Accuracy of prenatal detection of facial clefts and relation between facial clefts, additional malformations and chromosomal abnormalities: a large referral-center cohort

PURPOSE

Facial clefts belong to the most common congenital malformations and their prenatal diagnosis is a constant challenge. The aim of this study was to determine the accuracy of prenatal ultrasound in correctly classifying facial clefts. Furthermore, we aimed to specify the distribution of the type of clefts and underlying genetic conditions.

METHODS

All fetuses seen with suspected facial cleft in the Department of Obstetrics, Charité - Universitätsmedizin Berlin during a period of 23 years (1999-2022) were included in this retrospective study. Clefts were classified according to the classification of Nyberg. All additional prenatal findings were assessed and correlated with the outcome. The accuracy of prenatal diagnosis was assessed.

RESULTS

292 patients were included in the study. The most common type of clefts were unilateral cleft lip and palate (CL-P) (53.6%) and bilateral CL-P (30.6%), followed by CL (8.1%), CP (5.1%) and median CL-P (2.6%). The overall pre- and postnatal concordance rate corresponding to a correct prenatal diagnosis was high, 88.9%, ranging from 73.7% (CL) to 93.7% (unilateral CL-P). Most of the median clefts (95.2%) and CP (93.3%) were associated with other sonographic abnormalities, as well as 52.2% of bilateral CL-P. Chromosomal abnormalities, mostly trisomy 13 and trisomy 18, were observed in in the median CL-P (47.6%), bilateral CL-P (31.1%) and CP (26.7%) groups, in contrast to the CL (9.1%) and unilateral CL-P (12.9%) groups. It was exceptional to have a chromosomal abnormality without additional malformations (4.8%). The mortality rate including one late miscarriage, 5 IUFD's, 74 TOPs and 6 palliative cares at birth was 29.8%, particularly high for median clefts (90.5%).

CONCLUSION

Prenatal ultrasound exhibited a high accuracy to assess the type of facial clefts with an average rate of 88.9% (73.7%-93.7%) and a concordance rate of up to 93.7%, depending on the type of cleft. The search for additional malformations as well as clarifying underlying genetic conditions is essential. This allows for a targeted counseling of the parents and to best prepare for postnatal care, including surgery by the maxillofacial team.

Comparison of Alveolar Bone Grafting Outcomes using CBCT in Individuals with UCLP Based on the Presurgical Orthodontic Treatment Methods

OBJECTIVE

The purpose is to evaluate outcomes of alveolar bone grafting based on the pre-grafting orthodontic preparation methods.

DESIGN

Retrospective analysis of individuals with unilateral cleft lip and palate.

SUBJECTS AND SETTINGS

28 individuals with non-syndromic UCLP from two craniofacial centers, 14 individuals each from XXXX and XXXX.

INTERVENTIONS

The alignment group underwent maxillary expansion with incisors alignment while the non-alignment group underwent only maxillary expansion for presurgical orthodontic preparation.

METHODS

Initial and post-surgical CBCT scans were compared to observe changes in angulation of the incisor adjacent to the cleft site, alveolar bony root coverage, and bone graft outcomes.

RESULTS

In the alignment group, the buccolingual rotation decreased by 32.35 degrees (p = .0002), the anteroposterior inclination increased by 14.01 degrees (p = .0004), and the mesiodistal angulation decreased by 17.88 degrees (p = .0001). Alveolar bony coverage did not change after bone graft in both groups, and no difference was observed between the groups. Chelsea scale showed satisfactory bone graft outcome (category A, C) in 12 cases (85.71%) in the alignment group and 11 cases (78.51%) in the non-alignment group. The volumetric measurement showed the alignment group had better bone fill of 69.85% versus 51.45% in the non-alignment group (p = .0495).

CONCLUSIONS

Alveolar bony coverage on the tooth adjacent to cleft sites did not change with alveolar bone grafting surgery in either of the alignment and non-alignment group. Presurgical orthodontic alignment does not induce root exposure nor poorer bone grafting outcome.

Root Curvature in Non-Syndromic Oral Clefts: A Case-Control Study in a Brazilian Population

OBJECTIVE

This study assesses the degree of root curvature in patients with non-syndromic cleft lip and/or palate (NSCL/P).

DESIGN

Retrospective. Case-control study.

SETTING

Root curvature was assessed in lower premolars and molars in 800 panoramic radiographs: 400 from patients with cleft and 400 from healthy control individuals. Root curvature was classified according to its angulation, as well as its apical, medial, or coronal localization.

RESULTS

The frequency of mild curvature in the NSCL/P group compared to the control group was higher in premolars especially in the left second premolar in cleft palate (OR: 6.91; 95% CI: 3.23-14.77; P < .0001). The frequency of moderate curvature in molars was significantly higher in the cleft group, with the highest risk in the right first molar in the cleft lip group (OR: 2.74; 95% CI: 1.67-4.52; P < .0001). Inclination was more frequently observed in the apical third of the root in the group with cleft, whereas for the control group, the curvature was more frequent in the medial third. In patients with cleft, the OR of curvature in the apical third was significant in premolars (left lower second premolar: Cleft lip, OR: 1.91; 95% CI: 1.04-3.52; P = .03; right lower second premolar: Cleft lip, OR: 1.91, 95% CI: 1.04-3.50; P = .03, cleft lip and palate, OR: 1.75; 95% CI: 1.12-2.73; P = .01).

CONCLUSION

The results of the current study indicate differences in root curvature in patients with non-syndromic cleft lip and/or palate, which should be considered during the dental treatment planning of patients.

Biomechanical behavior of three maxillary expanders in cleft lip and palate: a finite element study

This study evaluated the stress distribution in the dentoalveolar and palatal bone structures during maxillary expansion in a 17-year-old male patient with bilateral cleft lip and palate (BCLP) using expanders with dental (HYRAX) and skeletal anchorage (MARPE). For the generation of the specific finite element models, cone-beam computed tomography was used, and the DICOM files were exported to Mimics 3-Matic (Materialise) and Patran (MSC Software) software. Three specific three-dimensional models were generated: A) HYRAX: conventional four-banded hyrax screw (9 mm); B) MARPE-DS: 3 miniscrews (1.8 mm diameter - 5.4 mm length) and four-banded dental anchorage; and C) MARPE-NoDS: 3 miniscrews without dental anchorage. Maxillary expansion was simulated by activating the expanders transversely 1 mm on the "X" axis. HYRAX resulted in higher levels of deformation predominantly in the dentoalveolar region. MARPE-DS showed stress in the dentoalveolar region and mainly in the center of the palatal region, at approximately 4,000 με. MARPE-NoDS exhibited evident stress only in the palatal region. High stress levels in the root anchoring teeth were observed for HYRAX and MARPE-DS. In contrast, MARPE-NoDS cause stress on the tooth structure. The stress distribution from the expanders used in the BLCP showed asymmetric expansive behavior. During the initial activation phase of expansion, the HYRAX and MARPE-DS models produced similarly high strain at the dentoalveolar structures and upper posterior teeth displacement. The MARPE-NoDS model showed restricted strain on the palate.

The evaluation of superior semicircular canal in patients with unilateral cleft lip and palate using CBCT

OBJECTIVES

The present study aims to evaluate the thickness and radiological patterns of the superior semicircular canal (SSC) in patients with unilateral cleft lip and palate (CL/P).

METHODS

Cone beam computed tomography (CBCT) images of the patients were evaluated in axial and Pöschl planes. CBCT images of 84 patients with unilateral CL/P and 168 healthy individual controls were included in the study. Three study groups were established: the CS-CL/P group (cleft side temporal bones of the CL/P patients), NCS-CL/P (non-cleft side temporal bones of the CL/P patients) and the control group. The radiological patterns of SSCs were categorized as dehiscence, papyraceous, normal, pneumatised and thick. The minimum bone thickness of SSC was measured.

RESULTS

It was found that the CS-CL/P group had a higher prevalence for SSCD compared to both the NCS-CL/P group and the control group. CS-CL/P group had a higher prevalence of dehiscence type and papyraceous type compared to the control group. The SSC thickness on the CS-CL/P patients was thinner than the NCS-CL/P patients and the control group sides (p = 0.033 and p < 0.001, respectively).

CONCLUSIONS

The mean thickness of SSC was found significantly lower in the CS-CL/P group compared to both the NCS-CL/P group and the control group. The elevated prevalence of dehiscence and papyraceous types in the CS-C/LP group compared to the control group implies that the presence of a cleft may be a predisposing factor for these types.

Evaluation of Orbitomalar Region Projection in Patients With Operated Cleft Lip and Palate (Cephalometric Study)

OBJECTIVE

The aim of this study was to compare the orbitomalar region projection in patients with cleft lip and palate (CLP) with skeletal class 1 cases.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Cephalometric data of 52 cases with unilateral CLP, 25 cases with bilateral CLP, and 60 healthy participants in skeletal class 1 without CLP were included.

MAIN OUTCOME MEASURE(S)

A total of 5 parameters, 3 in the orbital and 2 in the suborbital region, that determine the projection of the orbitomalar region on lateral cephalograms, and 13 parameters of the craniofacial region were evaluated.

RESULTS

Lateral, inferior, and anterior orbital parameters were similar between groups, while suborbital parameters were in a retrusive position in the CLP groups compared to the control group (P < .05). No significant difference was found between the CLP groups in terms of suborbital parameters. A moderate positive correlation was found between orbitomalar parameters and the anteroposterior positions of the maxilla and mandible. The lateral orbital region had a moderate negative correlation with anterior maxillary height, and the suborbital region had a negative moderate correlation with maxillary inclination.

CONCLUSION

Suborbital projection was more retrusive in CLP compared to the control group, but no difference was found between the CLP groups. On the other hand, the correlation between orbitomalar projection and maxillary and mandibular development was significant. The results show that there is a need for alternative treatment modalities for the suborbital region in patients with CLP.

Quantitative assessment of cleft volume and evaluation of cleft's impact on adjacent anatomical structures using CBCT imaging

OBJECTIVES

To determine pre-operative cleft volume and evaluate cleft´s impact on surrounding anatomical structures in children and adolescents with orofacial clefts using cone bean computed tomography (CBCT) imaging.

METHODS

The present retrospective study retrieved CBCT examinations of 68 patients from a previous study. The examinations had been exposed either before (n = 53) or after (n = 15) alveolar bone grafting. Pre-operative volume of cleft was determined, and type and location were evaluated. Morphological changes on the adjacent anatomical structures, including the incisive foramen, the nasal septum and floor, and the inferior turbinate, were assessed.

RESULTS

Mean bilateral cleft volume was 0.76 cm3, while mean unilateral cleft volume was 1.08 cm3; the difference was significant (p < 0.001). Variation in cleft volume, however, was large. The incisive foramen was not visible in the majority of cases with bilateral clefts (71%); the difference was significant (p = 0.001). In cases with unilateral clefts, the nasal septum in 87% was curved towards the cleft or graft side. Also, the mean size of the widest part of the inferior turbinate was 8.8 mm on the cleft or graft side and 10.4 mm on the non-cleft side. The difference was significant (p < 0.001).

CONCLUSIONS

When required, CBCT is a feasible method for quantitatively illustrating alveolar clefts and their impact on the morphological development of surrounding structures. Variation in cleft volume was large.

Prenatal detection of orofacial clefts in Denmark from 2009 to 2018

OBJECTIVE

To investigate the overall and type-specific prenatal detection rates (DRs) of orofacial clefts in a national cohort in Denmark.

METHODS

This study was based on data from the Danish Fetal Medicine Database and included all fetuses and children from singleton pregnancies diagnosed with an orofacial cleft prenatally and/or postnatally between 2009 and 2018. The types of cleft included unilateral, bilateral or median cleft lip (CL); unilateral, bilateral or median cleft lip with secondary cleft palate (CLP); and cleft palate (CP). The clefts were grouped as cleft lip with or without cleft palate (CL(P)) or as all clefts (including CP). All cases with discordance between prenatal and postnatal diagnoses were validated in the local patient files (Astraia). Cases without prenatal validation of the postnatal diagnosis were marked as undetected. Postnatally diagnosed cases with a strong prenatal suspicion of a cleft but without an International Classification of Diseases-10 code were registered as prenatally detected. Termination of pregnancy and intrauterine death were registered as true positives even if no autopsy could be performed. Liveborn cases with a prenatal diagnosis but without a postnatal validation were excluded.

RESULTS

A total of 994 cases were included in the study, of which 933 were liveborn. The prevalence of orofacial cleft was 1.6 per 1000 live births. There were no differences in the baseline characteristics between detected and undetected cases. The DR for CL(P) was 71.7% (95% CI, 64.8-78.9%), with an increase from 60.0% in 2009 to 73.0% in 2018 (P = 0.018). The type-specific DRs for the entire period were 56.4% (95% CI, 45.0-67.6%) for unilateral CL; 76.6% (95% CI, 71.7-82.9%) for unilateral CLP; 70.5% (95% CI, 52.1-87.6%) for bilateral CL; 82.3% (95% CI, 70.6-93.6%) for bilateral CLP; 0% (0/6) for median CL; 75.0% (3/4) for median CLP; and 3.3% (95% CI, 0.6-5.7%) for CP. A total of 20.9% (208/994) of the cases had associated findings, of which 33.2% (69/208) were genetic aberrations.

CONCLUSIONS

The DR for CL(P) has improved in Denmark over the last decade. The DR for CLP is high, with the highest DR for bilateral CLP. However, prenatal detection of CP remains a challenge. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of Internal Nasal Dimensions of Individuals With Cleft Lip and Palate and Obstructive Sleep Apnea Syndrome by Computed Tomography

To evaluate nasal cavity (NC) dimensions of individuals with cleft lip and/or palate (CL/P), obstructive sleep apnea (OSA), and primary snoring, by tomographic image analysis, compared to individuals with OSA without CL/P (N-CL/P).

Cross-sectional and retrospective.

Tertiary referral center.

Patients were divided into 2 groups: (G1) CL/P + OSA or primary snoring, n = 11; (G2) N-CL/P + OSA, n = 13.

NC tomographic images were reconstructed using ITK-SNAP software, and measurements were obtained from these three-dimensional models using SpaceClaim software.

Total NC volumes, right and left NC volumes, and volumes of the nostril to the nasal valve (V1) and from the nasal valve to the superior limit of the nasopharynx (V2), cross-sectional areas, and perimeters.

NC volumes (total, right, and left sides), V1, and V2, though smaller in the CL/P + OSA, did not differ significantly from the N-CL/P + OSA. Cross-sectional areas and perimeters of the superior limit of the nasopharynx, in the CL/P + OSA, presented significantly higher values compared to the N-CL/P + OSA (P ≤ .05).

The internal nasal dimensions of patients with CL/P do not seem to be part of the etiopathogenesis, nor constitute a risk factor for OSA with greater severity, in this special group of patients.

Evaluation of the Nasopalatine Canal of Patients With and Without Cleft Lip and Palate in CBCT Exams

OBJECTIVE

To identify and compare the morphology and dimensions of the nasopalatine canal (NPC) of individuals with and without cleft lip and palate using Conical Beam Computed Tomography (CBCT) images and to relate the results to the type of cleft and tooth absences in the region.

SETTING

This is a cross-sectional, analytical study with a retrospective sample.

PATIENTS, PARTICIPANTS

100 CBCT exams from patients with cleft lip and palate and 100 CBCT exams from patients without cleft lip and palate were used.

INTERVENTIONS

The NPC was evaluated for its morphology and measurements in the coronal, sagittal, and axial reformatting of CBCT exams.

RESULTS

It was obtained as a result that in the group of patients with a cleft, the shapes of funnel, banana, and needle of the NPC were more frequent than in the control group. Patients with cleft lip and palate had significantly a larger nasopalatine foramen and a larger NPC diameter, besides a significantly shorter NPC, compared to controls. In both groups, edentulous patients had less anterior maxillary bone thickness, when compared to patients with maxillary anterior teeth. Patients with clefts had a bone thickness buccal to the NPC less than in the control group.

CONCLUSIONS

This study confirms the anatomical variability of NPC in patients with cleft lip and palate. This finding reinforces the need for thorough surgical planning of the anterior region of the maxilla, in CBCT exams, by the dentist.

Three-dimensional nasal asymmetry analysis between adolescence and adulthood in postoperative patients with unilateral cleft lip and palate using computed tomography

AIM

To investigate the differences of the nasal soft and hard tissue asymmetry in postoperative patients with unilateral cleft lip and palate (UCLP) between adolescence and adulthood, and to explore the correlation of nasal soft and hard tissue asymmetry.

METHODS

CT data from 47 repaired UCLP patients were included and divided into two groups:1. adolescent group: 23 patients (15 males, 8 females; age: 10-12 years old). 2. adult group: 24 patients (16 males, 8 females; age:18-32 years old). The three-dimensional asymmetry in nasal soft and hard tissues was analyzed. Additionally, the correlation between nasal soft and hard tissue asymmetry was also analyzed.

RESULTS

Both the adolescent group and adult group showed asymmetries in nasal soft and hard tissues. Compared to the adolescent group, the adult group had a significantly increased horizontal asymmetry of nasal soft tissues Sbal (P < 0.05). Furthermore, the sagittal asymmetry of soft tissue Glat (P < 0.05), Sbal (P < 0.001), Sni (P < 0.001) and hard tissue LPA (P < 0.05) also increased significantly. In the adult group, there were more landmarks with a correlation between the asymmetry of nasal hard tissue and soft tissue compared to the adolescent group. There were moderate to strong correlations between nasal hard and soft tissue symmetries in the horizontal and sagittal directions (0.444 < r < 764), but no correlation in the vertical direction in the adult group (P > 0.05).

CONCLUSIONS

The asymmetry of nasal soft and hard tissues in patients with repaired UCLP becomes more apparent in the horizontal and sagittal dimensions from adolescence to adulthood. The correlation between the asymmetry of nasal hard tissue and soft tissue becomes stronger in the horizontal and sagittal dimensions. These factors should be taken into account when performing treatment for repaired UCLP patients in adolescence and adulthood.

Mandibular condyle volumes are associated with facial asymmetry in patients with cleft lip and palate: A retrospective cohort study

This study compares condylar volumetric asymmetry and facial asymmetry in patients with cleft lip and/or palate (CLP) and controls. The mandibular condyle is important to facial growth, but its role in facial asymmetry for those with CLP has not been described. Condylar volumes and mandibular asymmetry were retrospectively calculated using Mimics Version 23.0 (Materialise, Leuven, Belgium) from patients with CLP undergoing computed tomography (CT) imaging and a cohort of controls. A total of 101 participants, 60 with CLP and 41 controls, had mean condylar volumetric asymmetry of 16.4 ± 17.4 % (CLP) and 6.0 ± 4.0 % (controls) (p = 0.0002). Patients with CLP who had clinically significant chin deviation (>4 mm) had more asymmetric condyles than those without significant chin deviation (p = 0.003). The chin deviated toward the smaller condyle in patients with facial asymmetry more often than in patients without facial asymmetry (81 % vs. 62 %, p = 0.033). While controls had some degree of condylar asymmetry, it tended to be milder and not associated with facial asymmetry. There is a greater degree of condylar volumetric asymmetry in patients with CLP compared to individuals in the general population. Clinically significant facial asymmetry in CLP is associated with a higher degree of condylar asymmetry, with the facial midline deviating toward the smaller condyle.

Validation and comparison of 2D grading scales and 3D volumetric measurements for outcome assessment of bone-grafted alveolar clefts in children

BACKGROUND

Several methods have been proposed to assess outcome of bone-grafted alveolar clefts on cone beam computed tomography (CBCT), but so far these methods have not been compared and clinically validated.

OBJECTIVES

To validate and compare methods for outcome assessment of bone-grafted clefts with CBCT and provide recommendations for follow-up.

METHODS

In this observational follow-up study, two grading scales (Suomalainen; Liu) and the volumetric bone fill (BF) were used to assess the outcome of 23 autogenous bone-grafted unilateral alveolar clefts. The mean age at bone grafting was 9 years. The volumetric BF was assessed in five vertical sections. The bone-grafted cleft outcome was based on a binary coding (success or regraft) on a clinical multidisciplinary expert consensus meeting. Grading scales and volumetric assessment were compared in relation to the bone-grafted cleft outcome (success or regraft). Reliability for the different outcome variables was analyzed with intra-class correlation and by calculating kappa values.

LIMITATIONS

The study had a limited sample size. Clinical CBCT acquisitions had a varying tube current and exposure time.

RESULTS

Volumetric 3D measurements allowed for outcome assessment of bone-grafted alveolar clefts with high reliability and validity. The two grading scales showed highly reliable outcomes, yet the validity was high for the Suomalainen grading scale but low for the Liu grading scale.

CONCLUSIONS

Volumetric 3D measurement as well as the Suomalainen grading can be recommended for outcome assessment of the bone-grafted cleft. Yet, one must always make a patient-specific assessment if there is a need to regraft.

Congenital midline upper lip sinus in an infant

Congenital lip sinus is a rare entity with upper lip sinus being rarer than the lower lip sinus. It can be an isolated entity or associated with cleft lip, palate or Van der Woude syndrome. Syndromic association requires proper evaluation and aggressive surgical treatment. Preoperative delineation of the sinus tract with ultrasound sonography or MRI is mandatory. Simple excision is sufficient in cases of isolated sinuses. In this article, we report an infant with upper lip sinus managed successfully with simple excision and reviewed the literature.

Prenatal Diagnosis and Pregnancy Outcomes of Fetuses With Orofacial Cleft: A Retrospective Cohort Study in Two Centres in Hong Kong

OBJECTIVE

To evaluate the local incidence of orofacial cleft (OFC) encountered in fetal morphology scan and prenatal diagnosis, genetic etiology of fetuses with or without other structural abnormalities, and their pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

Two maternal fetal medicine units, tertiary hospitals, Hong Kong.

PARTICIPANTS

All pregnant women with antenatal diagnosis of fetal OFC between January 2016 and December 2020 (N = 66).

RESULTS

OFC has an incidence of 0.13% among pregnancies in Hong Kong and 28.8% (19/66) were syndromic cleft that exhibited other fetal structural anomalies. There were 55 cases (84.6%) who opted for invasive prenatal diagnostic testing. Genetic defects were identified in 25.8% (17/66) of this cohort, including 14 pathogenic variants. The detection rate in the syndromic cases is 68.4% (13/19) which was significantly higher than 8.5% (4/47) among non-syndromic cases. Aneuploidies would be the most common cause, accounting for 9.1% (6/66). Chromosomal microarray analysis (CMA) provided an incremental diagnostic yield of 6.1% compared to conventional karyotyping. A total of 29 live births including 3 cases of a variant of uncertain significance and 26 cases without genetic abnormalities detected have continued pregnancy to birth. There were 87.5% (21/24) without detectable pathogenic genetic abnormality reported good long-term outcomes. The chance of OFC fetuses having a good long-term outcome was significantly higher if no genomic variant was detected (P < .001).

CONCLUSIONS

Invasive prenatal tests with CMA should be offered to pregnancies with OFC regardless of the type. It has provided incremental diagnostic yield over conventional karyotyping and helped in prenatal and genetic counseling. A negative result in non-syndromic OFC favors couples to keep the pregnancy.

What is the Success Rate of Repeat Alveolar Bone Graft?

BACKGROUND

Success rates for alveolar bone grafting range from 30 to 96%. There is limited information regarding the success of repeat grafts.

PURPOSE

The purpose of this study was to determine the radiographic success rate of repeat alveolar bone grafts.

STUDY DESIGN

The study designs was a retrospective cohort study of patients who underwent repeat grafting by 1 surgeon over 15 years. To be included, subjects had to have: cleft lip and alveolus and a cone-beam computed tomography (CBCT) scan obtained >6 months after repeat graft. Patients were excluded if CBCT was inadequate.

PREDICTOR VARIABLE

Predictor variables were sex, age at repeat graft, cleft type, presence of an erupted canine, premaxillary osteotomy at time of repeat graft, presence of a visible oronasal fistula, size of bony defect, presence of a bony palatal bridge, and whether the surgeon who performed the repeat graft also performed the initial graft.

MAIN OUTCOME VARIABLE

The outcome variable was graft success determined using CBCT assessment and defined as a score of >3 out of 4 in each domain: vertical bone level, labiopalatal thickness, and piriform symmetry.

COVARIATES

The covariates were time from bone graft to CBCT (months) and age at time of CBCT (years).

ANALYSES

Frequency distributions, relative risk with 95% confidence intervals, medians, and interquartile ranges were calculated. Pearson c2 and Fisher exact tests were performed to determine predictors of outcome. A P < .05 was considered statistically significant.

RESULTS

Fifty subjects (54% male) who had repeat bone grafting to 59 cleft sites were included. Median follow-up time from repeat graft to CBCT was 7.0 months (interquartile range: 5.9 months). The radiographic success rate was 81.4%:91.7% if the same surgeon performed both initial and repeat grafts, but 78.7% if initial graft was completed by another surgeon (P = .43).

CONCLUSION AND RELEVANCE

Despite being a multifactorial issue, extensive and bilateral clefts, the presence of an erupted tooth in the cleft area, a visible oronasal fistula, and concomitant osteotomy of the premaxilla are warning signs of the possibility of failure. Performing repeat alveolar bone grafting by an experienced surgeon appears to increase the chance of success.

Objective and subjective evaluation of the efficacy of trans-sutural distraction osteogenesis: A correlation analysis between computed tomography measurements and FACE-Q scores

Previous studies on the efficacy of trans-sutural distraction osteogenesis (TSDO) to treat midface hypoplasia caused by cleft lip and palate (CLP) have mainly focused on objective measurements while ignoring the subjective feelings of patients. This study aimed to analyse the changes in and correlation between computed tomography (CT) measurements and FACE-Q scores in patients who underwent TSDO by performing a comprehensive evaluation from both objective and subjective perspectives. This retrospective study included 25 patients with an average age of 10.7 years who had midface hypoplasia caused by CLP and underwent TSDO between August 2018 and December 2022. The average follow-up time was 18.8 ± 7.7 months. Facial morphology and CT measurements, including A-CR, N-A⊥HR, the SNA angle and the L-ZA, indicated significant improvements in midface concavity (all p < 0.0001). All FACE-Q scores (except for facial function) exhibited a significant increase. The ΔA-CR, ΔN-A⊥HR, and ΔSNA angle were strongly correlated with specific aspects of the FACE-Q-Appearance items, including the ΔFACE-Q-Appearance of the cheeks (all p < 0.0001), the ΔFACE-Q-Appearance of the face (all p < 0.0001), the ΔFACE-Q-Appearance of the jaws (all p < 0.01), the ΔSatisfaction with decision (all p < 0.0001) and the ΔSatisfaction with outcome (all p < 0.001). However, the ΔA-CR, ΔN-A⊥HR, and ΔSNA were weakly correlated with other FACE-Q-Health-related quality of life and function items. These findings suggest that both CT findings and FACE-Q scores have their own emphases and advantages. It is necessary to establish an integrated curative effect evaluation model that combines FACE-Q scores with CT measurements to evaluate both the physical health and psychological status of patients.

The Hard Palate Sweep: a multiplanar 2-dimensional sonographic method for the prenatal detection of cleft palate

BACKGROUND

Prenatal diagnosis of cleft palate is challenging. Numerous 2-dimensional and 3-dimensional methods have been proposed to assess the integrity of the fetal palate, yet detection rates remain relatively low. We propose the "Hard Palate Sweep," a novel 2-dimensional method that enables clear demonstration of the entire fetal palate throughout pregnancy, in a single sweep, avoiding acoustic shadows cast by surrounding bones.

OBJECTIVE

This study aimed to assess the feasibility and performance of the Hard Palate Sweep, performed throughout pregnancy.

STUDY DESIGN

This was a prospective cross-sectional study performed between 2018 and 2022 in pregnant patients referred for a routine or targeted anomaly scan between 13 and 40 weeks of gestation. The presence or absence of a cleft palate was determined using the "Hard Palate Sweep." This was compared with the postnatal palate integrity assessment. Test feasibility and performance indices, including sensitivity, specificity, and positive and negative predictive values were calculated. Offline clips were reviewed by 2 investigators for the assessment of inter- and intraoperator agreement, using Cohen's kappa formula. The study protocol was approved by the institutional ethics committee. All participating patients were informed and provided consent.

RESULTS

A total of 676 fetuses were included in the study. The Hard Palate Sweep was successfully performed in all cases, and 19 cases were determined to have a cleft palate. Of these, 13 cases were excluded because postmortem confirmation was not performed, leaving 663 cases available for analysis. Six cases determined to have a cleft palate were confirmed postnatally. In 655 of 657 cases prenatally determined to have an intact palate, this was confirmed postnatally. In the 2 remaining cases, rare forms of cleft palate were diagnosed postnatally, rendering 75% sensitivity, 100% specificity, 100% positive predictive value, and 99.7% negative predictive value for the Hard Palate Sweep (P<.001). There was complete intra- and interoperator agreement (kappa=1; P<.0001).

CONCLUSION

The Hard Palate Sweep is a feasible and accurate method for prenatally detecting a cleft palate. It was successfully performed in all attempted cases between 13 and 40 weeks of gestation. This method is reproducible, offering high sensitivity and specificity. Implemented routinely, the Hard Palate Sweep is expected to increase the prenatal detection of cleft palate.

Dental and skeletal maturation of Chinese male children with unilateral cleft lip and palate

The aim of this study was to determine whether the relationship between dental age (DA), cervical stage (CS) and chronological age (CA) in Chinese male children with unilateral cleft lip and palate (UCLP) is similar to that of children without clefts. Panoramic and cephalometric radiographs of 105 male UCLP patients, aged from 8 to 16 years, were collected and compared to 210 age-matched healthy control males. The Demirjian and cervical vertebral maturation (CVM) methods were used to visually examine the radiographs and Spearman's correlation analysis was used to identify differences between the two groups with regards to CS, DA and CA. There was a significant positive correlation between DA and CA in both groups and the mean CA-DA difference was significantly higher in children with UCLP when compared to controls (0.319 vs. 0.003, p < 0.05). A significant delay in tooth development was detected in UCLP children from 10 to 12 years-of-age. Both the UCLP and control groups showed high correlations between CS and DA. Calcification stage D appeared only before CS3; however, from CS5 to 6, all teeth have almost completed their maturation phase. Chinese male UCLP patients are likely to experience delayed tooth development compared to healthy controls, especially during the fast-growing period. Evaluating the stages of tooth mineralization could represent a rapid method to assess growth potential.

Evaluation of maxillary alveolar ridge formation and ridge continuity after secondary alveolar bone grafting using cancellous and cortico-cancellous bone graft in unilateral cleft alveolus using cone beam computed tomographic scan - a randomized controlled trial

PURPOSE

The aim of present study was to compare and evaluate the maxillary alveolar ridge formation and ridge continuity using cancellous and corticocanellous bone graft harvested from anterior iliac crest for complete secondary unilateral cleft alveolus defects.

MATERIAL AND METHOD

All patients were randomized into two groups for secondary alveolar bone grafting. Group I (n = 10) patients treated with cancellous particulate bone graft and group II (n = 10) patients treated with cortico-cancellous block graft. Maxillary alveolar ridge bone formation was assessed with the help of cone beam computed tomography (CBCT) scan using Planmeca Romexis Viewer 5.0 software. Maxillary alveolar ridge continuity was assessed with axial section of CBCT scan and clinical occlusal photograph. Preoperative CBCT scan and occlusal photographs were compared with post-op 6-month CBCT scan and occlusal photographs.

RESULT

The mean preoperative volume of cleft defect in group I was 4.2576 cm3 whereas in group II it was 4.2268 cm3. The mean postoperative bone bridge formation after 6 months in group I was 4.055 cm3 whereas in group II it was 3.8103 cm3. Preoperative and 6-month postoperative axial sections of CBCT scans were compared and 100% maxillary alveolar ridge continuity was achieved in both groups. The preoperative and postoperative occlusal photographs of both the groups were compared and showed accurate bone and well aligned maxillary alveolar ridge formation in all patients.

CONCLUSION

The present study concluded that maxillary alveolar ridge formation rate is less in cortico-cancellous iliac crest block graft compared to cancellous iliac crest particulate graft, but is equally good as cancellous bone graft.

CLINICAL TRIAL REGISTRATION NO

(REF/2020/09/031605)/ CTRI/ 2020/09/028001.

3D evaluation of the maxillary sinus volumes in patients with bilateral cleft lip and palate

One of the most common congenital anomalies of the head and neck region is a cleft lip and palate. This retrospective case-control research aimed to compare the maxillary sinus volumes in individuals with bilateral cleft lip and palate (BCLP) to a non-cleft control group. The study comprised 72 participants, including 36 patients with BCLP and 36 gender and age-matched control subjects. All topographies were obtained utilizing Cone Beam Computed Tomography (CBCT) for diagnostic purposes, and 3D Dolphin software was utilized for sinus segmentation. Volumetric measurements were taken in cubic millimeters. No significant differences were found between the sex and age distributions of both groups. Additionally, there was no statistically significant difference observed between the BCLP group and the control group on the right and left sides (p > 0.05). However, the mean maxillary sinus volumes of BCLP patients (8014.26 ± 2841.03 mm3) were significantly lower than those of the healthy control group (11,085.21 ± 3146.12 mm3) (p < 0.05). The findings of this study suggest that clinicians should be aware of the lower maxillary sinus volumes in BCLP patients when planning surgical interventions. The utilization of CBCT and sinus segmentation allowed for precise measurement of maxillary sinus volumes, contributing to the existing literature on anatomical variations in BCLP patients.

Does Differential Maxillary Expansion Prior to Alveolar Cleft Bone Grafting Affect Nasal Width?

OBJECTIVE

Determine the effects of differential maxillary expansion on nasal width in patients with unilateral cleft lip and alveolus with or without cleft of the secondary palate (UCLA ± P).

DESIGN

Retrospective radiographic study.

SETTING

Institutional.

PARTICIPANTS

Forty patients with UCLA ± P who had alveolar bone grafting (ABG) between 2015 and 2020 and available preexpansion and postexpansion cone beam computed tomography (CBCT) scans. Twenty patients with UCLA ± P who underwent ABG without expansion were included as controls.

MAIN OUTCOME MEASURE

Percent change in width at the nasal pyriform, inferior turbinates, and alar base on cleft and noncleft sides.

RESULTS

The study included 40 patients (24 males, mean age 9.6 years) and 20 controls (10 males, mean age 10.1 years). After maxillary expansion, there was an increase in width on the cleft and noncleft sides compared to nonexpanded controls at nasal pyriform (10.9% cleft side, P ≤ 0.001 and 4.3% noncleft side, P ≤ .001), inferior turbinate (8.7%, P ≤ .001 and 4.5%, P = .01), and alar base (6.7%, P = <.001 and 0.8% P = .54). The increase in width was greater on the cleft side than the noncleft side at the nasal pyriform (7.1%, P ≤ .001), inferior turbinate (4.3%, P ≤ .001), and alar base (7.0%, P ≤ 0.001) in the expansion group. There was good to excellent intra-rater and inter-rater agreement for measurements.

CONCLUSION

Patients with UCLA ± P who undergo differential maxillary expansion before ABG exhibit greater nasal widening on the cleft side.

Three-Dimensional Quantification of Postoperative Facial Asymmetry in Patients With Unilateral Cleft lip and Palate Using Facial Symmetry Plane

OBJECTIVE

To quantitatively assess three-dimensional (3D) soft tissue facial asymmetry in patients with unilateral cleft lip and palate (UCLP) who have undergone primary lip repair.

DESIGN

Clinical, retrospective, comparative, methodological study.

PATIENTS/PARTICIPANTS

Twenty patients with UCLP were selected after a review of the records.

INCLUSION CRITERIA

Complete UCLP; surgically treated without secondary repair. An age-matched and sex-matched Control group was employed.

MAIN OUTCOME MEASURES

A 3D facial symmetry plane (FSP) was obtained by superimposing the point clouds of the original 3D facial image excluding the surgical site and including lip and nose areas and those of a mirrored facial image using the iterative closest point (ICP) adjustment method. The discrepancies in the depth and angle of the normal vector of the facial surface of each point cloud between right and left sides (cleft and non-cleft sides in the UCLP group, respectively) based on FSP were calculated.

RESULTS

Facial asymmetry in the UCLP group was significantly greater than in the Control group regarding both the discrepancies in the depth (1.34 ± 0.62, 0.73 ± 0.32 pixels, respectively) (P = .0004) and surface angle (18.0 ± 5.88, 12.8 ± 4.0°, respectively) (P = .0024). Biaxial assessment of the discrepancies in the depth and surface angle allowed us to visually extract UCLP patients with greater facial asymmetry.

CONCLUSIONS

Facial asymmetry analysis based on 3D FSP effectively facilitates the facial asymmetry quantification and soft tissue surgical outcome evaluation in patients with UCLP.

Divergent growth of the transient brain compartments in fetuses with nonsyndromic isolated clefts involving the primary and secondary palate

Cleft lip/palate is a common orofacial malformation that often leads to speech/language difficulties as well as developmental delays in affected children, despite surgical repair. Our understanding of brain development in these children is limited. This study aimed to analyze prenatal brain development in fetuses with cleft lip/palate and controls. We examined in utero MRIs of 30 controls and 42 cleft lip/palate fetal cases and measured regional brain volumes. Cleft lip/palate was categorized into groups A (cleft lip or alveolus) and B (any combination of clefts involving the primary and secondary palates). Using a repeated-measures regression model with relative brain hemisphere volumes (%), and after adjusting for multiple comparisons, we did not identify significant differences in regional brain growth between group A and controls. Group B clefts had significantly slower weekly cerebellar growth compared with controls. We also observed divergent brain growth in transient brain structures (cortical plate, subplate, ganglionic eminence) within group B clefts, depending on severity (unilateral or bilateral) and defect location (hemisphere ipsilateral or contralateral to the defect). Further research is needed to explore the association between regional fetal brain growth and cleft lip/palate severity, with the potential to inform early neurodevelopmental biomarkers and personalized diagnostics.

Prevalence and Features of Maxillary Sinus Septa in Patients with Cleft Lip and Palate: Cone Beam Computed Tomography Imaging Technique

OBJECTIVE

The development of the maxillary sinus is different in patients with cleft lip and palate (CLP) compared to non-CLP individuals. To investigate the prevalence and features of maxillary sinus septa (MSS) in patients with CLP in comparison with the non-CLP population.

DESIGN

Retrospective study.

INTERVENTION

Cone beam computed tomography (CBCT) evaluation.

SETTING

CLP center in Shiraz faculty of dentistry, Iran.

PATIENTS

A total 306 sinuses (88 cleft and 218 noncleft) on 153 images (CLP group: n  =  66; control group: n  =  87) were examined to determine the prevalence of septa and characterize them.

MAIN OUTCOME MEASURES

Sinus septa were characterized according to height, orientation, angle, origin, and location. The chi-square test, Mann-Whitney U test, and Fisher's exact test were used for statistical analysis.

RESULTS

The prevalence of septa was 28.9% and 32.1% in the CLP and control groups, respectively. No significant difference was found between the study groups in terms of prevalence, location, and orientation of MSS. The average height and angle of septa were significantly higher in the control group compared to the CLP group. Inferior origin was significantly more prevalent in the control group than in the CLP group (P = .004).

CONCLUSION

There was no difference in the prevalence of MSS between patients with CLP and non-CLP individuals. However, certain features of the septa were different in patients with CLP.

Surgery-First Orthognathic Approach for Correction of Dentofacial Deformity in Unilateral Cleft Lip and Palate

BACKGROUND

Although several studies have reported the advantages of the surgery-first approach for orthognathic correction of class III deformity, there is no report of the success of this approach for patients with cleft lip and palate. Therefore, the purpose of this study was to evaluate the stability and outcome of bimaxillary surgery for cleft-related dentofacial deformity using a surgery-first approach.

METHODS

Forty-one patients with unilateral cleft lip and palate who consecutively underwent Le Fort I and bilateral sagittal split osteotomies for skeletal class III deformity were included. Cone-beam computed tomographic scans before surgery, 1 week after surgery, and after orthodontic treatment were used to measure the surgical and postsurgical changes in jaw position by landmarks, and outcomes of jaw protrusion and relation, incisor angle and occlusion, and menton deviation after treatment. Self-report questionnaires regarding satisfaction with overall appearance of the face and seven facial regions were administered after treatment.

RESULTS

A clinically insignificant relapse was found in the maxilla (<1 mm) and mandible (<2 mm). There was a significant improvement in the jaw protrusion and relation, incisor angle and occlusion, and menton deviation. Responses from the self-report questionnaires completed after treatment indicated that patient satisfaction was high.

CONCLUSION

These findings demonstrate surgical-orthodontic treatment with a surgery-first approach can successfully improve cleft-related dentofacial deformity in patients with unilateral cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Long-term radiographic and periodontal evaluations of the bone-grafted alveolar cleft region in young adults born with a UCLP

BACKGROUND

Studies addressing the periodontal health of the teeth surrounding the bone-grafted cleft in patients born with unilateral cleft lip and palate disagree on whether periodontal health is compromised.

OBJECTIVES

To determine periodontal health differences between the cleft and the non-cleft sides nearly a decade after secondary alveolar bone grafting.

METHODS

This prospective, controlled (split-mouth design) study comprised an intraoral apical radiographic and a periodontal examination of 40 consecutive patients from one centre (n = 26 males) who had undergone bone grafting at mean age of 10.2 years (±1.6). Probing pocket depth, gingival index, gingival recession, and radiographic bone support were assessed.

RESULTS

No significant difference occurred in probing pocket depth between teeth at cleft and non-cleft sites (OR 1.8, P = .488). Gingival recession was present at 6.6% of all examined sites on the cleft side and at 1.7% on the non-cleft side (OR 17.3, P < .001). Gingival recession occurred most often on the buccal and disto-buccal surfaces of the central incisor on the cleft side. The gingival index was significantly higher on the cleft side (OR 8.0, P < .001). The Bergland index was I or II in most patients (87%).

LIMITATIONS

Recruitment of eligible patients was lengthy.

CONCLUSION

The teeth on the cleft side had high levels of gingival inflammation. Few pathological gingival pockets, however, were found. Shallow gingival recessions frequently occurred around the central incisor on the cleft side. Teeth in the bone-grafted cleft region generally had good bone support.

An Objective Evaluation of Cleft Lip Repair Deformities Based on Standardized Photographic Views

BACKGROUND

Several assessment systems of the cleft-related facial deformity have been reported in the medical literature. Assessments have been made from direct clinical evaluations, photographs, on-screen digital images, and 3-dimensional imaging. An evaluation method based on standardized photographic views is developed to evaluate the most common postoperative deformities and to detect the responsible factors for occurrence of these deformities and how to avoid them.

MATERIALS AND METHODS

One hundred forty-five cleft lip cases (105 unilateral and 40 bilateral) were evaluated by using standard sheet and scoring system designed by Operation Smile Inc (Virginia Beach). The scoring system is based on photographic analysis of items including Cupid's bow, nasal symmetry, vermilion contour, white roll continuity, and scar quality.

RESULTS

In the unilateral cleft cases, we found 0.4% excellent, 48.57% good, 38% fair, and 2.85% poor cases. For bilateral clef lip cases, we found 27.5% excellent, 47.5% good, 17.5% fair, and 7.5% poor outcomes. The most common postoperative deformities were nasal asymmetry, scar hypertrophy, deformed Cupid's bow, and vermilion contour asymmetry.

CONCLUSIONS

This objective evaluation system can determine the common cleft lip nasal deformities with detection of the responsible factors. Principles that guide optimum surgical repair have been advocated to avoid the common postoperative deformities. Scar formation is an independent factor that must be managed early and separately to maintain surgical outcomes.

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.

Prenatal diagnosis of Hartsfield syndrome with a novel genetic variant

A G2P0, 24-year-old woman presented at 17 weeks 3 days gestation for a fetal anatomy scan. Ultrasound identified bilateral upper and lower extremity ectrodactyly, semilobar holoprosencephaly, midface hypoplasia, and cleft lip and palate. Amniocentesis for a chromosome microarray demonstrated no significant copy number changes. Whole exome sequencing was subsequently completed, which revealed a de novo, likely pathogenic variant in FGFR1, c.2044G>A (D682N), consistent with FGFR1-related Hartsfield syndrome. This case highlights the first presumed molecularly confirmed prenatal diagnosis of Hartsfield syndrome and identifies a new pathogenic variant.

Cleft Lip and Cleft Palate: Time to Include Orofacial Ultrasound Markers Into the First-Trimester Anatomy Scan?

Orofacial clefts are one of the most common congenital malformations. The prenatal diagnosis is often made in the second trimester of pregnancy as result of ultrasound examination of the midface on coronal and axial planes. However, the diagnosis in the first trimester is elusive due to the small size of the facial structures and technical limitations present at this early gestational age. In this Commentary, we suggest the routine systematic ultrasound identification of easy-to-obtain landmarks to improve the detection of cleft lip and cleft palate in the first trimester. These include, but are not limited to, visualization of the primary palate using the coronal plane of the face looking for disruption at the base of the retronasal triangle, and visualization of the palate using the sagittal plane looking for the maxillary gap and loss of the superimposed line. Early prenatal detection of orofacial clefts would allow a more detailed search for associated chromosomal anomalies or genetic syndromes.

Prognostic Factors for Orthognathic Surgery in Children With Cleft Lip and/or Palate: Dentition and Palatal Morphology

To determine dental and palatal morphology in children with cleft lip and/or palate (CL/P) and identify morphological prognostic factors for orthognathic surgery (OGS).

Retrospective cohort study.

Orthodontic department of a university dental hospital.

This study included 80 patients with bilateral and unilateral CL/P who had lateral cephalograms at the ages of 7 (T1), 15 (T2) years, and a dental plaster model at T1.

Plaster models at T1 were scanned with a three-dimensional (3D) scanner. Morphological features were extracted from 3D models with geometric morphometrics software as principal components (PCs). The combinations of the PCs and other predictive factors (ie, the No. of clefts in the lip and alveolus, the palatal repair method, sex, cephalometric variables at T1, and the No. of missing teeth) were examined by logistic regression to determine the predictability for OGS. The need for OGS and skeletal and dental discrepancies at T2 were examined as outcomes.

Shrinkage of the palate, including vertical shallowing and transverse narrowing of the posterior maxilla and cleft-side asymmetry of the anterior maxilla at T1, as well as the No. of clefts in the lip and alveolus, the palatal repair method, male sex, several cephalometric variables for the sagittal and vertical dimensions, and the No. of missing teeth, were found to be predictive factors for OGS.

Morphological prognostic factors for OGS in children with CL/P were determined.

Utilization of images and three-dimensional custom-made nostril retainer fabricate for patients with cleft lip and cleft lip nose deformities at Siriraj Hospital: preliminary phase

A prospective study utilizing image analysis to assess nostril openings in post-operative patients with cleft lip and cleft lip nose deformities. This preliminary study seeks to employ two-dimensional (2D) images to fabricate a custom-made nostril retainer. This study was performed at Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand. This study included 30 healthy volunteers and 15 patients with cleft lip and cleft lip nose deformities. The nostril opening width and height for all participants were measured, and photographs were taken. An image analysis application was used to fabricate a three-dimensional (3D) custom-made nostril retainer. The mean differences between the direct measurements of the nostril aperture and the measurements obtained through the program did not exceed 2 mm in terms of nostril height, width, or columella. Two-dimensional photographs can be used to create a custom-made, three-dimensional nostril retainer. This retainer allows post-operative patients to maintain their nares without needing to visit the hospital, thereby reducing the cost of care.

Ultrasound measurements of fetal facial profile markers and their associations with congenital malformations during early pregnancy

BACKGROUND

Fetal facial profile could be measured during the early pregnancy. Its abnormalities might be associated with certain congenital malformations. We aimed to study the associations between fetal facial profile measurements with crown-rump length and congenital malformations (cleft lip and palate, micrognathia, and open spina bifida) during early pregnancy.

METHODS

We performed a prospective cross-sectional study between June 2019 and April 2022. Pregnant women at a gestational age between 11-13+ 6 weeks were enrolled. Two sonographers performed fetal facial profile measurements independently. The associations between these measurements with crown-rump length and congenital malformations were evaluated.

RESULTS

There were 406 and 25 fetuses without or with congenital malformations, respectively. Two sonographers showed satisfactory inter- and intra-observer agreements and reproducibility. The maxillary gap was only observed in 7.6% of normal fetuses, whereas all cleft lip and palate fetuses had a maxillary gap ≥ 0.8 mm. The crown-rump length was negatively correlated with frontomaxillary facial angle, inferior facial angle, and profile line distance but positively correlated with maxilla-nasion-mandible angle, facial maxillary angle, frontal space distance, and palatine maxillary diameter. These measurements showed various significant changes with different congenital malformations.

CONCLUSIONS

Measurements of fetal facial profile in early pregnancy were feasible with satisfactory reproducibility. These measurements correlated with crown-rump length and showed significant differences with certain fetal congenital malformations.

Ten-Year Cephalometric Comparison of Patients With Cleft Palate who Received Treatment With Active or Passive Pre-surgical Orthopedic Devices

BACKGROUND

Pre-surgical orthopedic (PSO) devices can be used in the management of patient with cleft lip/palate (CL/P) to narrow the alveolar gap (AG) prior to lip surgery. There are few studies comparing these 2 devices. The objective of this work was to compare the effects of active and passive PSO devices on facial growth in a single surgeon's cohort of patients with CL/P over a 10-year period.

METHODS

A retrospective review of all patients with CL/P in a single surgeon's practice from 2002 to 2018 was performed. Preoperative measurements of AG size were done using electronic calipers on patient molds. Patient radiographs were taken at 5 and 10 years of age and cephalometric landmarks were plotted using specialized software. Independent sample t-tests were used to compare means for maxillary, mandibular, vertical, and dento-alveolar growth parameters.

RESULTS

Twenty patients with an active device and 23 patients with a passive device were included. No differences were observed in the basic demographic information between the two groups. At the time of lip repair, patients with a passive device had significantly larger horizontal AGs (P < .01), but by the time of palate repair, there was no difference between the two groups (P = .94). There was no significant difference in any growth measurements between the active and passive device groups at 5 and 10 years.

CONCLUSIONS

Despite closing the AG more quickly, patients treated with an active device have no significant difference in facial growth at 10 years compared to patients treated with a passive device.

Orofacial clefts: Reflections on prenatal diagnosis and family history based on a series of cases of a tertiary children hospital

Prenatal diagnosis of orofacial clefts allows adequate counseling and planning for prenatal care and delivery. In 2001, two-dimensional ultrasound screening became universally used in Portugal by government guidelines, and after 2007 more advanced ultrasound became available. This study aimed to describe the prevalence of family history in patients with orofacial clefts and analyze prenatal diagnosis in patients born before 2001, between 2001 and 2007 and after 2007. Retrospective analysis of a cohort of patients with orofacial clefts followed by the trans-disciplinary team of a tertiary hospital. A total of 672 OFCs were identified: 40.9% isolated cleft palate, 38.1% cleft lip and palate, 19.7% cleft lip and 1.3% atypical cleft; 57.1% were male. The prevalence of family history was 26.0% of which 30.9% had a recognizable syndrome. Of those born before 2001, 13.7% had prenatal diagnosis; of those born between 2001 and 2007, 32.6% orofacial clefts were diagnosed in utero; and in children born after 2007, prenatal diagnosis increased to 47.1%. In our study, about one-fourth of children had a positive family history. Since the implementation of universal ultrasound screening in Portugal, more orofacial clefts were identified in utero (42.5% vs. 13.7%; p < 0.05) and after the availability of advanced ultrasound, prenatal diagnosis increased to 47.1% (vs. 20.4% before 2007; p < 0.05). Of all orofacial clefts diagnosed prenatally, ultrasound revealed more accuracy for the diagnosis of cleft lip and palate (65.4%) and cleft lip (24.8%). Cleft palate is the most difficult to detect in utero (9.3%). Prenatal ultrasound screening in Portugal has technically evolved with consequent better diagnostic accuracy for the identification of orofacial clefts, allowing better parenteral counseling.

Influence of osseous structure characteristics of unilateral alveolar cleft on outcomes of alveolar bone grafting: a retrospective study

BACKGROUND

To enhance the success rate of alveolar bone grafting, it is crucial to identify the factors that may influence the postoperative bone formation. This study aimed to investigate the impact of various osseous structure characteristics of alveolar clefts on the survival ratio of autogenous cancellous bone particle grafts.

METHODS

A retrospective study was conducted on 60 patients who underwent surgery performed by the same surgeon between 2016 and 2022. Two researchers measured and recorded the bone defect volume (DV), postoperative bone formation volume at 1 year, contact area between the graft and the bone surface within the cleft (S), cleft width (CW), osseous occlusion relationships, and presence of a cleft palate and initial bone bridge within the cleft for each patient. Pearson correlation analysis, Spearman's correlation analysis, and multiple linear regression analysis were performed.

RESULTS

The analysis results revealed statistical correlations between DV, CW, ratio of S to DV, cleft palate, initial bone bridge presence, and occlusion relationships with the survival rate. Multiple linear regression analysis showed that initial bone bridge and occlusion relationships affected the graft survival rate.

CONCLUSIONS

Based on the presence of initial bone bridges and occlusions, we can make a rough estimate of the postoperative bone formation outcome in patients. However, the underlying mechanisms by which these two factors influence the bone formation require further investigation. In addition, preoperative orthodontic treatment to improve occlusal relationships may improve the postoperative bone formation outcomes in alveolar bone grafting.

Perception of aesthetic features after surgical treatment of craniofacial malformations by observers of the same age: An eye-tracking study

The aim of this study is to evaluate where exactly children and adolescents of the same group look when they interact with each other, and attempt to record and analyse the data recorded by eye-tracking technology.

MATERIALS AND METHODS

60 subjects participated in the study, evenly divided into three age categories of 20 each in pre-school/primary school age (5-9 years), early adolescence (10-14 years) and late adolescence/transition to adulthood (15-19 years). Age groups were matched and categorized to be used both for creating the picture series and testing. Photographs of patients with both unilateral and bilateral cleft lip and palate were used to create the series of images which consisted of a total of 15 photos, 5 of which were photos of patients with surgically treated cleft deformity and 10 control photos with healthy faces, that were presented in random order. Using the eye-tracking module, the data on "area of first view" (area of initial attention), "area with longest view" (area of sustained attention), "time until view in this area" (time of initial attention) and "frequency of view in each area" (time of sustained attention) were calculated.

RESULTS

Across all groups, there was no significant difference for the individual regions for the parameters of initial attention (area of first view), while the time until first fixation of one of the AOIs (time until view in this area) was significant for all facial regions. A predictable path of the facial scan is abandoned when secondary facial deformities are present and attention is focused more on the region of an existing deformity, which are the nose and mouth regions.

CONCLUSIONS

There are significant differences in both male and female participants' viewing of faces with and without secondary cleft deformity. While in the age group of the younger test persons it was still the mouth region that received special attention from the male viewers, this shifted in the male test persons of the middle age group to the nose region, which was fixed significantly more often and faster. In the female participants, the mouth and nose regions were each looked at for twice as long compared to the healthy faces, making both the mouth and the nose region are in the focus of observation.

Piriform Rim Asymmetry in Unilateral Cleft Lip and Palate Patients Before Orthognathic Surgery

BACKGROUND

Complete unilateral cleft lip and palate (UCLP) creates a continuity defect on the nasal floor, which contributes to nasal asymmetry. Traditionally, piriform rim symmetry has been evaluated by comparing cleft and noncleft sides. No study has compared the magnitude of perinasal asymmetry in UCLP patients with a control group of patients without clefts.

PURPOSE

To address the following question: In UCLP patients, whose alveolar clefts are reconstructed with alveolar bone grafts (ABGs), is the magnitude of remaining piriform rim asymmetry similar to that of patients without UCLP?

STUDY DESIGN SETTING, SAMPLE

This is a retrospective cohort study that used the cone beam computed tomography of UCLP and non-UCLP patients to evaluate the piriform rim symmetry. The sample was derived from patients who presented for orthognathic surgery between January 2015 and December 2022. To be included, patients had to have a maxillary deficiency. The cleft group had ABG performed with symphyseal bone harvest and bone morphogenetic protein application. Patients were excluded from the control group if they had clinical asymmetry and nasal septum deviation. Patients from the UCLP group were excluded if they failed the first attempt of ABG or had a syndrome. Preorthognathic cone beam computed tomography was used to measure the distance from the inferior and lateral aspects of the piriform rim to reference lines.

PREDICTOR VARIABLE

UCLP status grouped as present or absent (control).

OUTCOME VARIABLES

The magnitude of piriform rim asymmetry defined as the millimetric distance from the inferior and lateral aspects of the piriform rim to reference lines.

COVARIATES

The covariates were age, sex, tissue thickness at the level of the alar base, and turbinate size.

ANALYSIS

Welch's two-sample t-test was utilized to compare means. A level of significance of 5% (P < .05) was used for all analyses. To analyze the reliability of the measurements intraexaminer and interexaminer errors were tested using the Weir method.

RESULTS

A total of 60 patients were included, 30 in each group. The mean age of UCLP patients was 16.76 (range 13 to 25), and the control group was 17 (range 13 to 25), P = .71. The UCLP group had 12 girls, and the control had 18 girls (P = .12). In the UCLP group, the mean discrepancy between affected and unaffected sides at the inferior aspect of the piriform rim was 3.9 mm (range 0.9 to 7 mm, P < .01), and in the control group the discrepancy between right and left sides was 0.1 mm (0-2.1 mm, P = .87). The mean discrepancy between affected and unaffected sides at the lateral aspect of the piriform rim was 3.6 mm (range 0.7 to 7.6 mm, P < .01) in the UCLP group, and in the control group the discrepancy between right and left sides was 0.1 mm (range 0.1 to 5.8 mm, P = .78) in the control group. The mean alar base soft tissue thickness discrepancy was 3.1 mm (range 0.9 to 7.9 mm, P < .01) in the UCLP group and 0 mm (range -1.8 to 1.9 mm, P = .97) in the control group. The mean difference in the turbinate area in the UCLP group was 314 mm2 (range 797 to 2,898) and in the control group 35 mm2 (range 702 to 2,302) (P = .19).

CONCLUSION

ABG with symphyseal bone and bone morphogenetic protein was not able to provide the same level of piriform symmetry observed in patients without a cleft. Alar base tissue was thicker on the cleft side, and the turbinate size demonstrated greater variability in the UCLP patients.

Single-stage Repair of Bilateral Cleft Lip and Bilateral Transverse Facial Cleft in Goldenhar Syndrome: A Case Report

Goldenhar syndrome (GS) is a rare congenital disorder characterized by multiple facial anomalies. This case report describes a GS presenting with bilateral cleft lip and palate and bilateral transverse facial cleft. We performed a single-stage surgery to repair the bilateral cleft lip and bilateral transverse facial cleft when the patient was 4-months-old. Bilateral cleft lip repair using the Mulliken method was performed first, and then the bilateral transverse facial cleft was corrected. Orbicularis oris muscle repair was done at each clefts. Anatomical approximation technique was used and the final oral commissure was determined considering symmetry. Satisfactory outcomes were achieved without complications.

Alveolar Cleft Size on Prenatal Two-Dimensional Ultrasonography Predicts Cleft of the Secondary Palate in Unilateral Cleft Lip

SUMMARY

Prenatal diagnosis of cleft palate (CP) is challenging. The current study's objective was to investigate whether prenatal alveolar cleft width is associated with the likelihood of a cleft of the secondary palate in unilateral cleft lip (CL). The authors reviewed two-dimensional ultrasound (US) images in fetuses with unilateral CL from January of 2012 to February of 2016. Images of the fetal face were obtained with a linear and/or curved probe in the axial and coronal planes. Measurements of the alveolar ridge gap were taken by the senior radiologist. Postnatal phenotype findings were compared with prenatal findings. Thirty patients with unilateral CL met inclusion criteria; average gestational age was 26.67 ± 5.11 weeks (range, 20.71 to 36.57 weeks). Ten fetuses were found to have an intact alveolar ridge by prenatal US; postnatal examination confirmed intact secondary palate in all. Small alveolar defects (<4 mm) were noted in three fetuses; postnatal examination documented CP in a single patient. CP was confirmed in 15 of the remaining 17 fetuses who had alveolar cleft width greater than 4 mm. An alveolar defect of greater than or equal to 4 mm on prenatal US was associated with greater likelihood of a cleft of the secondary palate [c 2 (2, n = 30) = 20.23; P < 0.001]. In the setting of unilateral CL, prenatal US documentation of alveolar defects greater than or equal to 4 mm are highly predictive of the presence of a cleft of the secondary palate. Conversely, an intact alveolar ridge is associated with an intact secondary palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Airway changes in patients with unilateral cleft lip/palate (UCL/P) after maxillary advancement

OBJECTIVES

To assess the effect on the retropalatal airway (RPA), retroglossal airway (RGA), and total airway (TA) volumes and cephalometrics (SNA, SNB, ANB, PP-SN, Occl-SN, N-A, A-TVL, B-TVL) after maxillary advancement orthognathic surgery in patients with unilateral cleft lip/palate (UCL/P) using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

The CBCT scans of 30 patients (13 males and 17 females, 17-20 years old) with UCL/P were evaluated at two time points: preoperative (T1) and postoperative (T2). The interval between T1 and T2 ranged from 9-14 weeks, except for two patients in whom the interval was 24 weeks. Intraexaminer reliability was measured with an intraclass correlation coefficient test. A paired t-test was used to compare the airway and cephalometric measurements between T1 and T2, with a P value of .05 being considered significant.

RESULTS

From T1 to T2, significant increases were found in the volumes of RPA (from 9574 ± 4573 to 10,472 ± 4767, P = .019), RGA (from 9736 ± 5314 to 11,358 ± 6588, P = .019), and TA (from 19,121 ± 8480 to 21,750 ± 10,078, P = .002). In addition, the RGA (from 385 ± 134 to 427 ± 165, P = .020) and TA (from 730 ± 213 to 772 ± 238, P = .016) sagittal area increased significantly. For minimal cross-sectional area (MCA), only the RPA increased significantly (from 173 ± 115 to 272 ± 129, P = .002). All cephalometric changes were statistically significant between T1 and T2 except for SNB.

CONCLUSIONS

Maxillary advancement in patients with UCL/P produces statistically significant increases in the retropalatal (volumetric and MCA), retroglossal (volumetric and sagittal), and total (volumetric and sagittal) airways based on data from CBCT imaging.

Assessment of Skeletal Maturation in Nonsyndromic Cleft and Non-cleft Children-A Comparative Study

The study aims to determine the difference in the skeletal maturation of unilateral cleft lip and palate (UCLP) and non-cleft children. This study also attempts to determine sexual dimorphism in attaining skeletal maturation between UCLP and non-cleft children. This was a retrospective, cross-sectional study. The total sample consisted of the lateral cephalogram of 131 UCLP (62 female and 71 male) children and 500 (274 female and 226 male) non-cleft children. The reviewer used the Baccetti method (2005) to review all the cephalograms for the cervical vertebrae maturation (CVM) stages. T -test was used to compare the mean chronological age and skeletal maturation of cleft and non-cleft children at each CVM stage. There was no significant difference in the mean chronological age and skeletal maturation status of UCLP and non-cleft children. There was no significant difference in skeletal maturation based on sex. The intraobserver assessment showed 80% and 85% kappa agreement, signifying absolute agreement. The correlation coefficient between chronological age and CVMIs was 0.86 ( P <0.001) in cleft children and 0.76 ( P <0.001) in non-cleft children, which was highly significant. The study indicates no significant difference in the skeletal maturation of UCLP and non-cleft children and no sex-related difference.

Volumetric assessment of the nose after primary unilateral cleft rhinoplasty using Laberge's technique

BACKGROUND

There is a lack of standardized surgery for cleft rhinoplasty. We felt that the technique described by Dr Louise Caouette Laberge is an ideal way to approach this problem, thus we tried to quantify the outcome of surgery by volumetric assessment.

MATERIAL AND METHOD

We recorded 3D images using an Artec scanner and performed volume calculations of the cleft side and noncleft side of the nose. These readings were taken once in the preoperative and then 2 weeks postoperative. Another scan of the face was performed 2 years after the surgery to compare the volumes of the cleft and noncleft side nostril.

RESULTS

Of the 31 patients with unilateral cleft lip operated on (mean age 3-8 months), we found a significant increase in the cleft side volume at 3 weeks postoperative from 3.95 mm3 to 5.65 mm3 (p < 0.001 on paired t-test). A repeat scan done on the study population at 2 years postoperative found that the mean volume of the cleft side was 30.43 mm3 (standard deviation [SD], 2.49) and that of the normal side was 30.82 mm3 (SD, 2.51). An independent t-test found that there was no significant difference between the two volumes (p > 0.05) CONCLUSION: The use of volumetric data in the evaluation of postoperative outcomes provides an objective criterion for assessing the aesthetics as well as the growth. Our study concludes that the Laberge technique provides a good aesthetic outcome with minimal scarring for the management of cleft nose and lip with the anterior palate.

Proboscis Lateralis With Basal Encephalocele: A Report of Clinical Management and Reconstructive Approach

Proboscis lateralis is a rare craniofacial anomaly in which a rudimentary nasal appendage arises at the medial canthal area. The severity depends on organ involvement, including eyes, nose, cleft lip/palate, and/or concomitant intracranial anomalies. Here, we present a child with proboscis lateralis and associated trans-ethmoidal encephalocele. We suggest doing the preoperative CT and/or MRI to rule out associated intracranial anomalies and reliably preoperative planning tools. Moreover, we proposed an alternative nasal reconstructive technique using a composite graft from the proboscis mass at the same time as encephalocele repair with promising results.

Maxillary Sinus Volume in Patients With Unilateral Cleft Lip and Palate by CBCT

Cleft lip and palate (CLP) is one of the most common congenital craniofacial anomalies, which can change the morphology of the skull, face, and maxillary sinus due to the disruption in the fusion of palatal shelves. This study aimed to investigate the volume and dimensions of the maxillary sinus in unilateral CLP patients along with comparing the healthy and affected sides. This cross-sectional study was conducted on 27 cone-beam computed tomography stereotypes (14 male and 13 female) of patients with unilateral CLP. Maxillary sinuses were traced separately on each side and analyzed by OnDemand3D software in a separate room with low light. The height and base area of the maxillary sinuses were measured on each side. After dividing each sinus into smaller pyramids, the volume of the sinus was obtained using the partial frustum model method and analyzed by paired t test. There was no significant difference between cleft and noncleft sides in terms of mean volume and height of the sinus ( P > 0.05). The average area of the sinus base on the cleft side was 32.77 mm 2 more than the noncleft side, and this difference was statistically significant ( P = 0.027). The mean upper maxillary sinus volume on the cleft side was 541.62 mm 3 larger than the noncleft side, but this difference was not statistically significant ( P = 0.075). Considering the age groups, the average upper sinus volume on the cleft side in patients under 20 years old was 4.66 mm 3 less than the noncleft side. In the age group of more than 20 years, the average volume of the upper sinus on the cleft side was 978.66 mm 3 more than the noncleft side. The mean volume of the lower sinus on the cleft side was 505.92 mm 3 lower than the noncleft side, and this difference was statistically significant ( P = 0.010). The average area of the sinus base of the cleft side was significantly higher than the noncleft side. Also, the lower sinus volume of the cleft side was significantly lower than the noncleft side. However, no significant difference was observed in upper sinus volume between the cleft and noncleft sides.

Cephalometric Soft Tissue Morphology of Adults With Unoperated Submucous Cleft Palate

The aim of this study was to compare craniofacial soft tissue characteristics between subjects with unrepaired submucous cleft palate (SMCP) and noncleft individuals.

This retrospective cross-sectional study was performed on 27 subjects with unrepaired SMCP (13 male and 14 female subjects; mean age, 21.77 ± 4.09 years) and 30 noncleft controls (14 male and 16 female subjects; mean age, 22.67 ± 4.28 years). The predictor variable was cleft deformity. The outcome variable was cephalometric soft tissue measurements. Other study variables were gender and age. Independent samples t test and Mann-Whitney U test were used for intergroup comparison. P value was set at .05.

Significant differences were observed in the facial profile angle, total facial profile angle, soft tissue A-N-B angle, nasal base prominence, upper lip length, lower lip protrusion, and the ratio of upper lip length to mentolabial height between subjects with unoperated SMCP and noncleft controls.

The primary deformity of the cleft palate leads to unsatisfactory facial soft tissue morphology, especially in the middle facial region.

Interpretable artificial intelligence for classification of alveolar bone defect in patients with cleft lip and palate

Cleft lip and/or palate (CLP) is the most common congenital craniofacial anomaly and requires bone grafting of the alveolar cleft. This study aimed to develop a novel classification algorithm to assess the severity of alveolar bone defects in patients with CLP using three-dimensional (3D) surface models and to demonstrate through an interpretable artificial intelligence (AI)-based algorithm the decisions provided by the classifier. Cone-beam computed tomography scans of 194 patients with CLP were used to train and test the performance of an automatic classification of the severity of alveolar bone defect. The shape, height, and width of the alveolar bone defect were assessed in automatically segmented maxillary 3D surface models to determine the ground truth classification index of its severity. The novel classifier algorithm renders the 3D surface models from different viewpoints and captures 2D image snapshots fed into a 2D Convolutional Neural Network. An interpretable AI algorithm was developed that uses features from each view and aggregated via Attention Layers to explain the classification. The precision, recall and F-1 score were 0.823, 0.816, and 0.817, respectively, with agreement ranging from 97.4 to 100% on the severity index within 1 group difference. The new classifier and interpretable AI algorithm presented satisfactory accuracy to classify the severity of alveolar bone defect morphology using 3D surface models of patients with CLP and graphically displaying the features that were considered during the deep learning model's classification decision.

Co-Occurrence of Taurodontism in Nonsyndromic Cleft Lip and Palate Patients in Subset of Indian Population: A Case-Control Study Using CBCT

The present study aimed to assess the co-occurrence of taurodontism in nonsyndromic cleft lip and palate (NSCLP) patients in a subset of Indian population using cone beam computed tomography (CBCT).

The study was a retrospective case-control kinds assessing 1500 CBCT scans over a period of 2 years; 67 scans out of 1500 showed cleft lip and palate (CLP). After fulfilling the inclusion and exclusion criteria, 38 subjects out of 67 comprised the case group; 80 randomly selected subjects constituted the control group. The first and second permanent molars in both the arches (8 teeth) of each subject were assessed for the presence and severity of taurodontism using the objective criteria. Statistical analysis was done using the χ2 test. Inter and intraobserver agreement was evaluated by Kappa statistics.

71.05% subjects showed taurodontism in case group, while 45% subjects showed its presence in control group; results being significant for both the groups. However, the comparison of number of teeth with taurodontism in the 2 groups came out to be statistically insignificant. Also no significant association of taurodontism was seen with gender or the different types of cleft (P = .437). Hypotaurodontism was the most prevalent type.

There was a higher prevalence of taurodontism in both groups which had been underestimated in the previous studies. This emphasizes the significance of the use of CBCT in detection of dental anomalies which would otherwise go undetected.

Prenatal diagnosis of cleft lip and/or palate: What do we tell prospective parents?

Cleft lip and/or palate (CL/CP) is the most common congenital craniofacial anomaly and parents often ask, "how did this happen?" Patients and families may benefit from access to a multidisciplinary team (MDT) from prenatal diagnosis into early adulthood. Multiple factors can contribute to the development of a cleft. We discuss the epidemiology and risk factors that increase the likelihood of having a newborn with a cleft. The purpose of this article is to review the prenatal investigations involved in the diagnosis and workup of these patients in addition to postpartum treatment, prognostic factors, and counseling families regarding future recurrence risk.