P = .004, 95% CI 67.00-37.7) along with Asian/Pacific-Islander race (11 additional days, P = .006, 95% CI 3.26-18.9) compared to white race. Spanish-speaking patients had significantly later cleft palate repairs by 19 days, (P < .001, 95% CI 10.8-27.7) compared with English-speaking. Further distances from the hospital were significantly associated with later cleft surgeries with out-of-state patients undergoing surgery 52 days later (P < .001, 95% CI 11.3-24.3). Managed care plans and Medi-Cal were significantly associated with earlier surgical repair compared with private insurance.

CONCLUSION

Black, Asian Pacific Islander, and Spanish-speaking patients and greater distance traveled to hospital were associated with delayed cleft palate repairs. These results underscore the importance of addressing structural and social barriers to care to improve outcomes and reduce health disparities for patients with cleft palate.

Damaging Mutations in Contribute to Risk of Nonsyndromic Cleft Lip With or Without Cleft Palate

Novel or rare damaging mutations have been implicated in the developmental pathogenesis of nonsyndromic cleft lip with or without cleft palate (nsCL ± P). Thus, we investigated the human genome for high-impact mutations that could explain the risk of nsCL ± P in our cohorts.

We conducted next-generation sequencing (NGS) analysis of 130 nsCL ± P case-parent African trios to identify pathogenic variants that contribute to the risk of clefting. We replicated this analysis using whole-exome sequence data from a Brazilian nsCL ± P cohort. Computational analyses were then used to predict the mechanism by which these variants could result in increased risks for nsCL ± P.

We discovered damaging mutations within the AFDN gene, a cell adhesion molecule (CAMs) that was previously shown to contribute to cleft palate in mice. These mutations include p.Met1164Ile, p.Thr453Asn, p.Pro1638Ala, p.Arg669Gln, p.Ala1717Val, and p.Arg1596His. We also discovered a novel splicing p.Leu1588Leu mutation in this protein. Computational analysis suggests that these amino acid changes affect the interactions with other cleft-associated genes including nectins (PVRL1, PVRL2, PVRL3, and PVRL4) CDH1, CTNNA1, and CTNND1.

This is the first report on the contribution of AFDN to the risk for nsCL ± P in humans. AFDN encodes AFADIN, an important CAM that forms calcium-independent complexes with nectins 1 and 4 (encoded by the genes PVRL1 and PVRL4). This discovery shows the power of NGS analysis of multiethnic cleft samples in combination with a computational approach in the understanding of the pathogenesis of nsCL ± P.

The Life Cycle of Orofacial Cleft Operations

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

A Unique Appliance for Median Facial Cleft Management With Sleep Apnea due to Undeveloped Nasal Septum: A Rare Case Report

The role of a prosthodontist in the management of facial cleft patients is the restoration of feeding, respiration, facial harmony, dental harmony and phonation. This case report presents the fabrication of an appliance for a pediatric patient with congenital median facial cleft who had sleep apnea due to the absence of nasal septum, which is a rare condition, with a unique method that fulfilled the patient's needs and improved quality of life. The patient also had median cleft lip and premaxilla along with hypertelorism.

Oral health-related quality of life in patients with cleft lip and/or palate or Robin sequence

PURPOSE

To compare the oral health-related quality of life (OHRQoL) in patients with cleft lip and/or palate or Robin sequence versus a healthy control group using the Child Oral Health Impact Profile (COHIP-G19). Factors such as age, gender, and cleft type were considered.

METHODS

Over an 8-month period, the OHRQoL was surveyed by using the COHIP-G19 questionnaire. Included were patients with a craniofacial disorder (n = 61; average age 11.24 years) and a healthy control group (n = 70, average age 12.63 years) for a total of 131 patients (average age 11.99 years) from the Department of Orthodontics University Hospital Tübingen, Germany. These were divided into two age groups (6-11 years; 12-18 years).

RESULTS

Statistically, patients with a craniofacial disorder presented a significantly lower OHRQoL than the control group (p = 0.0055). In the craniofacial disorder group, older patients revealed a significantly (p = 0.005) lower OHRQoL than the younger patients. Female patients showed in nearly all groups a better OHRQoL than male patients, but this difference was not statistically significant (p > 0.05). Males with a craniofacial disorder scored significantly lower than males without (p = 0.016); females showed no differences between the groups. Visibility, location, and severity of the craniofacial malformation did not have a significant influence on the OHRQoL.

CONCLUSION

The occurrence of a craniofacial malformation impacted the OHRQoL especially in older and male affected patients, unrelated to the expression level or localization. An early instruction about oral health, rehabilitation and functional training should be considered in therapy.

Unraveling a Major Burden of Orofacial Clefts Analyses: Classification of Cleft Palate Fistulas by Cleft Surgeons

OBJECTIVE

The objective of this study was to investigate how cleft surgeons classify palatal fistulas. We focused on three different anatomical locations (ie, hard palate, soft palate, junction hard/soft palate) to analyze agreement/disagreement at various anatomical locations.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

Participants in an international webinar that focused on palatal fistula treatment were included.

INTERVENTION

Participants were presented with a survey pre- and post-webinar.

MAIN OUTCOMES

Frequency of used classification systems for classifying oronasal fistulas and the inter-rater reliability of the Pittsburgh classification system.

RESULTS

A total of 141 participants completed the questionnaires prior to the webinar and 109 participants completed the survey after the webinar. In total, four classification systems were used (ie, Pittsburgh, Pakistan Comprehensive Fistula Classification [PCFC], anatomical and 'other'). The Pittsburgh classification was the most commonly used system in all cases. However, Pittsburgh inter-rater reliability was low (κ = 0.136 pre-webinar, and κ = 0.174 post-webinar). Surprisingly, a substantial shift was observed from the anatomical to Pittsburgh classification after the webinar, indicating increased awareness of the usability of the Pittsburgh classification system.

CONCLUSIONS

This study demonstrates a large heterogeneity with regards to the classification of cleft palate fistulas. Interestingly, a shift was observed from the anatomical to Pittsburgh classification after the webinar. However, the inter-rater reliability for using the Pittsburgh classification was low. Classifying palatal fistulas in a homogenous fashion could enhance comparison of primary palate repair and could improve treatment of palatal fistulas.

Psychological and Peer Difficulties of Children with Cleft Lip and/or Palate: A Systematic Review and Meta-Analysis

OBJECTIVES

A systematic review and meta-analysis were conducted to determine if children born with cleft lip and/or palate are at increased risk of psychological and peer difficulties, and if so, which difficulties they develop.

METHODS

EMBASE, MEDLINE, and PsycINFO were searched for English language studies published between January 2005 and January 2022 which investigated the psychological outcomes and peer function of children with nonsyndromic cleft lip and palate. Outcomes included internalizing problems, such as anxiety and depression, externalizing problems, such as hyperactivity, conduct disorders, self-concept including self-image and self-esteem, peer problems, resilience, coping, and overall psychological function. A risk of bias assessment was performed using the Newcastle-Ottawa Scale. Random effects models were used in the meta-analysis to compare the outcomes for children born with a cleft and those without.

RESULTS

In total 41 studies met inclusion criteria, with 9 included in the meta-analysis. Children born with a cleft appear to have similar psychological outcomes compared to normative controls when using the strengths and difficulties questionnaire. There are some minor differences between self-report and parent report, with parents generally reporting that their child with a cleft has increased emotional, conduct, and hyperactivity problems. The small differences between the study cohort and control cohorts are unlikely to imply any differences on a clinical level.

CONCLUSIONS

Overall psychological outcomes appear to be similar between children born with a cleft and the nonaffected population, however, some symptoms such as anxiety and depression appear higher in children with cleft lip and/or palate.

Harnessing the Power of Artificial Intelligence in Cleft Lip and Palate: An In-Depth Analysis from Diagnosis to Treatment, a Comprehensive Review

Cleft lip and palate (CLP) is the most common craniofacial malformation, with a range of physical, psychological, and aesthetic consequences. In this comprehensive review, our main objective is to thoroughly examine the relationship between CLP anomalies and the use of artificial intelligence (AI) in children. Additionally, we aim to explore how the integration of AI technology can bring about significant advancements in the fields of diagnosis, treatment methods, and predictive outcomes. By analyzing the existing evidence, we will highlight state-of-the-art algorithms and predictive AI models that play a crucial role in achieving precise diagnosis, susceptibility assessment, and treatment planning for children with CLP anomalies. Our focus will specifically be on the efficacy of alveolar bone graft and orthodontic interventions. The findings of this review showed that deep learning (DL) models revolutionize the diagnostic process, predict susceptibility to CLP, and enhance alveolar bone grafts and orthodontic treatment. DL models surpass human capabilities in terms of precision, and AI algorithms applied to large datasets can uncover the intricate genetic and environmental factors contributing to CLP. Additionally, Machine learning aids in preoperative planning for alveolar bone grafts and provides personalized treatment plans in orthodontic treatment. In conclusion, these advancements inspire optimism for a future where AI seamlessly integrates with CLP management, augmenting its analytical capabilities.

The presence and distribution of various genes in postnatal CLP-affected palatine tissue

BACKGROUND

Worldwide cleft lip with or without a cleft palate (CL/P) is the most common craniofacial birth defect. Apart from changes in facial appearance, additionally affected individuals often suffer from various associated comorbidities requiring complex multidisciplinary treatment with overall high expenses. Understanding the complete pathogenetic mechanisms of CL/P might aid in developing new preventative strategies and therapeutic approaches, help with genetic counselling, and improve quality of life. Many genes have been associated with the development of orofacial clefts; however, the majority require further research. Based on the role of PAX7, PAX9, SHH, SOX3, WNT3A, and WNT9B in orofacial development, the intention was to use chromogenic in situ hybridization to detect the six genes in postnatal CLP-affected palatine tissue and compare their distribution within the tissue samples.

RESULTS

Statistically significant differences in the distribution of PAX7, PAX9, WNT3A, and WNT9B were observed. In total, 19 pairs of moderate to very strong positive correlations were noted.

CONCLUSIONS

Changes in the cleft-affected palatine epithelium primarily seem to be associated with the PAX7 gene; however, PAX9, WNT3A, WNT9B, and SOX3 role seems to be more limited. Whilst connective tissue changes seem to depend on PAX7 only, SHH seems to participate individually and indistinctly. Numerous positive correlations reflect the complicating interactions of the pathways and their components in the orofacial cleft morphopathogenesis.

Prevalence and Factors Associated with Behavioral Problems in 5-Year-Old Children Born with Cleft Lip and/or Palate from the Cleft Collective

OBJECTIVES

To determine the UK prevalence of behavioral problems in 5-year-old children born with isolated or syndromic cleft lip and/or palate (CL/P) compared to the general population and identify potentially associated factors.

DESIGN

Observational study using questionnaire data from the Cleft Collective 5-Year-Old Cohort study and three general population samples.

MAIN OUTCOME MEASURE

The Strengths and Difficulties Questionnaire (SDQ).

PARTICIPANTS

Mothers of children (age: 4.9-6.8 years) born with CL/P (n  =  325). UK general population cohorts for SDQ scores were: Millennium Cohort Study (MCS) (n  =  12  511), Office of National Statistics (ONS) normative school-age SDQ data (n  =  5855), and Avon Longitudinal Study of Parents and Children (ALSPAC) (n  =  9386).

RESULTS

By maternal report, 14.2% of children born with CL/P were above clinical cut-off for behavioral problems, which was more likely than in general population samples: 7.5% of MCS (OR  =  2.05 [1.49-2.82], P < 0.001), 9.8% of ONS (OR  =  1.52 [1.10-2.09], P  =  0.008), and 6.6% of ALSPAC (OR  =  2.34 [1.70-3.24], P < 0.001). Children in the Cleft Collective had higher odds for hyperactivity, emotional and peer problems, and less prosocial behaviors. Maternal stress, lower maternal health-related quality of life and family functioning, receiving government income support, and maternal smoking showed evidence of association (OR range: 4.41-10.13) with behavioral problems, along with maternal relationship status, younger age, and lower education (OR range: 2.34-3.73).

CONCLUSIONS

Findings suggest elevated levels of behavioral problems in children born with CL/P compared to the general population with several associated maternal factors similar to the general population.

Is the Nasolabial Region Symmetric in Individuals With Cleft Lip and Palate?

OBJECTIVE

To assess the nasolabial symmetry in smile and resting position in individuals with nonsyndromic unilateral cleft lip and palate (UCLP) and compare with Class I individuals without cleft lip and palate (CLP).

MATERIALS AND METHODS

Frontal photographs of 40 individuals with UCLP (mean age 14.30 ± 0.25 years; 20 female, 20 male) and 40 skeletal Class I individuals without CLP (mean age 14.60 ± 0.34 years; 20 female and 20 male) were examined. Bland-Altman Levels of Agreements, Mann-Whitney U test, independent sample t-test were conducted, and intraclass correlation coefficients (ICCs) were calculated for statistical analysis.

RESULTS

Differences in the transverse lip distance (d-d') and vertical lip height at crista philtri (e-e') were lesser in the UCLP group at smile (P = .001; P = .005, respectively). When comparing the differences in these measurements at rest between control and UCLP groups, vertical lip height was longer at crista philtri (e-e') (P = .014), crista philtri was more laterally located (f-f') (P = .002), and the transverse lip distance was greater (d-d') (P = .004) in the UCLP group. Distance of the crista philtri to the midline of the face (f-f') (P = .007) were higher in the UCLP group during smiling compared to control group.

CONCLUSIONS

Nasolabial region asymmetry in smiling and rest position in individuals with UCLP was significantly different from the control group. However, the asymmetry in the nasolabial region, which is more evident in the resting position in individuals with UCLP, decreases during smiling.