Two-stage palate repair with delayed hard palate closure is related to favorable maxillary growth in unilateral cleft lip and palate

Craniofacial morphological variability in orthodontic patients with non-syndromic orofacial clefts: an approach using geometric morphometrics

OBJECTIVES

Orofacial clefts are complex congenital anomalies that call for comprehensive treatment based on a thorough assessment of the anatomy. This study aims to examine the effect of cleft type on craniofacial morphology using geometric morphometrics.

MATERIALS AND METHODS

We evaluated lateral cephalograms of 75 patients with bilateral cleft lip and palate, 63 patients with unilateral cleft lip and palate, and 76 patients with isolated cleft palate. Generalized Procrustes analysis was performed on 16 hard tissue landmark coordinates. Shape variability was studied with principal component analysis. In a risk model approach, the first nine principal components (PC) were used to examine the effect of cleft type.

RESULTS

We found statistically significant differences in the mean shape between cleft types. The difference is greatest between bilateral cleft lip and palate and isolated cleft palate (distance of means 0.026, P = 0.0011). Differences between cleft types are most pronounced for PC4 and PC5 (P = 0.0001), which together account for 10% of the total shape variation. PC4 and PC5 show shape differences in the ratio of the upper to the lower face, the posterior mandibular height, and the mandibular angle.

CONCLUSIONS

Cleft type has a statistically significant but weak effect on craniofacial morphological variability in patients with non-syndromic orofacial clefts, mainly in the vertical dimension.

CLINICAL RELEVANCE

Understanding the effects of clefts on craniofacial morphology is essential to providing patients with treatment tailored to their specific needs. This study contributes to the literature particularly due to our risk model approach in lieu of a prediction model.

Speech Outcomes after Delayed Hard Palate Closure and Synchronous Secondary Alveolar Bone Grafting in Patients with Cleft Lip, Alveolus and Palate

Background  The best timing of closure of the hard palate in individuals with cleft lip, alveolus, and palate (CLAP) to reach the optimal speech outcomes and maxillary growth is still a subject of debate. This study evaluates changes in compensatory articulatory patterns and resonance in patients with unilateral and bilateral CLAP who underwent simultaneous closure of the hard palate and secondary alveolar bone grafting (ABG). Methods  A retrospective study of patients with nonsyndromic unilateral and bilateral CLAP who underwent delayed hard palate closure (DHPC) simultaneously with ABG at 9 to 12 years of age from 2013 to 2018. The articulatory patterns, nasality, degree of hypernasality, facial grimacing, and speech intelligibility were assessed pre- and postoperatively. Results  Forty-eight patients were included. DHPC and ABG were performed at the mean age of 10.5 years. Postoperatively hypernasal speech was still present in 54% of patients; however, the degree of hypernasality decreased in 67% ( p  < 0.001). Grimacing decreased in 27% ( p  = 0.015). Articulation disorders remained present in 85% ( p  = 0.375). Intelligible speech (grade 1 or 2) was observed in 71 compared with 35% of patients preoperatively ( p  < 0.001). Conclusion  This study showed an improved resonance and intelligibility following DHPC at the mean age of 10.5 years, however compensatory articulation errors persisted. Sequential treatments such as speech therapy play a key role in improvement of speech and may reduce remaining compensatory mechanisms following DHPC.

What We Learned from Performing the Inverse Malek Procedure to Repair Bilateral Cleft Lips and Palates: A Single-Center Retrospective Study

Background: This study reviews the surgical and functional outcomes of children diagnosed with a bilateral cleft lip and palate and treated by the same surgical team following specific surgical protocols 18 years after surgery and during the follow-up. Methods: Based on a single-center retrospective design, demographic and surgical data were gathered by the authors from international institutions. Most of the data were quantitative in nature, and descriptive statistical and non-parametric tests were employed for analysis. All children born with a bilateral cleft from 1982 to 2002 were considered. Children affected by a syndrome were excluded. Complications and speech results were the main items measured. Results: Thirty patients were selected; 73.3% were treated using the inverse Malek procedure, and 26.7% underwent a modified two-stage procedure. Seventy percent developed an oronasal fistula. An alveolar bone graft was performed in 83%, and 53.3% underwent Le Fort osteotomy. Thirty-six percent required a pharyngeal flap, with good speech results. The median number of times general anesthesia was used among all the interventions considered was 5.5 (4.25-6). Conclusions: This study presents the long-term results of using the inverse Malek procedure to treat children with a bilateral cleft lip and palate. It is shown that this is related to a high risk of developing a fistula, but has good long-term speech results.

Maxillary Development and Dental Arch Relationships Following Early Two-Stage Palatoplasty: A Comparative Study

OBJECTIVE

To examine skeletal morphology and dental arch relationships at 8 years of age following early 2-stage palatoplasty, which consists of soft palate plasty at 1 year of age and hard palate closure at 1.5 years of age, and to compare the results with those of conventional pushback palatoplasty.

DESIGN

Retrospective.

SETTING

Single institutional study.

PATIENTS

Eighty-six patients with nonsyndromic complete unilateral cleft lip and palate (UCLP) were selected.

INTERVENTION

The subjects were divided into 2 groups according to the palatoplasty protocols, as follows: 45 patients, who underwent early 2-stage palatoplasty (ETS group), and 41 patients, who underwent 1-stage pushback palatoplasty (PB group).

MAIN OUTCOME MEASURES

Skeletal morphology was assessed using lateral cephalometric analysis, and dental arch relationships were examined using the GOSLON yardstick.

RESULTS

Cephalometric analysis revealed that the anterior-posterior length of the maxilla, measured by PTM-A and PTM-ANS, both projected to the nasal floor (NF) plane, was longer in the ETS group than in the PB group (PTM-A/NF, p = .04; PTM-ANS/NF, p = .03, unpaired t-test), although no significant difference was observed in SNA (p = .09, unpaired t-test). Upper posterior facial height was shorter in the ETS group than in the PB group (p = .02, unpaired t). Assessments with the GOSLON yardstick showed that the ETS group presented better dental arch relationships than the PB group (p = 0.04, Mann-Whitney's U-test).

CONCLUSIONS

The present results suggested that the ETS protocol reduced the negative effects of palatal surgery on facial development and dental arch relationships in patients with complete UCLP at 8 years of age.

Does cleft lip and palate affect the severity of malocclusion?

OBJECTIVE

The purpose of this study was to evaluate the 3D anatomical features of unilateral (UCLP) and bilateral (BCLP) complete cleft lip and palate with those of skeletal Class III dentofacial deformities.

MATERIALS AND METHODS

In total, 92 patients were divided into cleft and noncleft groups. The cleft group comprised 29 patients with UCLP and 17 patients with BCLP. The noncleft group comprised 46 patients with Class III dentofacial deformities. 3D anatomical landmarks were identified and the corresponding measurements were made on the cone-beam computed tomography (CBCT).

RESULTS

The differences between the affected and unaffected sides of the patients with UCLP were nonsignificant. The differences between the patients with UCLP and BCLP were nonsignificant except for the SNA angle. Significant differences between the patients with clefts and Class III malocclusion were identified for the SNA, A-N perpendicular, and A-N Pog line, indicating that the maxillae of the patients in the cleft group were more retrognathic and micrognathic. Relative to the noncleft group patients, the cleft group patients had a significantly smaller ramus height.

CONCLUSION

The affected and unaffected sides of the patients with UCLP did not exhibit significant differences. The maxillae of the patients with UCLP were significantly more retrognathic than those of the patients with BCLP. The maxillae and mandibles of the patients in the cleft group were more micrognathic and retropositioned relative to those of the noncleft Class III patients.

CLINICAL RELEVANCE

The maxillary and mandibular findings indicated greater deficiencies in the patients with UCLP or BCLP than in those with skeletal Class III malocclusion. Appropriate surgical design should be administered.

Impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate: a preliminary comparative study

OBJECTIVE

To estimate the impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate.

STUDY DESIGN

A Retrospective Cohort Study.

METHODS

A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate underwent primary palatoplasty (30 patients received the Sommerlad-Furlow modified technique without relaxing incision (S.F-RI group), and 30 received Sommerlad-Furlow modified technique with relaxing (S.F+RI group) with no significant difference found between them regarding the cleft type, cleft width, and age at repair. While the other 30 were healthy noncleft participants with skeletal class I pattern as a Control group. The control group (C group) was matched with the patient groups in number, age, and sex. All participants had lateral cephalometric radiographs at least 5 years old age. The lateral cephalometric radiographs were taken with the same equipment by the same experienced radiologist while the participants were in centric occlusion and a standardized upright position, with the transporionic axis and Frankfort horizontal plane parallel to the surface of the floor. A well-trained assessor (S. Elayah) used DOLPHIN Imaging Software to trace twice to eliminate measurement errors. All the study variables were measured using stable landmarks, including 12 linear and 10 angular variants.

RESULTS

The mean age at collection of cephalograms was 6.03 ± 0.80 in the S.F+RI group, 5.96 ± 0.76 in the S.F-RI group, and 5.91 ± 0.87 in the C group. Regarding cranial base, the results showed no statistically significant differences between the three groups in S-N and S-N-Ba. While the S.F+R.I group had a significantly shortest S-Ba than the S.F-R.I & C groups (P = 0.01 & P < 0.01), but there was no statistically significant difference between S.F-R.I & C groups (P = 0.71). Regarding the skeletal maxilla, there was no significant difference between the S.F+R.I and S.F-R.I groups in all linear measurements (N-ANS and S-PM) except Co-A, the S.F+R.I group had significantly shorter Co-A than the S.F-R.I & C groups (P =  < 0.01). While the angular measurement, S.F+R.I group had significantly less SNA angle than the S.F-R.I & C groups (P =  < 0.01). Regarding mandibular bone, there were no statistically significant differences in all linear and angular mandibular measurements between the S.F+R.I and S.F-R.I.groups. Regarding intermaxillary relation, the S.F+R.I group had significant differences in Co-Gn-Co-A and ANB compared to the S.F-R.I & C groups (P =  < 0.01). While there was no statistically significant difference in PP-MP between the three groups.

CONCLUSION

As a preliminary report, the Sommerlad-Furlow modified technique without relaxing incisions was found to have a good maxillary positioning in the face and a satisfactory intermaxillary relationship compared to the Sommerlad-Furlow modified technique with relaxing incisions.

A comparison of maxillofacial growth in Chinese children with isolated cleft palate treated with two different palatoplasty techniques without relaxing incisions: a preliminary study

OBJECTIVE

To assess the maxillofacial growth of patients with isolated cleft palate following the Sommerlad-Furlow modified technique and compare it with the effect of the Sommerlad technique.

STUDY DESIGN

A Retrospective Cohort Study.

METHODS

A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate (ISHCP) underwent primary palatoplasty without relaxing incision (30 patients received the Sommerlad-Furlow modified (S-F) technique and 30 received Sommerlad (S) technique). While the other 30 were healthy noncleft participants with skeletal class I pattern (C group). All participants had lateral cephalometric radiographs at least 5 years old age. All the study variables were measured by using stable landmarks, including 11 linear and 9 angular variants.

RESULTS

The means age at collection of cephalograms were 6.03 ± 0.80 (5-7 yrs) in the S group, 5.96 ± 0.76 (5-7 yrs) in the S-F group, and 5.91 ± 0.87 (5-7 yrs) in the C group. Regarding cranial base, the results showed that there were no statistically significant differences between the three groups in S-N and S-N-Ba. The S group had a significantly shortest S-Ba than the S-F & C groups (P = 0.01), but there was no statistically significant difference between S-F and C groups (P = 0.80). Regarding skeletal maxillary growth, the S group had significantly shorter Co-A, S- PM and significantly less SNA angle than the C group (P =  < 0.01). While there was no significant difference between S-F & C groups (P = 0.42). The S group had significantly more MP-SN inclination than the C group (P =  < 0.01). Regarding skeletal mandibular growth, there were no statistically significant differences in all linear and angular mandibular measurements between the three groups, except Co-Gn of the S group had a significantly shorter length than the C group (P = 0.05). Regarding intermaxillary relation, the S-F group had no significant differences in Co-Gn-Co-A and ANB as compared with the C group. The S group had significantly less ANB angle than S-F & C groups (P = 0.01 & P =  < 0.01). In addition, there were no significant differences in all angular occlusal measurements between the three groups.

CONCLUSION

As a preliminary report, Sommerlad-Furlow modified technique showed that maxillary positioning in the face tended to be better, and the intermaxillary relationship was more satisfactory than that in Sommerlad technique when compared them in healthy noncleft participants.

Comparison of Maxillofacial Morphology Between Modified Furlow's and Modified two-Flap Palatoplasty in Orofacial Clefts During the Primary Dentition Period

OBJECTIVE

To assess the effect of two palatoplasty procedures, modified Furlow's palatoplasty (F procedure) and modified two-flap palatoplasty (T procedure), on the maxillofacial morphology of unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) during the primary dentition period.

DESIGN

Retrospective cohort study.

SETTING

Department of Orthodontics, School of Dentistry, Showa University.

PARTICIPANTS

We enrolled 106 pediatric patients (63 boys, 43 girls; aged 4.43  ±  0.34 years) with non-syndromic orofacial clefts who underwent cheiloplasty and palatoplasty.

INTERVENTIONS

Patients were divided into four groups according to cleft type (BCLP or UCLP) and palatoplasty procedure type (F or T procedure).

MAIN OUTCOME MEASURES

Maxillofacial morphology was assessed by examining parameters on lateral cephalograms.

RESULTS

Multiple comparisons revealed significant differences among N-A, N-ANS, and ANS-PNS distances and SNA and ANB angles among the groups. There were significant differences in N-A, N-ANS, ANS-PNS, SNA, and SNB among the UCLP and BCLP groups. The calculated effect sizes were all within 0.3-0.5. The statistical power was as follows: N-A, 86.41%; N-ANS, 79.77%; ANS-PNS, 97.49%; SNA, 96.88%; and ANB, 99.25%.

CONCLUSIONS

Although UCLP and BCLP both exhibited differences in craniofacial distances and angles, the procedure type (either F or T procedure) had no significant effect on the maxillofacial morphology (as determined by lateral cephalograms). However, to rule out additional bias, patient-specific factors should be considered that may be affected by maxillofacial development when deciding surgical approaches.

A Cross-Sectional Study of the Dental Arch Relationship and Palatal Morphology after Cleft Surgery in Italian Children with Unilateral Cleft and Lip Palate

Dental arch relationships (DARs) and palatal morphology (PM) were evaluated in in non-syndromic complete unilateral cleft lip and palate (UCLP) Italian patients after surgery. Pre- and postnatal factors affecting the results were investigated. Sixty-six children with UCLP (40 boys and 26 girls, with a mean age of 10.1 ± 2.9 years), predominantly Caucasian (77%), were consecutively enrolled in this cross-sectional study. Twenty children had received a one-stage protocol consisting of an early periosteal palate surgical repair and lip closure and forty-six were submitted to a staged surgical protocol with delayed palate repair (DPR). A single clinician collected data on their medical history and carried out a dental examination. The DAR and PM were graded on dental casts according to the Eurocran index and dichotomised as favourable and unfavourable based on the treatment outcome. Multiple logistic regression analyses demonstrated that female sex (OR = 6.08, 95% CI: 1.47-25.23, p = 0.013), DPR (OR = 4.77, 95% CI: 1.14-19.93, p = 0.032) and the use of a neonatal plate (OR = 4.68, 95% CI: 1.27-17.16, p = 0.020) increased the odds of having favourable DAR, while only DPR (OR = 9.76, 95% CI: 2.40-39.71, p = 0.001) was significantly associated with a favourable PM. Based on these findings, only DPR had a significantly favourable effect on both DAR and DM in Italian children with complete UCLP.

Outcomes of alveolar cleft repair in complete cleft lip and palate after tertiary gingivoperiosteoplasty and segmental Le Fort I osteotomy

OBJECTIVES

Gingivoperiosteoplasty is often used for reconstruction of alveolar defects in infants with cleft lip and palate. This study aimed to examine outcomes of tertiary gingivoperiosteoplasty, which has not previously been investigated.

MATERIALS AND METHODS

This prospective study included 11 adults with complete cleft lip and palate (n = 12 sites) who consecutively underwent segmental Le Fort I osteotomy and concomitant gingivoperiosteoplasty for correction of skeletal class III deformity, nasoalveolar fistula and alveolar cleft. Outcomes included clinical and radiographic evaluations of gingivoperiosteoplasty at the time of osteotomy (presence of nasoalveolar fistula, residual cleft defect and unsupported root ratio of cleft-adjacent teeth), and determination of influencing factors for the clinical success of alveolar cleft repair. Study variables included age, gender, pre-surgical orthodontic treatment and alveolar cleft width of cleft-adjacent canine and angulation between cleft-adjacent teeth before surgery and 1-week postsurgery.

RESULTS

Posttreatment, no nasoalveolar fistula remained. The residual cleft defect decreased significantly (p < 0.01). The unsupported root ratio of cleft-adjacent teeth did not differ (p > 0.05); eight cleft sites reached Bergland I or II (67% success). One-week postsurgery, the minimal alveolar cleft width of cleft-adjacent canine was significantly less in the success group compared with the failed group (p = 0.01).

CONCLUSIONS

Tertiary gingivoperiosteoplasty and segmental Le Fort I osteotomy decreased nasoalveolar fistulas and induced alveolar bone formation. The minimal alveolar cleft width immediately after surgery was the major influencing factor of clinical success.

CLINICAL RELEVANCE

Segmental Le Fort I osteotomy with simultaneous gingivoperiosteoplasty efficaciously repairs adult alveolar clefts.

Quality of life and phonatory and morphological outcomes in cognitively unimpaired adolescents with Pierre Robin sequence: a cross-sectional study of 72 patients

Background

Pierre Robin sequence (PRS) is a heterogeneous condition involving retro(micro)gnathia, glossoptosis and upper airway obstruction, very often with posterior cleft palate. Patients with PRS, either isolated or associated with Stickler syndrome have good intellectual prognosis. Nevertheless, the quality of life in adolescence and the phonatory and morphological outcomes are rarely analysed. We assessed the phonatory and morphological outcomes of 72 cognitively unimpaired adolescents with PRS, studied their oral (COHIP-SF19), vocal (VHI-9i) and generic quality of life (QoL; KIDSCREEN-52), and searched for determinants of these outcomes.

Results

Two-thirds of our adolescents retained low or moderate phonation difficulties, but risk factors were not identified. For 14%, morphological results were considered disharmonious, with no link to neonatal retrognathia severity. Only one vs two-stage surgery seemed to affect final aesthetic results. The oral QoL of these adolescents was comparable to that of control patients and was significantly better than that of children with other craniofacial malformations (COHIP-SF19 = 17.5, 15.4 and 25.7, respectively). The oral QoL of the adolescents with non-isolated PRS was significantly worse (COHIP-SF19 = 24.2) than that of control patients and close to that of children with other craniofacial malformations. The vocal QoL of the adolescents (mean [SD] VHI-9i = 7.5 [5.4]) was better than that of patients with other voice pathologies and better when phonation was good. The generic QoL of the adolescents was satisfactory but slightly lower than that of controls, especially in dimensions concerning physical well-being, relationships and autonomy. QoL results were lower for adolescents with non-isolated than isolated PRS. Only non-isolated PRS and low oral QoL affected generic QoL.

Conclusion

Morphological or phonatory impairments remain non-rare in adolescents with PRS but do not seem to be directly responsible for altered QoL. These adolescents, especially those with non-isolated PRS, show self-confidence and social-relation fragility. We must focus on long-term functional and psychological results for PRS patients and improve therapy protocols and follow-up, notably those affecting the oral aspects of the disease.

3D morphometric evaluation of the dental arches in children with cleft lip and palate submitted to different surgical techniques

OBJECTIVES

This study aimed to compare dimensional alterations of dental arches in children with unilateral complete cleft lip and palate before and after different techniques of primary plastic surgeries.

MATERIALS AND METHODS

The sample was divided into two groups: group 1-cheiloplasty by Millard's technique and one-stage palatoplasty by von Langenbeck's technique; group 2-cheiloplasty by Millard's technique and two-stage palatoplasty: anterior palatoplasty by Hans Pichler's technique and posterior palatoplasty by Sommerlad's technique. Dental arches were evaluated before (T1), after the first phase (T2), and 1 year after the second phase (T3) of primary surgeries. Linear measurements and palatal area were assessed. To analyze the method's error, interclass correlation coefficient was applied. ANOVA (followed by Tukey test), dependent, and independent t-test were used (p < 0.05).

RESULTS

At T1, the intertuberosity distance was statistically greater in G2 (p = 0.004). At T2, the anterior length of the dental arch was statistically greater in G2 (p = 0.025), while the area of the smaller palatal segment (p = 0.001), cleft area (p = 0.014), and total area (p = 0.002) were statistically smaller in G2. At T3, the intertuberosity distance was statistically greater in G2 (p = 0.017).

CONCLUSION

This study suggests that cheiloplasty and one-stage palatoplasty resulted in smaller growth of maxilla than cheiloplasty and two-stage palatoplasty in the linear measurements (T-T' and I-CC') and total area of the dental arches.

CLINICAL RELEVANCE

Surgical protocols need to be evaluated to verify their effects aiming at improving the clinical practice of the interdisciplinary team, determining new parameters for the rehabilitation of individuals with cleft lip and palate.

Does the Timing of 1-Stage Palatoplasty With Radical Muscle Dissection Effect Long-Term Midface Growth? A Single-Center Retrospective Analysis

OBJECTIVE

To evaluate the long-term effect of timing of 1-stage palatoplasty on midfacial growth in patients with cleft lip and palate (CLP).

DESIGN

Retrospective observational cohort study.

STUDY SETTING

Institutional hospital.

PATIENTS

One hundred twelve patients with CLP who underwent palatoplasty and were divided into 3 groups: group I: operated between 9 and 11 months; group II: operated between 18 and 20 months; and group III: operated between 21 and 24 months.

INTERVENTIONS

All patients underwent von Langenbeck palatoplasty technique, which was converted to a Bardach 2-flap technique in case of any technical difficulties. The patients were followed up between 8 and 9 years when they reported for secondary alveolar bone grafting. Postsurgical cephalometric and dental casts measurements were taken for midfacial growth analysis.

MAIN OUTCOME MEASURES

The cephalometric measures were analyzed for midfacial growth and compared within the groups.

RESULTS

Statistically significant difference (P < .01) was found on comparing the cephalometric parameters such as sella-nasion-A point angle (SNA), A point-nasion-B point angle (ANB), n toperpendicular to point A (N-perpA), condylon to point A (Co-A), anterior nasal spine to posterior nasal spine (ANS-PNS), nasion to Anterior nasal spine (N-ANS), nasion to menton (N Me), and witts appraisal (Witt (AO-BO)) in group I when compared to both group II and group III patients, implying deficient midfacial growth in group I. No statistical difference was found in the cephalometric values between group II and group III. Group II had better cephalometric measurements than group III, showing better growth in group II than group III. Overall, there was less incidence of midfacial hypoplasia in patients treated between 18 and 20 months (group II).

CONCLUSION

We conclude that palatal closure carried out at 18 to 20 months and 21 to 24 months is associated with better midfacial growth when compared to closure at 9 to 11 months. The best time to operate would be between 18 and 20 months to avoid speech disturbances. Midfacial growth can be greatly influenced by the timing of 1-stage palatoplasty.

Speech and Audiology Outcomes After Single-Stage Versus Early 2-Stage Cleft Palate Repair

PURPOSE

The timing and management of patients with cleft palates have been controversial. Early soft palate closure at the time of cleft lip repair followed by hard palate closure at a second stage has been hypothesized to improve speech and audiology outcomes. This study compares cleft palate patients who have undergone single-stage versus 2-stage cleft palate repairs and the outcomes on speech and hearing.

METHODS

A retrospective chart review identified patients with diagnosis of cleft lip with complete cleft palate who underwent either single or 2-stage repair from 2006 to 2012. Data collected included age at each surgery, necessity of further speech surgery for velopharyngeal insufficiency, frequency of tympanostomy tube placement, presence of hearing loss, and speech assessment data graded per the validated Americleft speech scale.

RESULTS

A total of 84 patients were identified and subdivided into groups of single-stage and 2-stage repair. The mean age at the time of single-stage palate repair was 13.3 months. For the 2-stage group, the mean ages were 4.2 and 11.8 months for the soft palate and hard palate repairs, respectively. Comparing the single-stage versus 2-stage palate repairs, there was no significant difference in all speech parameters including hypernasality, hyponasality, nasal air emission, articulation, expressive language, receptive language, speech intelligibility, and speech acceptability for both unilateral and bilateral cleft lip/palate patients. Two-stage repair was associated with increased number of tympanostomy tube placement compared with single-stage repair (relative risk, 1.74; P = 0.009), and the first set of tubes was performed at a statistically significantly younger age, 4.5 months in the 2-stage repair compared with 16.9 months in the single-stage (P = 0.012) with 87.5% performed with first stage of repair. However, there was no difference in the types, degrees of hearing loss, or the presence of at least mild conductive hearing loss at latest follow-up audiograms between the groups.

CONCLUSIONS

There was no significant benefit with respect to speech or hearing outcomes between single-stage and 2-stage cleft palate repairs. This advocates for surgeon and family preference in the timing of cleft palate repair.

Incidence of Fistula Formation and Velopharyngeal Insufficiency in Early Versus Standard Cleft Palate Repair

The goals of cleft palate repair are well-established; however, there does exist difference in practice patterns regarding the most appropriate patient age for palatoplasty. The optimal timing is debated and influenced by cleft type, surgical technique, and the surgeon's training. The objective of this study was to compare the rates of post-operative fistula formation and velopharyngeal insufficiency (VPI) in "early" versus "standard" cleft palate repair in a cohort of patients treated at a single craniofacial center.A retrospective chart review identified 525 patients treated for cleft palate from 2000 to 2017 with 216 meeting inclusion criteria. "Early repair" is defined as palatoplasty before 6-months of age (108 patients). "Standard repair" is palatoplasty at or beyond 6-months old (108 patients). Rates of fistula formation were found to be significantly higher in early repairs (Chi-square statistic 9.0536, P value = 0.0026). Development of VPI was not significantly different between the 2 groups (Chi-square statistic 1.2068, P value = 0.27196). As expected, the incidence of post-palatoplasty VPI was significantly higher in patients who had a post-operative fistula when compared to those who healed without fistula formation (Chi-square statistic 4.3627, P value = 0.0367).There is significant debate regarding the optimal timing of cleft repair to maximize speech outcomes and minimize risks. The authors' data show that post-operative fistula formation occurs at a higher rate when performed prior to 6 months old. Furthermore, while the rate of VPI was not significantly affected by age at time of surgery, it was significantly higher in those who experienced a post-operative fistula.

Innovative Molecular and Cellular Therapeutics in Cleft Palate Tissue Engineering

Clefts of the lip and/or palate are the most prevalent orofacial birth defects occurring in about 1:700 live human births worldwide. Early postnatal surgical interventions are extensive and staged to bring about optimal growth and fusion of palatal shelves. Severe cleft defects pose a challenge to correct with surgery alone, resulting in complications and sequelae requiring life-long, multidisciplinary care. Advances made in materials science innovation, including scaffold-based delivery systems for precision tissue engineering, now offer new avenues for stimulating bone formation at the site of surgical correction for palatal clefts. In this study, we review the present scientific literature on key developmental events that can go awry in palate development and the common surgical practices and challenges faced in correcting cleft defects. How key osteoinductive pathways implicated in palatogenesis inform the design and optimization of constructs for cleft palate correction is discussed within the context of translation to humans. Finally, we highlight new osteogenic agents and innovative delivery systems with the potential to be adopted in engineering-based therapeutic approaches for the correction of palatal defects. Impact statement Tissue-engineered scaffolds supplemented with osteogenic growth factors have attractive, largely unexplored possibilities to modulate molecular signaling networks relevant to driving palatogenesis in the context of congenital anomalies (e.g., cleft palate). Constructs that address this need may obviate current use of autologous bone grafts, thereby avoiding donor-site morbidity and other regenerative challenges in patients afflicted with palatal clefts. Combinations of biomaterials and drug delivery of diverse regenerative cues and biologics are currently transforming strategies exploited by engineers, scientists, and clinicians for palatal cleft repair.

Increased Risk of Velopharyngeal Insufficiency in Patients Undergoing Staged Palate Repair

OBJECTIVE

To evaluate the association of 2-stage cleft palate (CP) surgery on velopharyngeal insufficiency (VPI) incidence, speech surgeries, and cleft-related surgical burden.

DESIGN

Retrospective cohort with follow-up of 4 to 19 years.

SETTING

Academic, tertiary children's hospital.

PATIENTS

Patients who underwent CP surgery between 2000 and 2017. Exclusions included submucous CP or age at last contact under 3.9.

INTERVENTIONS

Cleft palate surgery, completed in either a single-stage or 2-stage repair.

MAIN OUTCOME MEASURE(S)

Rates of VPI diagnosis and speech surgery and total cleft surgeries; t tests, tests of proportion, and linear and logistic regression were performed. Total cleft-related surgeries were examined in a subset (n = 418) of patients with chart reviews.

RESULTS

A total of 1047 patients were included; 59.6% had 2-stage CP repair, 40.4% had single-stage repair. Approximately 32% of children with 2-stage CP repair were diagnosed with VPI, as opposed to 22% of single-stage patients (P < .001). Children with 2-stage CP repair were 1.8 times as likely to be diagnosed with VPI (P < .001). Speech surgery rates were similar across groups. Patients who had 2-stage repair received an average of 2.3 more cleft-related procedures, when excluding prosthesis management procedures.

CONCLUSION

Our data show an increased risk of VPI diagnosis and increased surgical burden among patients receiving 2-stage CP repair.

A Surgical and Educational Video of the Inferior Turbinate Mucosal Flap for the Nasal Floor and Intraoral Reconstruction in Unilateral Complete Cleft Lip Repair

Since the original description of Millard rotation advancement principle for cleft lip repair, many important contributions have subsequently been described by other surgeons worldwide. However, the reconstruction of the nasal floor and intraoral lining has received less attention over time. This article demonstrates a modified unilateral complete cleft lip repair using the rotation advancement principle plus multipurpose inferior turbinate mucosal flap. The accompanying videos display the 10 key steps for rationale, design, and proper execution of the inferior turbinate mucosal flap for the nasal floor and intraoral reconstruction.

The Influence of Four Different Treatment Protocols on Maxillofacial Growth in Patients with Unilateral Complete Cleft Lip, Palate, and Alveolus

BACKGROUND

The purpose of this study was to evaluate the effect of four different treatment protocols on maxillofacial growth in patients aged 7 to 8 years with unilateral complete cleft lip, palate, and alveolus.

METHODS

Sixty-one patients with nonsyndromic unilateral complete cleft lip, palate, and alveolus were entered into this study and grouped as follows: group 1 patients had a repaired lip and an unrepaired palate; group 2 patients underwent one-stage palatoplasty; group 3 patients underwent two-stage palatoplasty; and group 4 patients underwent lip adhesion and two-stage palatoplasty. The control group was composed of 16 patients with unilateral incomplete cleft lip. The Kolmogorov-Smirnov test was used to test the nature of data distribution. The Bonferroni test and the Kruskal-Wallis H test were used for multiple comparisons.

RESULTS

Group 5 showed a more protruding maxilla (basion-nasion-A point, basion-nasion-anterior nasal spine, sella-nasion-anterior nasal spine; p < 0.05), longer maxillary sagittal length (anterior nasal spine-posterior maxillary point; p < 0.05) and maxillary basal sagittal length (A point-posterior maxillary point; p < 0.05), and a better jaw relationship (A point-nasion-B point angle; p < 0.05) than groups 2, 3, and 4. Group 2 had higher anterior facial height (anterior nasal spine-nasion, anterior nasal spine-menton, nasion-menton; p < 0.05) and posterior facial height (registration point-posterior maxillary point; p < 0.05) than groups 3 and 4. Groups 2 and 3 had better maxillary position (sella-pterygomaxillary fissure; p < 0.05) and deeper bony pharynx (basion-posterior maxillary point; p < 0.05) than group 4.

CONCLUSIONS

In patients aged 7 to 8 years with unilateral complete cleft lip, palate, and alveolus, both one- and two-stage palatoplasty inhibited maxillary sagittal growth. Vomer flap repair with denuded bone inhibited maxillary vertical growth. Lip adhesion did adversely affect maxilla position.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Craniofacial Interventions in Children

Craniofacial interventions are common and the surgical options continue to grow. The issues encountered include micrognathia, macroglossia, midface hypoplasia, hearing loss, facial nerve palsy, hemifacial microsomia, and microtia. In addition, a unifying theme is complex upper airway obstruction. Throughout a child's life the focus of interventions may change from airway management to speech, hearing, and language optimization, and finally to decannulation and procedures aimed at social integration and self-esteem. Otolaryngologists play an important role is this arena and provide high-quality care while continuing to expand what can be done for our patients.

Early or delayed palatoplasty in complete unilateral cleft lip and palate patients? A systematic review of the effects on maxillary growth

The aim of this study was to review the effects of early and late hard palate repair on maxillary growth. PubMed, Scopus, Web of Science, LILACS, Cochrane Library CENTRAL databases, OpenGrey, Google Scholar, and Clinical Trials were searched using a PICO strategy, with terms related to unilateral cleft lip and palate (UCLP) and timing of repair. Methodological quality evaluation was carried out using the Fowkes and Fulton guidelines, and quality (or certainty) of evidence and strength of recommendations were evaluated using GRADE (grading of recommendations, assessment, development and evaluation). Five retrospective and non-randomized studies were included in the study. Folkes and Fulton assessment showed a high risk of bias in all articles and very low levels of certainty (GRADE). The results showed conflicting findings for comparisons of the effects of timing of repair of hard palate in UCLP. Two studies presented better maxillary growth in a group operated on later (18 months after birth), two presented no differences between the results, and another presented better results in the group operated on earlier than 18 months of age. At this point, it cannot be proven or refuted that postponing hard palate surgery brings benefits for maxillary growth. Studies included in this review did not show similar conclusions. Randomized clinical trials present some ethical issues that make them difficult to perform.

Effect of One-Stage versus Two-Stage Palatoplasty on Hypernasality and Fistula Formation in Children with Complete Unilateral Cleft Lip and Palate: A Randomized Controlled Trial

BACKGROUND

Is one-stage or two-stage palatoplasty more effective for preventing fistula formation and hypernasality in patients with complete unilateral cleft lip and palate?

METHODS

This parallel blocked randomized controlled trial included 100 patients with nonsyndromic complete unilateral cleft lip and palate with a repaired cleft lip, divided into two equal groups. Group A had one-stage palatoplasty patients at age 12 to 13 months while group B had two-stage palatoplasty patients with soft palatoplasty at age 12 to 13 months and hard palatoplasty at age 24 to 25 months. Presence of a fistula was tested clinically at 3 years and speech was tested using nasometry and perceptual analyses at 6 years. Group C consisted of noncleft controls (n = 20, age 6 years) for speech using nasometry. Fistula rates, hypernasality ratings, and nasalance scores were compared between groups A and B. Nasometry recordings of groups A and B were compared with control group C.

RESULTS

There was no difference in fistula rates between groups A and B (p = 0.409; 95 percent CI, 0.365 to 11.9). Mean nasalance scores of group A showed higher nasalance than group B (p = 0.006; 95 percent CI, 1.16 to 6.53). Perceptual analysis showed no difference between groups A and B (p = 0.837 and p = 1.000). Group A showed higher mean nasalance than group C (p = 0.837 and p = 1.000), whereas group B showed no difference (p = 0.088; 95 percent CI, -0.14 to 2.02).

CONCLUSIONS

There was no difference in fistula rates between groups. Nasalance was slightly higher in patients in the one-stage palatoplasty group than two-stage palatoplasty group, but the difference was not clinically significant.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Determining postoperative outcomes after cleft palate repair: A systematic review and meta-analysis

BACKGROUND

A lack of high-level evidence exists on the outcomes of different cleft palate repair techniques. A critical appreciation for the complication rates of common repair techniques is paramount to optimize cleft palate care.

METHODS

A literature search was conducted for articles on the measurement of fistula and velopharyngeal insufficiency (VPI) rates following cleft palate repair. Study quality was determined using validated scales. The heterogeneity between studies was evaluated using the I² statistic. Random-effect model analysis and forest plots were used to report pooled relative risks (RRs) with 95% confidence intervals for treatment effect. P-values of 0.05 were considered statistically significant.

RESULTS

Of 2386 studies retrieved, 852 underwent screening and 227 met inclusion criteria (130 studies (57%) on fistulas and 122 studies (54%) on VPI). Meta-analyses were performed using 32 studies. The Furlow technique was associated with less postoperative fistulae than the von Langenbeck and Veau/Wardill/Kilner techniques (RR = 0.56 [0.39-0.79], p < 0.01 and RR = 0.25 [0.12-0.52], p < 0.01, respectively). One-stage repair was associated with less fistulae compared to two-stage repair (RR = 0.42 [0.19-0.96], p = 0.04). The Furlow repair was also associated with a less VPI than the Bardach palatoplasty (RR = 0.41 [0.23, 0.71], p < 0.01), and the one-stage repair was associated with a reduction in VPI rates compared to two-stage repair (RR = 0.55 [0.32, 0.95], p = 0.03).

CONCLUSION

The Furlow repair is associated with less risk of fistula formation than the von Langenbeck and Veau/Wardill/Kilner techniques and less VPI compared to the Bardach repair. One-stage repair is associated with less risk of fistula formation and VPI than two-stage repair.

A semi-automated virtual workflow solution for the design and production of intraoral molding plates using additive manufacturing: the first clinical results of a pilot-study

Computer-aided design and computer-aided manufacturing (CAD/CAM) technology has been implemented in the treatment of cleft lip and palates (CLP) by several research groups. This pilot study presents a technique that combines intraoral molding with a semi-automated plate generation and 3D-printing. The clinical results of two intraoral molding approaches are compared. This is the first clinical investigation of semi-automated intraoral molding. Our study included newborns with unilateral CLP. Plaster models were digitalized and measured by two independent observers. Two methods of CAD/CAM-assisted intraoral molding were compared: (i) stepwise manual design of molding plates (conventional CAD/CAM-intraoral molding) and (ii) a semi-automated approach with an automated detection of alveolar ridges (called RapidNAM) assisted by a graphical user interface (GUI). Both approaches significantly narrowed the clefts and resulted in a harmonic alveolar crest alignment. The GUI was easy to use and generated intraoral molding devices within minutes. The presented design solution is an efficient technical refinement with good clinical results. The semi-automated plate generation with a feasible GUI is fast but allows individual adaptations. This promising technique might facilitate and foster the more widespread use of CAD/CAM-technology in intraoral molding therapy.

Effects of Nasoalveolar Molding Therapy on Alveolar and Palatal Cleft Deformities in Unilateral and Bilateral Cleft Lip and Palate

OBJECTIVE

The purpose of this study was to evaluate and compare the efficacy of nasoalveolar molding (NAM) therapy in the improvement of alveolar and palatal cleft deformity on unilateral (UCLP) versus bilateral (BCLP) cleft lip and palate.

MATERIALS AND METHODS

A total of 19 UCLP (14 boys and 5 girls) and 8 BCLP (7 boys and 1 girl) infants completed NAM therapy were included in this study. Standardized parameters of cleft width of alveol and palate were measured on photocopies taken from the pre- and post-treatment plaster casts. To assess the intragroup differences, paired-samples test in UCLP and Wilcoxon test in BCLP groups were used. Mann-Whitney U test was used to evaluate the differences between the groups.

RESULTS

Significant decreases in alveolar and palatal cleft gaps were achieved in an average period of 3.3 ± 1.9 and 3.7 ± 1.6 months in UCLP and BCLP patients, respectively. The alveolar cleft decreased 7.85 ± 4.59 mm in UCLP and 4.25 ± 3.13 and 3.81 ± 3.50 mm in right and left alveolar cleft sides in BCLP, respectively. The palatal clefts were decreased 4.63 ± 2.44 mm in medial and 3.72 ± 2.62 mm in posterior parts in UCLP. The decrements in BCLP were 3.00 ± 2.75 mm in medial and 2.88 ± 2.75 mm in posterior palatal cleft distances. No significant differences were determined in the amount of alveolar or palatal cleft closure between UCLP and BCLP groups. The only decrease in arch width was 1.39 mm in medial part of palate in UCLP.

CONCLUSION

The NAM device provides significant decreases in both alveolar and palatal cleft deformities in UCLP and BCLP infants, as compared with their birth status.

Long-Term Incisal Relationships After Palatoplasty in Patients With Isolated Cleft Palate

PURPOSE

Various palatoplasty techniques have limited incisions in the hard palate due to concerns that these incisions may limit maxillary growth. There is little convincing long-term evidence to support this. Our purpose is to determine incisal relationships, an indicator for future orthognathic procedure, in patients after repair of an isolated cleft of the secondary palate.

METHODS

Our craniofacial database was used to identify patients aged 10 years or greater with an isolated cleft of the secondary palate who underwent palatoplasty between 1985 and 2002. Data collected included age at palatoplasty and follow-up, cleft type, associated syndrome, Robin sequence, surgeon, repair technique, number of operations, and occlusion. Incisal relationship was determined through clinical observation by a pediatric dentist and orthodontist.

RESULTS

Seventy eligible patients operated on by 9 surgeons were identified. Class III incisal relationship was seen in 5 patients (7.1%). Palatoplasty techniques over the hard palate (63 of 70 patients) included 2-flap palatoplasty, VY-pushback, and Von Langenbeck repair. There was an association between class III incisal relationship and syndromic diagnosis (P <0.001). Other study variables were not associated with class III incisal relationships.

CONCLUSION

In patients with an isolated cleft of the secondary palate, there was no association between class III incisal relationship and surgeon, age at repair, cleft type, palatoplasty technique, or number of operations. Increased likelihood of class III incisal relationship was associated primarily with syndromic diagnosis.

Computed Tomographic Estimation of Particulate Cancellous Bone and Marrow Weight for Successful Transplant in Unilateral Cleft Lip and Palate Patients

Objective

The defect volume measured on computed tomography (CT) for secondary bone graft (SBG) is well correlated to the actual amount of particulate cancellous bone and marrow (PCBM) transplanted in unilateral cleft lip and palate (UCLP) patients. However, the validity of such measurements have not been completely verified due to lack of evaluation of treatment results. The objective of this study was to propose an estimation method by CT based on the data of successfully treated patients. For this purpose, the association was initially verified between the weight of transplanted PCBM and the defect volume measured on CT using the results of successfully treated patients.

Methods

Treatment results were evaluated 1 year after SBG by intraoral radiography in 50 UCLP patients. For the patients with good results, the correlation was investigated between the defect volume on CT and the transplanted PCBM weight, and a method was proposed based on PCBM density, calculated as PCBM weight divided by defect volume on CT.

Results

In successfully treated patients showing level 3 or 4 alveolar resorption, a strong correlation ( r = .87) was found between the volume on CT and the PCBM weight. Level 4 results were observed in 22 of 23 (95.7%) patients who had calculated PCBM densities of more than 6 g/cm3.

Conclusions

Volume estimation on preoperative CT was confirmed to have sufficient validity. The weight of PCBM transplanted should be greater than the defect volume on CT multiplied by 6.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

One-flap Palatoplasty: A Cohort Study to Evaluate a Technique for Unilateral Cleft Palate Repair

Background:

The 2-flap palatoplasty technique is actually the approach most commonly used in the United States for cleft palate repair. This is a one-time surgery that enables closure under minimal tension, lowering rates of subsequent fistula development. However, its primary disadvantage is potential detriment to maxillary growth (due to extent of dissection on both sides of the cleft and raw lateral surfaces). Since 2007, a surgical technique using only one mucoperiosteal flap from the noncleft side has been performed by us, reducing the extent of the surgery and its potential nondesirable effects over the palate. The purpose of this study is to evaluate the utility of this technique for unilateral cleft palate repair.

Methods:

This is a retrospective, simple-blinded cohort study between 2 groups of 120 patients each with unilateral cleft palate who were operated on using the 2-flap and 1-flap techniques by the Outreach Surgical Center Program Lima from 2007 to 2012. Data collection was accomplished by physical examination to evaluate the presence or absence of a fistula and to evaluate the presence of hypernasality. Postoperative bleeding was also studied.

Results:

We have observed no increase in the rate of fistulas and velopharyngeal insufficiency between these 2 studied groups (P = 0.801 and P = 1.000).

Conclusions:

Use of a 1-flap technique for unilateral cleft palate repair allowed us to achieve results comparable to those of a 2-flap technique in terms of postoperative fistula development and hypernasal speech. Additional studies are required to evaluate the effect of this technique on palatal growth.

The impact of cleft lip and palate repair on maxillofacial growth

Surgical correction is central to current team-approached cleft treatment. Cleft surgeons are always concerned about the impact of their surgical maneuver on the growth of the maxilla. Hypoplastic maxilla, concaved mid-face and deformed dental arch have constantly been reported after cleft treatments. It is very hard to completely circumvent these postoperative complications by current surgical protocols. In this paper, we discussed the factors that inhibit the maxillofacial growth on cleft patients. These factors included pre-surgical intervention, the timing of cleft palate and alveolae repair, surgical design and treatment protocol. Also, we made a review about the influence on the maxillary growth in un-operated cleft patients. On the basis of previous researches, we can conclude that most of scholars express identity of views in these aspects: early palatoplasty lead to maxilla growth inhibition in all dimensions; secondary alveolar bone graft had no influence on maxilla sagittal growth; cleft lip repair inhibited maxilla sagittal length in patients with cleft lip and palate; Veau's pushback palatoplasty and Langenbeck's palatoplasty with relaxing incisions were most detrimental to growth; Furlow palatoplasty showed little detrimental effect on maxilla growth; timing of hard palate closure, instead of the sequence of hard or soft palate repair, determined the postoperative growth. Still, scholars hold controversial viewpoints in some issues, for example, un-operated clefts have normal growth potential or not, pre-surgical intervention and pharyngoplasty inhibited maxillofacial growth or not.

Influence of different palate repair protocols on facial growth in unilateral complete cleft lip and palate

OBJECTIVE

To address the question of whether one- or two-stage palatal treatment protocol has fewer detrimental effects on craniofacial growth in patients aged 5 years with unilateral complete cleft lip and palate.

MATERIALS AND METHODS

Forty patients with non-syndromic unilateral complete cleft lip and palate (UCCLPs) who had received primary cleft lip repair at age 6-12 months and cleft palate repair at age 18-30 months were selected in this study. Eighteen UCCLP patients who received two-stage palate repair were selected as group 1, and 22 UCCLP patients who received one-stage palate repair were selected as group 2. The control group consisted of 20 patients with unilateral incomplete cleft lip (UICL patients) whose age and gender matched with UCCLP patients. A one-sample Kolmogorov-Smirnov test was used to analyze the nature of data distribution. Bonferroni test and Kruskal-Wallis H tests were used for multiple comparisons.

RESULTS

Both case groups showed reduced maxillary sagittal length (ANS-PMP, A-PM, p < 0.05) and retrusion of the maxilla (S-Ptm, p < 0.05), A point and ANS point (Ba-N-A, Ba-N-ANS, p < 0.05). Patients treated with two-stage palate repair had a reduced posterior maxillary vertical height (R-PMP, p < 0.05).

CONCLUSIONS

Our results indicated that maxillary sagittal length and position could be perturbed by both one- and two-stage palate repair. Vomer flap repair inhibited maxilla vertical growth. Delayed hard palate repair showed less detrimental effects on maxillary growth compared to early hard palate repair in UCCLP patients aged 5 years.

Occlusal Classification in Relation to Original Cleft Width in Patients With Unilateral Cleft Lip and Palate

OBJECTIVE

To determine a correlation between the width of the cleft palate measured at the time of lip adhesion, definitive lip repair, and palatoplasty and the subsequent occlusal classification of patients born with unilateral cleft lip and palate.

DESIGN

Retrospective, observational study.

SETTING

Referral, urban, children's hospital Participants : Dental models and records of 270 patients were analyzed.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Angle occlusion classification.

RESULTS

The mean age at which occlusal classification was determined was 11 ± 0.3 years. Of the children studies, 84 were diagnosed with Class I or II occlusion, 67 were diagnosed with Class III occlusion, and 119 were lost to follow up or transferred care. Mean cleft widths were significantly larger in subjects with Class III occlusion for all measures at time of lip adhesion and definitive lip repair (P < .02). At time of palatoplasty, cleft widths were significantly greater at the alveolus (P = .025) but not at the midportion of the hard palate (P = .35) or posterior hard palate (P = .10).

CONCLUSION

Cleft widths from the lip through to the posterior hard palate are generally greater in children who are diagnosed with Class III occlusion later in life. Notably, the alveolar cleft width is significantly greater at each time point for patients who went on to develop Class III occlusion. There were no significant differences in cleft widths between patients diagnosed later with Class I and Class II occlusions.

Influence of modified Furlow double opposing Z-plasty on mandibular growth in Oriental patients with cleft palate and/or lip

The purpose of this study was to statistically analyze mandibular growth disturbance in the Oriental cleft population and compare this with that of non-cleft children through cephalometric analysis. Thirty-six children with cleft palates, repaired using a modification of Furlow double opposing Z-plasty, were chosen. Comparative analyses among 3 types of cleft were performed. Statistical analyses of 8 linear and angular measurements were performed in cleft patients and the non-cleft population using Fisher Z-transformation. Comparative analysis showed no significant difference among the 3 types of cleft. In the Oriental cleft group treated with modified double opposing Z-plasty, the spatial position of the mandible showed significant differences compared with the non-cleft group. A backward inclination of the anterior surface of the mandible and downward rotation of the mandibular body were identified. Some of our results regarding gonial angle and length of the mandibular body conflicted with previous Western studies.

Early hard palate closure using a vomer flap in unilateral cleft lip and palate: effects on cleft width

OBJECTIVES

Although no universal consensus exists on treatment of cleft palates, early hard palate closure is commonly performed. The aim of the present study was to determine the influence of a vomer flap for early hard palate closure on residual palatal cleft width in patients with a unilateral complete cleft lip and palate (UCLP).

MATERIALS AND METHODS

Forty-seven UCLP patients were retrospectively divided into two groups. Group A consisted of 25 patients who underwent early lip closure and simultaneous hard palate closure using a vomer flap. Group B included 22 patients who had lip closure only at first surgery. Palatal cleft widths of both groups were measured at two time points and were compared using the Mann-Whitney U test to examine the influence of vomerplasty in this very early stage.

RESULTS

No significant difference of baseline characteristics between the groups was found, and comparison of age at the time of surgeries was not significantly different. Mean age at the time of vomerplasty was 4.0 months. After the first surgery, a significantly greater total cleft width reduction of 5.0 mm average was found in group A compared to only 1.5 mm reduction in group B. This reduction took place after an average of 7.1 and 7.0 months, respectively.

CONCLUSIONS

Lip closure accompanied by early hard palate closure using a vomer flap is associated with a significant postoperative reduction of the residual cleft when compared to lip closure only.

CLINICAL RELEVANCE

This study shows another great advantage of performing early hard palate closure using a vomer flap.

Speech outcomes of early palatal repair with or without intravelar veloplasty in children with complete unilateral cleft lip and palate

We compared the early speech outcomes of 40 consecutive children with complete unilateral cleft lip and palate (UCLP) who had been treated according to different 2-stage protocols: the Malek protocol (soft palate closure without intravelar veloplasty at 3 months; lip and hard palate repair at 6 months) (n=20), and the Talmant protocol (cheilorhinoplasty and soft palate repair with intravelar veloplasty at 6 months; hard palate closure at 18 months) (n=20). We compared the speech assessments obtained at a mean (SD) age of 3.3 (0.35) years after treatment by the same surgeon. The main outcome measures evaluated were acquisition and intelligibility of speech, velopharyngeal insufficiency, and incidence of complications. A delay in speech articulation of one year or more was seen more often in patients treated by the Malek protocol (11/20) than in those treated according to the Talmant protocol (3/20, p=0.019). Good intelligibility was noted in 15/20 in the Talmant group compared with 6/20 in the Malek group (p=0.010). Assessment with an aerophonoscope showed that nasal air emission was most pronounced in patients in the Malek group (p=0.007). Velopharyngeal insufficiency was present in 11/20 in the Malek group, and in 3/20 in the Talmant group (p=0.019). No patients in the Talmant group had an oronasal fistula (p<0.001). All other outcomes were similar. Despite later closure of the soft and hard palate, early speech outcomes were better in the Talmant group because intravelar veloplasty was successful and there were no fistulas after closure of the hard palate in 2 layers.

Long-Term, Longitudinal Follow-Up of Individuals with UCLP after the Gothenburg Primary Early Veloplasty and Delayed Hard Palate Closure Protocol: Maxillofacial Growth Outcome

Objective

To study long-term maxillofacial development in a sample of patients born with unilateral cleft lip and palate. The patients’ palatal repair had been performed according to a two-stage protocol with early velar closure and delayed hard palate surgery.

Design

Retrospective, longitudinal cohort study.

Subjects

The sample consisted of 50 consecutive patients with unilateral cleft lip and palate born from 1980 to 1989. All of them had been operated on at the Sahlgrenska University Hospital in Gothenburg, Sweden.

Methods

Certain maxillary casts as well as lateral roentgencephalograms, obtained at 5, 10, 16, and 19 years of age, were analyzed.

Results

Our patients’ maxillofacial growth was very good even up to the final examination in early adulthood. We ascribe the advantageous midfacial morphology of our patients particularly to limited growth restriction from palatal scars due to the surgical protocol used in our cleft center.

Conclusion

The two-stage protocol we advocate for repair of the palatal cleft resulted in very satisfactory growth outcome. A palatal scar, which might impair maxillary development, was created only by the velar surgery. If this scar is located close to the posterior border of the hard palate, it might result in less maxillary growth restriction than if it is positioned further anteriorly.

Palate Dimensions in Six-Year-Old Children with Unilateral Cleft Lip and Palate: A Six-Center Study on Dental Casts

Objective

To compare palatal dimensions in 6-year-old children with unilateral cleft lip and palate (UCLP) treated by different protocols with those of noncleft children.

Design

Retrospective intercenter outcome study.

Patients

Upper dental casts from 129 children with repaired UCLP and 30 controls were analyzed by the trigonometric method.

Setting

Six European cleft centers.

Main outcome measures

Sagittal, transverse, and vertical dimensions of the palate were observed.

Statistics

Palate variables were analyzed with descriptive methods and nonparametric tests. Regarding several various characteristics measured on a relatively small number of subjects, hierarchical, k-means clustering, and principal component analyses were used.

Results

Mean values of the observed dimensions for five cleft groups differed significantly from the control (p < .05). The group with one-stage closure of the cleft differed significantly from all other cleft groups in most variables (p < .05). Principal component analysis of all 159 cases identified three clusters with specific morphologic characteristics of the palate. A similar number of treated children were classified into each cluster, while all children without clefts were classified in the same cluster. The percentage of treated children from a particular group that fit this cluster ranged from 0% to 70% and increased with age at palatal closure and number of primary surgical procedures.

Conclusion

At 6 years of age, children with stepwise repair and hard palate closure after the age of two more frequently result in palatal dimensions of noncleft control than children with earlier palatal closure and one-stage cleft repair.