Orthodontic Treatment of the Patient with Complete Clefts of Lip, Alveolus, and Palate: Lessons of the past 60 Years

Establishment of a novel classification system for alveolar morphology in infants with unilateral complete cleft lip and palate

OBJECTIVES

Unilateral complete cleft lip and palate (UCCLP) is one of the most severe clinical subtypes among cleft lip and palate (CLP), making repair surgery and subsequent orthodontic treatment particularly challenging. Presurgical nasoalveolar molding (PNAM) has shown conflicting and heterogeneous results in the treatment of UCCLP patients, raising questions about whether the diversity in alveolar anatomical morphology among these patients plays a role in the effectiveness of PNAM treatment.

MATERIALS AND METHODS

We collected 90 digital maxillary models of infants with UCCLP and performed mathematical clustering analysis, including principal component analysis (PCA), decision tree modeling, and area under the ROC Curve (AUC) analysis, to classify alveolar morphology and identify key measurements. We also conducted clinical evaluations to assess the association between the alveolar morphology and CLP treatment outcomes.

RESULTS

Using mathematical clustering analysis, we classified the alveolar morphology into three distinct types: average form, horizontal form, and longitudinal form. The decision tree model, AUC analysis, and comparison analysis revealed that four measurements (Trans ACG-ACL, ML length, MG length and Inc length) were essential for clustering the alveolar morphology of infants with UCCLP. Furthermore, the blinded clinical evaluation indicated that UCCLP patients with alveolar segments of horizontal form had the lowest treatment outcomes.

CONCLUSION

Overall, our findings establish a novel quantitative classification system for the morphology of alveolar bone in infants with UCCLP and suggest that this classification may be associated with the outcomes of CLP treatment.

CLINICAL RELEVANCE

The multidisciplinary CLP team should thoroughly evaluate and classify the specific alveolar morphology when administering PNAM to infants with UCCLP.

The orthodontic management of patients with cleft lip and palate: from the permanent dentition and the adult returning to the service

This is the second of two papers outlining the orthodontic management of patients with cleft lip and palate. The first paper reviewed orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. In this second paper, I will discuss tooth management across the grafted cleft site and its impact on the bone graft itself. I will also discuss the some of the challenges of the adult patient returning to the service.

Reconstruction of Oronasal Fistula with Tongue Flap: A Cleft Palate Report

Oronasal fistula can persist after conventional secondary alveolar bone graft surgery, which may lead to functional issues, such as regurgitation of fluids from the oral to the nasal cavity. This manuscript describes a clinical case of a patient with a bilateral cleft lip and palate that underwent tongue graft surgery for closure of an oronasal fistula after three failed local mucosa flap surgeries. The multidisciplinary treatment was comprised of orthodontic treatment, mucosa and alveolar grafts for palate closure and aesthetic rehabilitation of the anterior maxillary teeth. Smile aesthetics were noticeably improved, enhancing the patient’s self-perception and confidence.

Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts

ABSTRACT

Management of residual clefts of the alveolus and maxilla requires the coordinated effort of multiple members of the craniofacial team including surgeon, orthodontist, and when teeth are hypoplastic or absent, the prosthodontist to achieve complete habilitation. Such cooperation among specialists begins early in the patient's life and continues through completion of care.Although numerous publications on this topic exist, few present definitive multidisciplinary reconstructive outcomes with longterm results. In this review paper, the authors present our comprehensive, multidisciplinary protocols, experience, and techniques as they have evolved with over 35 years of practice at our Craniofacial Center.Details of our updated protocols for each intervention and procedure, including our current thoughts on appropriate timing, follow up and advantages from the incorporation of current technologies are discussed. Close cooperation among specialists at all stages of care, the use of evolving technology, and adherence to, and modification where indicated, of time honored team protocols enables us to consistently achieve successful functional and esthetic outcomes, while minimizing complications.

Camouflage treatment of skeletal Class III malocclusion in an adult cleft-palate patient using passive self-ligating system

This case report describes the successful camouflage treatment to correct a moderate skeletal Class III malocclusion in a 19-year-old male cleft-palate patient. Early closure of the palate produced palatal scar tissue that inhibited midfacial growth, causing maxillary arch deficiency, severe maxillary crowding, and anterior and posterior crossbites. Combined surgical-orthodontic therapy would have been the preferred treatment of choice; however, the patient declined this option because of surgical risks and costs. Therefore, nonextraction camouflage treatment using a passive self-ligating bracket system was used. Treatment aims including expansion of the maxillary arch and correction of the anterior and posterior crossbites were achieved without the use of an additional maxillary arch expander or other auxiliary appliances. This treatment resulted in satisfying facial esthetics and a normal dental occlusion.

Long-Term Follow-Up of UCLP Patients: Surgical and Orthodontic Burden of Care during Growth and Final Orthognathic Surgery Need

Objective

The goal of this study was to evaluate the craniofacial morphology at 5 and 10 years of age and at the completion of growth, the need for final orthognathic surgery, and the orthodontic burden in a sample of patients with unilateral cleft lip and palate consecutively treated by the same surgeon with the same two-step protocol.

Design

A sample of 62 adult patients with unilateral cleft lip and palate was retrospectively collected (mean age, 17.5 years). Lateral cephalograms at three time points were traced. The need for orthognathic surgery was assessed, subdividing the sample into an orthognathic surgery group and nonorthognathic surgery group. Time and modality of orthodontic treatment were recorded.

Results

Cephalometric values related to maxillary growth (SNA, SNAns) and maxillomandibular relation (ANB, NAPg) were significantly different between the two groups already at 5 and 10 years of age. All patients presenting an ANB smaller than 2° at 5 years needed a Le Fort I osteotomy. Mandibular protrusion (SNB, SNPg) was not different at 5 and 10 years, but was different at the completion of growth. Patients with the same initial maxillomandibular relation did not show better growth when subjected to earlier or longer orthodontic treatment.

Conclusion

Patients needing final jaw surgery had a more severe skeletal discrepancy during early childhood. The ANB angle at 5 years allowed doctors to identify 45% of the need for orthognathic surgery. The final craniofacial pattern does not seem to change significantly with early or prolonged orthodontic treatment.

Asymmetric Anterior Distraction for Transversely Distorted Maxilla and Midfacial Anteroposterior Deficiency in a Patient With Cleft Lip/Palate: Two-Stage Surgical Approach

The present report describes a male patient with a unilateral cleft lip and palate who presented with midfacial anteroposterior and transverse deficiency. Correction involved a two-stage surgical-orthodontic approach: asymmetric anterior distraction of the segmented maxilla followed by two-jaw surgery (LeFort I and bilateral sagittal splitting ramus osteotomies). The present case demonstrates that the asymmetric elongation of the maxilla with anterior distraction is an effective way to correct a transversely distorted alveolar form and midfacial anteroposterior deficiency. Furthermore, successful tooth movement was demonstrated in the new bone created by distraction.

Application of the International Classification of Functioning, Disability, and Health–Children and Youth Version (ICF-CY) to Cleft Lip and Palate

Objective

In recent health policy discussions, the World Health Organization has urged member states to implement the International Classification of Functioning, Disability, and Health: Children and Youth Version in their clinical practice and research. The purpose of this study was to identify codes from the International Classification of Functioning, Disability, and Health: Children and Youth Version relevant for use among children with cleft lip and/or palate, thereby highlighting the potential value of these codes for interprofessional cleft palate-craniofacial teams.

Design

The scope of recent published research in the area of cleft lip and/or palate was reviewed and compared with meaningful terms identified from the International Classification of Functioning, Disability, and Health: Children and Youth Version. In a five-step procedure, a consensus-based list of terms was developed that was linked separately to International Classification of Functioning, Disability, and Health: Children and Youth Version categories and codes. This provided a first draft of a core set for use in the cleft lip and/or palate field.

Conclusions

Adopting International Classification of Functioning, Disability, and Health: Children and Youth Version domains in cleft lip and/or palate may aid experts in identifying appropriate starting points for assessment, counseling, and therapy. When used as a clinical tool, it encourages health care professionals to go beyond treatment and outcome perspectives that are focused solely on the child and to include the children's environment and their familial/societal context. In order to establish improved, evidence-based interdisciplinary treatments for children with cleft lip and/or palate, more studies are needed that seek to identify all the influencing conditions of activities, children's participation, and barriers/facilitators in their environments.

Presurgical Orthopedics Has No Effect on Archform in Unilateral Cleft Lip and Palate

Objective

Evaluation of the effect of presurgical orthopedics on maxillary archform up to 6 months of age.

Design

Retrospective, single-blinded, case-control study.

Participants

Study model sets of 75 infants with consecutive, nonsyndromic, complete unilateral cleft lip and palate (excluding Simonart bands) from 1995 to 2005.

Interventions

All patients (PSO group, n = 14; non-PSO group, n = 61) received lip repair/vomer flap at 3 months and soft palate repair at 6 months by the same consultant surgeon. The two groups were comparable at birth ( p > .01) in all archform variables.

Main Outcome Measures

Sixteen variables were computed, following single-blinded analysis using the Reflex Microscope to describe the archform in the transverse, anteroposterior, and vertical dimensions and the arch circumference. Data were analyzed using a repeated-measures hierarchical analysis of variance with a significance level of 1%.

Results

Repeatability studies showed good measurement precision. Presurgical orthopedics produced no statistically significant mean change in any archform variable when compared with the non-PSO group. The difference in the mean reduction in the alveolar cleft width between the groups was 0.69 mm (95% confidence interval, −0.89 to 2.28 mm, p = .52). Lip repair produced greater change in archform than did presurgical orthopedics, reducing the mean alveolar cleft width by 4.45 mm (95% confidence interval, 3.53 to 5.37 mm; p < .001).

Conclusions

There was no evidence that presurgical orthopedics produced any significant effect on archform, raising questions for its continued use in this context. Lip repair had a greater impact on arch dimensions than did presurgical orthopedics.