The purposes of this study were to investigate mandibular asymmetry changes from primary to early mixed dentition stages in patients with unilateral cleft lip and palate (UCLP), and compare the changes with those in patients with bilateral cleft lip and palate (BCLP). Panoramic radiographs taken at primary and early mixed dentition stages of 23 patients with UCLP and 17 patients with BCLP were included. Condylar, ramal and condylar plus ramal heights and gonial angle were measured bilaterally and asymmetry indices were calculated. Mann-Whitney U test was used to compare the parameters between the UCLP and BCLP groups. The growth changes from primary to early mixed dentition stages were assessed using Wilcoxon test. Condylar, ramal, condylar plus ramal heights increased significantly from primary to mixed dentition in both groups. Gonial angle did not change in the BCLP group although it decreased significantly in the UCLP group at the cleft side. No statistically significant change in condylar, ramal, condylar plus ramal height and gonial angle was found between the cleft and non-cleft sides in the UCLP group and left and right sides in the BCLP group. Condylar, ramal and condylar plus ramal asymmetry indices did not exhibit any significant difference between the UCLP and BCLP groups from primary to early mixed dentition. Patients with UCLP were observed to have symmetrical mandibles during primary and early mixed dentition, similar to those with BCLP. It may be too early to diagnose mandibular asymmetry in these dentition stages.

Our group has recently established the first ex vivo cadaveric models to simulate unilateral and bilateral cleft lip surgery. We have shown that these porcine snout disc models are suitable for novice cleft surgeons to understand the basic principles of cleft lip surgery and to practice the essential surgical steps. In this study we want to show that the ex vivo cleft lip models are not only suitable and helpful for residents, but also for students and experienced surgeons with and without experience in cleft surgery. Three courses were held to evaluate the ex vivo cleft lip models: One for oral and maxillofacial surgeons from German cleft centers and two courses for dental students. All operated on the unilateral and bilateral ex vivo cleft lip models using the Millard technique. Questionnaires were used to assess their subjective opinion of the ex vivo cleft lip models. Tasks for the students were carried out to objectify their learning success. Three-dimensional scans were taken and analyzed using a previously validated intraoral scanner to objectively assess the outcome. The ex vivo cleft lip models are suitable for the training of students and experienced surgeons with varying levels of experience in cleft lip repair. Both models were rated as realistic in terms of tissue resemblance, surgical planning, and surgical management. In addition, the specialists rated the models as realistic overall. The models also provide students with several advantages, such as improved surgical skills and a better understanding of cleft surgery. Participants felt that the models should be made available not only to residents, but also to consultants and senior consultants and should be implicated in the dental curriculum. The ex vivo cleft lip models made of porcine snout discs are suitable for a wide range of users starting from students to experienced surgeons to train in cleft lip surgery. The great advantage of these models is that experienced surgeons can work with an inexpensive and readily available model to improve their skills and modify their techniques.

ObjectiveTo investigate whether the use of buccal fat pad flap during cleft palate repair reduces the risk of post-operative palatal fistula formation.DesignRetrospective analysis of cleft palate repairs undertaken by a single surgeon over the period 2013-2025.SettingTertiary care institution in London.PatientsTwo hundred and seventy-seven patients (146 female, 131 male) who underwent cleft palate repair between 2013 and 2025 were included in the study. One hundred and seventy-three patients had an isolated cleft palate, 78 patients had a unilateral cleft lip and palate, and 26 patients had a bilateral cleft lip and palate. The range of cleft width treated was 3-22 mm. The standard surgical technique employed a Sommerlad style intravelar veloplasty with von Langenbeck releases where necessary.InterventionsThe utilization of pedicled buccal fat pad flap in primary cleft palate repairs.Main Outcome Measure(s)Development of post-operative palatal fistula.ResultsAmong 277 patients, 21 (7.6%) patients developed a post-operative fistula, most commonly in Zone IV (52%). The fistula rate was 3.7% with buccal fat pad flap use compared with 8.5% without (P = 0.39). Bayesian logistic regression showed a two-thirds reduction in the odds of fistula formation (odds ratio [OR] = 0.33; 95% credible interval [CrI]: 0.15-0.74), suggesting a high probability of a protective effect.ConclusionsThis study demonstrates that the use of buccal fat pad flaps in primary cleft palate repair is an effective adjunct associated with a reduced incidence of post-operative oronasal fistula.

ObjectiveBilateral cleft lip outcomes are heavily influenced by original anatomic deformity, but a reliable and widely accepted classification of preoperative severity has yet to emerge. This study validates the Bilateral Cleft Lip Severity Index (BCLSI) by assessing interrater reliability and the relationship between preoperative severity and aesthetic outcomes.DesignRetrospective cohort study.SettingTertiary care pediatric hospital.Patients/ParticipantsPatients who underwent lip repair for bilateral cleft lip.InterventionsCleft surgeons and layperson raters graded preoperative cleft severity.Main Outcome Measure(s)Anthropometric analyses and crowdsourced aesthetic assessments using Likert scales and pairwise comparisons.ResultsIntraclass correlation coefficient was 0.94 (95% confidence interval [CI] 0.90-0.97) among cleft surgeon raters (n = 7), 0.84 (95% CI 0.73-0.92) among layperson raters (n = 10), and 0.88 (95% CI 0.80-0.94) in the combined group (n = 17). Among 18 patients, a higher BCLSI correlated with a greater columellar-labial angle (r = 0.686, P = .002). BCLSI predicted pairwise rank-derived coefficients (β = -1.289, P = .015), lateral ratings (β = 0.752, P < .001), frontal ratings (β = 0.440, P = .038), and composite ratings (β = 0.551, P = .006) independent of age at surgery, age at postoperative photograph, history of nasoalveolar molding, lip repair technique, sex, and race. A greater columellar-labial angle correlated with poor lateral (r = .729, P < .001) and composite (r = .471, P = .048) ratings.ConclusionsThe BCLSI demonstrates good interrater reliability among cleft surgeons and layperson raters. A higher BCLSI correlated with a greater columellar-labial angle and predicted poorer nasal appearance ratings by crowdsourced layperson assessments at 5 years postoperatively. The BCLSI is a simple, reliable, and informative tool that can standardize bilateral cleft lip classification and advance cleft outcomes research.

A whistle deformity is a common secondary deformity of upper lip volume deficiency in the tubercle following bilateral cleft lip repair. The whistle deformity is a significant aesthetic stigma of bilateral cleft lip repair and challenging to correct. In the most severe situations, it can also lead to functional speech issues due to the inability to seal the lips during plosive consonant sounds. Various secondary surgical methods have been proposed to address secondary tubercle deformities requiring revision surgery. Volume deficiency can occur in the tubercle with any surgical technique used, with some being more prone than others. We present a novel fibroadipose tissue flap to improve tubercle fullness during primary bilateral cleft lip repair using tissue that is otherwise normally discarded. The prolabial augmentation of the upper lip (PAUL) flap is a random pattern fibroadipose flap distally based off the undersurface of the prolabial skin flap. The fibroadipose tissue in the premaxillary segment is preserved, dissected and everted for auto-augmentation of the tubercle. The PAUL flap is inset into a submucosal pocket in the vermilion over the orbicularis muscle repair as one of the final steps of repair. This is an effective adjunct to prevent a whistle deformity and can be used with any skin pattern technique designed for the prolabial skin flap in the primary bilateral cleft lip repair.

ObjectiveTo evaluate outcomes of precision dermal fat grafting (PDFG) for vermilion deficiency following cleft lip repair.DesignRetrospective cohort study. SettingTertiary care pediatric hospital. PatientsIndividuals with vermilion deficiency following repaired unilateral or bilateral cleft lip.InterventionsDermal fat grafts were placed at the site of deficiency. Grafts were oriented with dermis-side contacting and secured to the orbicularis oris, then covered with a V-Y mucosal advancement flap.Main Outcome MeasuresUpper lip measurements were obtained from pre- and postoperative photographs. Two vertical heights were measured from the point of greatest deficiency: (1) actual height-from the point of greatest deficiency to the upper vermilion border, and (2) expected height-from the upper to the lower vermilion border. Two reviewers performed measurements; interrater reliability was assessed using the intraclass correlation coefficient (ICC). Associations between patient factors and revision surgery were analyzed.ResultsThe vermilion height ratio improved from 0.72 to 0.94 postoperatively (P < .001), demonstrating increased vermilion volume. ICC was 0.81 (95% CI: 0.72-0.87), indicating excellent interrater reliability. Patients requiring revision had a lower preoperative actual-to-expected vermilion height ratio compared to those not requiring revision (P = .043), suggesting that more severe initial defects may increase the likelihood of revision. Five patients required revision: 4 for excess (treated with excision) and 1 for deficiency (requiring repeat PDFG).ConclusionsPDFG is a safe and reliable technique for correcting vermilion deficiency in unilateral and bilateral cleft lip, offering predictable volume restoration with minimal complications.

Objective To compare the accuracy and speed of artificial intelligent (AI) cephalometric analysis with automatic landmark identification, to computer-based and paper tracing on patients diagnosed with a cleft lip and palate.Materials and methods In total, 39 cephalograms of patients from the cleft clinic with a repaired unilateral or bilateral cleft lip and palate were included, where 30 of the patients had a severe skeletal discrepancy. The AI software used was WebCeph. One orthodontist carried out cephalometric analysis via four methods: 1) paper; 2) computer-based; 3) AI fully automated; and 4) AI followed by manual adjustment of the landmarks as required. Each method had intra-rater reliability testing. Inter-group comparisons were performed using ANOVA followed by a post-hoc Tukey test.Results The landmarks most commonly requiring adjustment following automatic identification were nasion, A-point, anterior nasal spine, and upper and lower incisors. Four of the 16 cephalometric values had statistically significant differences between groups: s-n-a (p <0.01), Ar-Go-Me (p <0.05), S-NPNS-ANS (p <0.05), and ANS-Me/N-Me (p <0.01). The greatest differences occurred between AI fully automated and either paper or computer-based however. AI with manual as required was comparable to computer-based and paper. The AI methods, with or without adjustment, were both significantly quicker than computer based or paper (p <0.01).Conclusion Landmark identification in WebCeph cannot be wholly relied upon in patients with repaired cleft lip and palate and significant skeletal discrepancies in comparison to paper and computer-based. However, manual adjustment of the automatically identified landmarks by a clinician provides similar results to paper and computer-based with much improved speed.

Comparative biomechanical analysis of three rapid maxillary expanders in BCLP patients: A three-dimensional finite element study.

Secondary bilateral cleft lip repair: An orbicularis oris muscle reorientation technique for philtrum reconstruction.

Cleft lip and palate (CLP) is a common craniofacial anomaly that predisposes affected children to orofacial trauma due to altered anatomy. Among the subtypes of CLP, patients with bilateral cleft lip and palate (BCLP) present with a prominent protruding premaxilla, which significantly increases their vulnerability to trauma during early development. Despite this, data on trauma patterns and anatomical risk factors in infants and toddlers with BCLP remain limited. To investigate the prevalence, mechanisms and severity of oral and facial trauma in BCLP patients aged 0-3 years and to assess the association between Premaxillary Position and Trauma (PPT) Risk using a structured scoring system. A retrospective analysis of 13,975 cleft cases over a 10-year period (2015-2025) was performed at a tertiary cleft center. A total of 4388 patients who underwent primary cheiloplasty, 513 BCLP patients aged 0-3 years were included. Trauma incidence, injury characteristics, and premaxillary position were assessed using the PPT Risk score, which includes transverse, anteroposterior, and vertical position assessments. Thirty-five BCLP patients sustained trauma, with age-specific differences in injury mechanisms: falls from heights and vehicular incidents were common in preoperative infants (≤ 6 months), whereas ground-level falls predominated in postoperative toddlers (6-36 months). Soft tissue injuries were most common (45.71%), followed by premaxillary mobility disorders (17.14%) and dental trauma (17.14%). Patients with a highly protruding premaxilla (Type 1b, 2b, and 3a) had the highest trauma incidence (54.29%), indicating a strong correlation between premaxillary position and injury risk. BCLP patients, especially those with anteriorly and vertically prominent premaxilla, have a significantly increased risk of trauma in early childhood. The PPT score is an effective tool for trauma risk stratification and supports the implementation of early interventions such as presurgical orthopedics and targeted caregiver education.

The birth prevalence of cleft lip and/or palate (CL/P) varies globally, and regional differences have previously been observed within Sweden. Updated data on CL/P birth prevalence is needed and has been requested nationally and internationally. This study investigated regional differences and temporal trends in the birth prevalences of CL/P and specific cleft subtypes across Sweden's six health care regions (HC regions) from 2000 to 2020. Using data from the Swedish Medical Birth Register and the National Register of Congenital Anomalies (coverage 97-99%), the study included 2,230,771 children. Variables included were year and region of birth, and cleft diagnoses: cleft lip and/or palate (CL/P), cleft palate without cleft lip (CP), cleft lip with/without cleft palate (CL ± P), bilateral cleft lip with/without cleft palate (BCL ± P), and unilateral/bilateral cleft lip and palate (UCLP, BCLP). Poisson regression models were used to assess regional differences and trends. The Stockholm HC region had the lowest prevalence for all cleft types except CP. The Northern HC region had a higher CP prevalence, while clefts involving the lip (CL ± P, BCL ± P) were more common in the Southeastern and Southern HC regions. Declining trends were observed in at least two regions for all cleft types except CP. CL/P, CL ± P, and BCL ± P showed decreasing prevalence in three regions. The findings confirm some previously reported regional patterns, including a higher CP birth prevalence in northern Sweden. Potential explanations for the regional differences include genetic variation, differences in attitude towards pregnancy termination, socioeconomic factors, and exposure to other risk factors, but need further examination.

Background: This research compares the Frankfort-mandibular plane angle (FMA) measurements between individuals with cleft lip and palate (CLP) disorders and those without clefts (NC). Additionally, it examines gender differences in FMA measurements within the study population. Materials and Methods: A sample of 123 individuals provided demographic information, including gender distribution and types of cleft conditions. FMA measurements were calculated and compared across genders and cleft conditions using independent samples tests, descriptive statistics, analysis of variance (ANOVA), and multiple comparisons. Results: The study found that 56.1% of participants were male and 43.9% were female. Furthermore, 74.8% had CLP conditions, with bilateral cleft lip and palate being the most prevalent (23.6%). No significant differences in FMA measurements were observed between males and females (p &gt; 0.05). However, significant differences were found in FMA measurements between individuals with NC and CLP conditions (p &lt; 0.05). ANOVA revealed significant differences in mean FMA measurements across various types of cleft conditions. Conclusion: The findings indicate that while gender does not significantly affect FMA measurements, substantial differences exist between individuals with NC and CLP conditions. Understanding these distinctions is crucial for personalized orthodontic and craniofacial treatment planning in patients with cleft lip and palate disorders.

Comparison of differential and conventional rapid maxillary expansion on upper airway dimensions in children with bilateral complete cleft lip and palate: A CBCT-based secondary analysis of a clinical trial.

IntroductionDDX3X-related neurodevelopmental disorder (DDX3X-NDD) is a rare genetic condition that primarily affects females, leading to developmental delays and intellectual disability. DDX3X variants, primarily de novo, account for an estimated 1% to 3% of females with unknown causes of intellectual disability. Affected males have also been reported, often with the variant being inherited from an asymptomatic or mildly symptomatic mother.Case DescriptionCase 1. The patient is a 22-month-old female, born full-term, with a history of developmental delay and complete bilateral cleft lip and palate (CLP). Whole exome sequencing (WES) identified a de novo pathogenic missense variant in the DDX3X gene, DDX3X c.1039G > T (p.Asp347Tyr). Developmentally, the patient is progressing gradually-can sit unassisted, but remains nonverbal.Case 2. The patient is a 4-year-old female, born full-term, with a history of right hemifacial microsomia and DDX3X-NDD, and no known family history. The patient has global developmental delay, but is able to speak in 3- to 4-word sentences. WES identified a de novo DDX3X frameshift variant, c.841_842delC>A (p.Gln281AspfsX13). Facial features include right-sided hemifacial microsomia, with right enophthalmos, microtia, mandibular hypoplasia, and bilateral facial nerve weakness. The patient is well-managed at home and receives regular care from neurology and speech therapy at school.DiscussionAlthough there have been numerous reports on the neurodevelopmental aspects of DDX3X-NDD, craniofacial findings such as hemifacial microsomia and CLP have been minimally reported in the literature. Given the association between DDX3X variants and craniofacial findings, plastic surgeons and their multidisciplinary team should be aware of this genetic condition.

Primary tip rhinoplasty at the time of bilateral cleft lip (BCL) repair has become the standard of care. However, there are limitations in fully correcting the interdomal deformity, resulting in variations in early nasal tip shape. The authors offered BCL patients who demonstrated unfavorable nasal tip growth after BCL repair an open tip rhinoplasty at 3-5 years of age. This study retrospectively compared basic nasal morphometrics in these patients relative to matched controls who did not have the surgery. Nasal tip projection and nostril height to width ratios were measured for 25 consecutive patients who underwent early open tip rhinoplasty using standardized submental and lateral photographs over time. Twenty-five historical controls who did not undergo the surgery but had similar starting nasal morphology to the surgery group were matched by ethnicity and sex. The measurements were plotted to demonstrate trends in the 2 groups over time. Both tip projection and relative nostril height were comparable between the 2 groups after primary lip-nose repair but before any secondary nasal surgery. Immediately after surgery, the study group had greater tip projection and relative nostril height than before surgery, and these measures remained stable or improved over time. The historical control group measurements did not exhibit appreciable change from baseline over time. In carefully selected BCL patients demonstrating unfavorable nasal growth before adolescence, open tip rhinoplasty improves both relative nostril height and tip projection relative to comparable patients who did not undergo the procedure. Further studies are required to determine whether this early intervention can improve patient satisfaction through school-age years and decrease the need for definitive rhinoplasty at maturity.

Background and objective:This study focuses on children aged 8–12 with cleft lip and palate, a critical period for surgical and orthodontic interventions that can significantly impact facial development and psychosocial well-being. Assessing the satisfaction and quality of life of patients and their parents during this stage can provide valuable insights to optimize care and support outcomes.Methods:A cross-sectional study was conducted among parents and 32 patients with unilateral and bilateral complete cleft lip and palate who received continuous treatment at the Tawanchai Center during the year 2024. Data were collected using a general information questionnaire, the THAICLEFT quality of life Questionnaire, and a patient self-assessment. Data were analyzed using descriptive statistics, including percentage, mean, and standard deviation. Psychosocial satisfaction was compared using the Mann–Whitney U test.Results:Among 32 participants, patients (68.75% male, mean age 10.38 ± 1.52 years) with predominantly unilateral cleft lip and palate (68.75%) reported high satisfaction across five psychosocial domains (mean 4.00 ± 1.26). Parents reported highest satisfaction with service quality (4.65 ± 0.52) and moderate-to-high satisfaction across medical, cost, and psychosocial domains (means 3.54–4.21). Family impact remained low (2.25 ± 1.71). Communication ability showed significant between group differences (p = 0.02).Conclusion:Parents reported high satisfaction in three domains, while patients showed high satisfaction in five psychosocial aspects. The findings from this study will be used to improve patient and family care, enhancing their overall quality of life.

To compare the prevalence and morphological characteristics of canalis sinuosus (CS) between unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP) and control groups. The sample consisted of 238 CBCT images (476 sides) from 98 UCLP subjects (196 sides), 36 BCLP subjects (72 sides) and 104 healthy controls (208 sides). Recorded parameters included prevalence of CS, diameter, location of the teeth and adjacent structures. Afterwards, the recorded parameters were compared between the UCLP, BCLP and control groups. The prevalence of CS in the control, UCLP and BCLP groups showed significant differences. The BCLP group revealed a significantly lower prevalence of CS than the UCLP and control groups. There was a considerable increase in CS diameter in the CLP groups compared with the control group. The terminal location of CS was in the canine region for the CLP groups and in the lateral incisor region for the control group. CLP had a significant impact on the location of the end of the CS. CEJB (cementoenamel junction buccal) and CEJL (cementoenamel junction lingual) measurements showed significant differences between the CLP cases and control groups. Different characteristics was revealed between the control, UCLP and BCLP groups. Assessment of CS in patients with CLP with CBCT images is crucial before performing surgical procedures.

Background:Deficiency of the free border of the lip and “whistling lip” deformity are encountered in secondary repairs of unilateral and bilateral cleft lip. We have reported the use of the de-epithelialized oral vestibular flap (boot flap) for secondary cleft lip repair. We experienced more cases using this method and analyzed them.Methods:Fifty-nine patients with a cleft lip underwent secondary repair using this method. In unilateral cases, total scores were determined by evaluating the height of the notch, the volume of the upper lip tubercle, and the upper lip volume of the cleft side. In bilateral cases, total scores were determined by evaluating the height of the notch and the volume of the median lip tubercle.Results:Of the 46 patients with a unilateral cleft lip, 3 patients underwent a second boot flap operation due to undercorrection, and 1 patient underwent boot flap revision. Of the 12 patients with a bilateral cleft lip, 1 patient underwent a second boot flap operation due to flap atrophy. The second operation could be performed without any difficulty in either unilateral or bilateral cases. Compared with the preoperative scores, the postoperative scores improved significantly in both unilateral and bilateral cases.Conclusions:We experienced a recurrent notch deformity after direct suturing in a patient with a unilateral cleft lip. This was thought to be caused by scar contracture. To prevent a recurrent deformity, it is important to interrupt the plane where scar contracture occurs by incorporating a boot flap and augmenting the volume.

Background:The complexity of bilateral cleft lip deformities and the delicate interrelation between muscular arrangement and external lip features require a comprehensive approach for proper management. The principles developed by Mulliken for cleft repair have been a cornerstone in cleft management. In this study, the operative principles for bilateral cleft lip repair described by Mulliken are applied, with functional muscle reconstruction in the form of interlacing orbicularis oris muscle fibers using the basket-weave technique.Methods:Eighty patients underwent surgery using modifications of the technique described by Mulliken for bilateral cleft lip repair, involving skin tailoring, lateral flap size, and basket-weave muscle repair, with a mean follow-up period of 1 year and 2 months.Results:The overall results were extremely satisfactory regarding function and appearance, with no major complications. A full central segment with prominent philtral ridges, an adequate white roll, and a thick vermilion with a seam-like median tubercle were obtained. Based on the 10 parameters for assessment and scoring, 32 (40%) patients had excellent results, 36 (45%) patients had very good results, 8 (10%) patients had good results, and 4 (5%) patients had fair results.Conclusions:A basket-weave muscle reconstruction technique for bilateral cleft lip patients is presented, along with the major sites of distortion in the lip, sulcus, and nasal floor addressed during the primary surgery. This technique has shown improved dynamics and 3-dimensional configurations of the repaired lip both at rest and in function.

ABSTRACT This research note presents an acoustic field distribution analyser with sample visualisations, applied to the study of typical and disordered laterality and nasality in speech – an area lacking fully non-invasive diagnostic tools. A portable system was developed by combining a custom circular microphone array with software for temporal, spectral and spatial speech analysis in both horizontal and vertical planes. The array comprises 16 micro-electro-mechanical microphones equipped with pulse-density modulators, along with a laser distance sensor that focuses the acoustic beam on the facial contours and compensates for the speaker’s head movements – thereby increasing the array’s focusing precision. Two case studies visualise disordered speech in patients with (1) occlusal development disorders and compensatory articulation, and (2) bilateral cleft lip and palate with resonance issues, compared to typical speech patterns. Spatial analysis of the acoustic field distribution enabled a non-invasive comparison of articulation symmetry and air pressure distribution in both the horizontal and vertical planes, facilitating the investigation of (undesired) lateral and (hyper)nasalised pronunciations. The system allows for the investigation of the acoustic field distribution around the speaker’s face, offering potential for research, diagnostic and therapeutic uses. Further validation involving a larger group of patients is underway.