Complete Cleft Palate Research Articles

Orthodontic-care burden for patients with unilateral and bilateral cleft lip and palate.

Cleft lip and palate (CLP) cause severe malocclusion, which requires numerous orthodontic interventions in specialized centers. There is little literature regarding the overall orthodontic burden of care for these patients. The aim of the study was the evaluation of orthodontic-care burden for patients treated in the Division of Facial Abnormalities at the Department of Dentofacial Orthopedics and Orthodontics of Wroclaw Medical University in Poland. The medical data of patients with complete unilateral and bilateral cleft lip and palate (ULCP and BLCP) who finished orthodontic treatment between 2012 and 2019 was evaluated. The duration of orthodontic treatment, the number of removable appliances, the number of kilometers traveled as well as the number of visits and surgical procedures performed were recorded. The sample was divided into 2 groups according to the World Health Organization (WHO) International Classification of Diseases (ICD-10) diagnosis codes. All data was subjected to statistical analysis. For the UCLP patients (n = 54), the mean time of orthodontic treatment was 9.24 years, the mean number of orthodontic appointments was 62.91, the mean number of removable appliances was 4.12, the mean number of surgical procedures was 3.35, and the mean distance traveled to visit the center for orthodontic appointments was 5,466.95 km. For the BCLP patients (n = 19), the mean time of orthodontic treatment was 10.16 years, the mean number of orthodontic appointments was 66.26, the mean number of removable appliances was 4.12, the mean number of surgical procedures was 4.05, and the mean distance traveled to visit the center for orthodontic appointments was 3,758.23 km. The orthodontic treatment of patients with UCLP and BCLP is very burdensome for the patients. However, the burden of care in the Division of Facial Abnormalities at the Department of Dentofacial Orthopedics and Orthodontics of Wroclaw Medical University in Poland is not greater than in other European countries.

Pattern of Morphological Variability in Unrepaired Unilateral Clefts With and Without Cleft Palate May Suggest Intrinsic Growth Deficiency.

In individuals with cleft lip and palate (CLP) an iatrogenic effect of operations on subsequent maxillary growth is well-known. Much less is known about the association between occurrence of CLP and intrinsic growth deficiency of the maxillofacial complex. The aim of this study was to compare morphological variability in subjects with unilateral cleft lip and alveolus/palate and unaffected controls using geometric morphometric methods. The research hypothesis was that if subjects with unrepaired unilateral CLP have intrinsic growth deficiency, the pattern of their craniofacial growth variation may differ from that in unaffected individuals. Lateral cephalograms were available of three groups of the same ethnic background (Proto-Malayid): (a) non-syndromic unrepaired unilateral complete cleft lip, alveolus, and palate (UCLP), N = 66, mean age 24.5 years (b) non-syndromic unrepaired unilateral complete cleft lip and alveolus (UCLA), N = 177, mean age 23.7 years, and (c) NORM (N = 50), mean age 21.2 years without a cleft. Using geometric morphometrics shape variability in groups and shape differences between groups was analyzed. Principal component analysis (PCA) was used to examine shape variability, while differences between groups and sexes were evaluated with canonical variate analysis. Sexual dimorphism was evaluated with discriminant function analysis (DA). Results showed that in comparison to NORM subjects, shape variability in UCLA and UCLP is more pronounced in the antero-posterior than in vertical direction. Pairwise comparisons of the mean shape configurations (NORM vs. UCLA, NORM vs. UCLP, and UCLA vs. UCLP) revealed significant differences between cleft and non-cleft subjects. The first canonical variate (CV1, 68.2% of variance) demonstrated that differences were associated with maxillary shape and/or position and incisor inclination, while in females, the CV1 (69.2% of variance) showed a combination of differences of “maxillary shape and/or position and incisor inclination” and inclination of the cranial base. Shape variability demonstrated considerable differences in subjects with UCLA, UCLP, and NORM. Moreover, in subjects with a cleft, within-sample variability was more pronounced in the antero-posterior direction, while in non-cleft subjects, within-sample variability was more pronounced in the vertical direction. These findings may suggest that subjects with unilateral clefts have intrinsic growth impairment affecting subsequent facial development.

Establishment of a dexamethasone-induced congenital cleft palate model in New Zealand rabbits

Objective: To develop a new congenital cleft palate model suitable for the evaluation of cleft palate surgery and other related treatments. Methods: Ten New Zealand female rabbits (aged 40 weeks, 4.5-5.0 kg) were selected. The next day after mating with male rabbits of the same strain was regarded as the day 1 of gestation (GD1). Ten pregnant rabbits were enrolled with intramuscular injection 1.0 mg dosage of dexamethasone once a day from GD13 to GD16. The caesarean section was performed to obtain the newborn rabbits on GD31 for each pregnant rabbit. Then the rates of the survival and cleft palate rabbits were calculated. The rabbits were divided into two groups according to the method of random number table (10 non-cleft palate rabbits as the control group and 10 cleft palate rabbits as the experimental group). The body weights and physiological behaviors of the rabbits were evaluated and recorded at the age of 1, 2 and 4 weeks respectively after being fed by using standardized gastric tube feeding method. At 4 weeks old, three rabbits in each group were randomly selected for the observation of local anatomy of different layers of the mouth and upper jaw. The anatomical results were photographed for comparative analysis. Results: In this experiment, 48 infants of 10 pregnant rabbits survived under the condition with a survival rate of 66% (48/73), among which the incidence of cleft palate was 60% (29/48). All the rabbits in the control group and the experimental group were able to survive for at least 1 month with stable weight gain. There was no significant difference in weight (P>0.05) and physiological appearance between the two groups. In cleft palate group, most of fetuses showed complete cleft palate with significant differences in the anatomical structure of the upper jaw compared with the control group including the changes in the morphology of the palatal mucosa, the terminal distribution of the soft palate muscles, and the dysplasia and absence of bone structures along the mid-maxillary line. Conclusions: In this study, it was the first time to successfully establish the dexamethasone-induced congenital cleft palate model in New Zealand rabbits for cleft surgical research.

Complete Unilateral Cleft Lip and Palate Repair: A Modification of the Millard Surgical Technique

Since 390 B.C.E., the treatment of upper lip clefts has represented a challenge for surgeons...

A Three-Dimensional Comparison of Nasolabial Soft Tissue between Children with Repaired Unilateral Complete Cleft Lip and Palate and Unaffected Children in Khon Kaen, Thailand.

The objectives were to assess the treatment outcomes of unilateral cleft lip and palate after primary surgery on nasolabial soft tissue of children ages 4-5 years old as compared with unaffected children and to establish a nasolabial soft tissue norm within Khon Kaen. This cross-sectional study consisted of 60 unaffected subjects living in Khon Kaen province and 20 subjects with repaired complete unilateral cleft lip and palate who were treated at Srinagarind Hosipital, Khon Kaen, Thailand. 3D images were taken by a Morpheus 3D Scanner and measured by the Morpheus 3D program. Independent t-tests and paired t-tests were used to analyze the significant differences between subjects with cleft and unaffected subjects. There were statistically significant differences (p<0.05) of nasolabial measurements between affected subjects and unaffected subjects. Unilateral measurements showed decreased nostril height, columella lengths, and nose protrusion from ala base and ala length in the affected group. In addition, bilateral measurements found decreased upper lip protrusion, philtrum length, upper lip height, upper vermillion thickness, and lip angle. This study attempted to establish a norm for evaluating the treatment outcome of cleft lip and cleft palate repair at Srinagarind Hospital in relation to unaffected or noncleft individuals. The results suggest that the noncleft side in affected patients is not an optimal surgical guide for cleft repair and the surgeon should correct both sides of lip and nose features according to the norms. A surgical treatment plan should emphasize correcting nostril height, columella length, nose protrusion from ala base, ala length, and upper lip features.

ASSESSMENT OF PRESURGICAL NASOALVEOLAR MOULDING (PNAM) IN UNILATERAL CLEFT LIP AND PALATE

Background: Midface symmetry is an important indicator of success of complete unilateral cleft lip and palate (CUCLP) treatment. There is little literature on the long-term effects of Presurgical Nasoalveolar Molding (PNAM) on Midface symmetry in children treated for CUCLP.&#x0D; Material and Methods: This case-control study was carried out in the Department of Burn and Plastic Surgery at Government Medical College and Hospital, Bettiah, Bihar, India from may 2018 to Dec 2019. Complete unilateral CL+P patients had basilar and frontal photographs at two time points: (1) initial (2) postsurgical. 30 nasal molding patients and 20 control patients were included. Presurgical nasal molding was performed prior to primary lip repair in intervention group. No nasal molding was performed in control group.&#x0D; Results: A statistically significant difference was found for postsurgical nostril height-width ratio (P&lt; .05). No other statistically significant differences were found.&#x0D; Conclusion: Nasal molding and surgery resulted in more symmetrical nostril height-width ratios than surgery alone. Alar groove ratios were not statistically significantly different between groups perhaps because application of nasal molding was not early enough; postsurgical nasal splints were not utilized; overcorrection was not performed for nasal molding

Assisted Nursing: A Case Study of an Infant With a Complete Unilateral Cleft Lip and Palate.

This case presents a mother's feeding experience of an infant born with a complete unilateral cleft lip and palate from birth until both were repaired. She fed him directly at the breast with assistance, controlling the delivery of the mother's own milk. The infant received only his mother's own milk, no bottles, and the excess expressed milk was donated to a milk bank. The Cleft Team supported the mother's wish to breastfeed but expressed realism that cleft lip and palate infants could not create suction. Success had never been observed in the unit. Instead, the team suggested expressing to deliver as much of the mother's own milk. The mother had previously breastfed her three children and was keen on finding innovative ways to breastfeed. Several techniques were trialed with the help of an International Board Certified Lactation Consultant. The most sustainable and successful was the use of a nipple shield applied to the maternal nipple areola complex to cover the lip palate. Underneath, a nasogastric tube connected to a syringe delivered the mother's own milk. Exclusive expressing protected maternal supply, the infant's nutrition and growth were monitored carefully and this technique reinforced mother-infant bonding. Feeding with the modifications was challenging at times. However, maternal satisfaction was high because the mother had achieved her goal of breastfeeding without assistance post cheiloplasty and palatoplasty. This case adds to the limited body of research about feeding infants with cleft lips and palates directly at the breast.

The Effectiveness of Preoperative Correction Techniques in Improving Nasal Deformity in Children With Unilateral Complete Cleft Lip and Palate.

Unilateral complete cleft lip and palate (UCCLP) is associated with apparent nasal deformities before the cheilorrhaphy. The aim of this study was to determine whether preoperative correction techniques are effective in the treatment of nasal deformities in infant with unilateral UCCLP used by the systematic review and meta-analysis. We searched Medline, Cochrane Library, EMBASE, PubMed, and Chinese BioMedical Literature Database (CBM) until January 31, 2019, to identify studies that compared the effectiveness of preoperative correction techniques in the treatment of nasal deformities in infant with UCCLP. Two authors individually extracted the data and performed the quality assessments. The height of nasal columella, the width of the affected side nasal ala and the inclination of the nasal columella were evaluated. Seven articles were incorporated into the systematic review, and 5 (274 participants) in the meta-analysis according to the inclusion criteria. The preoperative correction could increase the height of nasal columella in children with UCCLP [SMD: 2.64 mm; 95% confidence intervals (CI); (1.35 mm, 3.94 mm); P < 0.0001]. Moreover, the preoperative correction resulted in reduced width of the affected side nasal ala [SMD: -5.14 mm; 95% CI; (-8.96 mm, -1.31 mm); P = 0.008]; However, the evidence was insufficient to determine a significant effect on the inclination of the nasal columella [SMD: -3.48 degrees; 95% CI; (-7.56 degrees, 0.59 degrees); P = 0.09]. Preoperative correction for children with UCCLP can increase the height of nasal columella, reduce the width of the affected side nasal ala, improve the nasal symmetry, and reduce nasal deformity, however, no significant effect could be observed for the inclination of the nasal columella.

Altered BMP-Smad4 signaling causes complete cleft palate by disturbing osteogenesis in palatal mesenchyme.

As the major receptor mediated BMP signaling in craniofacial development, Bmpr1a expression was detected in the anterior palatal shelves from E13.5 and the posterior palatal shelves from E14.5. However, inactivating BMP receptor in the mesenchyme only leads to anterior cleft palate or submucous cleft palate. The role of BMP signaling in posterior palatal mesenchyme and palatal osteogenesis is still unknown. In this study, a secreted BMP antagonist, Noggin was over-expressed by Osr2-creKI to suppress BMP signaling intensively in mouse palatal mesenchyme, which made the newborn mouse displaying complete cleft palate, a phenotype much severer than the anterior or submucous cleft palate. Immunohistochemical analysis indicated that in the anterior and posterior palatal mesenchyme, the canonical BMP-Smad4 signaling was dramatically down-regulated, while the non-canonical BMP signaling pathways were altered little. Although cell proliferation was reduced only in the anterior palatal mesenchyme, the osteogenic condensation and Osterix distribution were remarkably repressed in the posterior palatal mesenchyme by Noggin over-expression. These findings suggested that BMP-Smad4 signaling was essential for the cell proliferation in the anterior palatal mesenchyme, and for the osteogenesis in the posterior palatal mesenchyme. Interestingly, the constitutive activation of Bmpr1a in palatal mesenchyme also caused the complete cleft palate, in which the enhanced BMP-Smad4 signaling resulted in the premature osteogenic differentiation in palatal mesenchyme. Moreover, neither the Noggin over-expression nor Bmpr1a activation disrupted the elevation of palatal shelves. Our study not only suggested that BMP signaling played the differential roles in the anterior and posterior palatal mesenchyme, but also indicated that BMP-Smad4 signaling was required to be finely tuned for the osteogenesis of palatal mesenchyme.

Load Transfer during Magnetic Mucoperiosteal Distraction in Newborns with Complete Unilateral and Bilateral Orofacial Clefts: A Three-Dimensional Finite Element Analysis

The primary correction of congenital complete unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) is challenging due to inherent lack of palatal tissue and small extent of the palatal shelves at birth. The tissue deficiency affects the nasal mucosa, maxillary bone and palatal mucosa. This condition has driven the evolution of several surgical and non-surgical techniques for mitigating the inherent problem of anatomical deficits. These techniques share the common principle of altering the neighboring tissues around the defect area in order to form a functional seal between the oral and nasal cavity. However, there is currently no option for rectifying the tissue deficiency itself. Investigations have repeatedly shown that despite the structural tissue deficiency of the cleft, craniofacial growth proceeds normal if the clefts remain untreated, but the cleft remains wide. Conversely, craniofacial growth is reduced after surgical repair and the related alteration of the tissues. Therefore, numerous attempts have been made to change the surgical technique and timing so as to reduce the effects of surgical repairs on craniofacial growth, but they have been only minimally effective so far. We have determined whether the intrinsic structural soft and hard tissue deficiency can be ameliorated before surgical repair using the principles of periosteal distraction by means of magnetic traction. Two three-dimensional maxillary finite element models, with cleft patterns of UCLP and BCLP, respectively, were created from computed tomography slice data using dedicated image analysis software. A virtual dental magnet was positioned on either side of the cleft at the mucoperiosteal borders, and an incremental magnetic attraction force of up to 5 N was applied to simulate periosteal distraction. The stresses and strains in the periosteal tissue induced by the magnet were calculated using finite element analysis. For a 1 N attraction force the maximum strains did not exceed 1500 µstrain suggesting that adaptive remodeling will not take place for attraction forces lower than 1 N. At 5 N the regions subject to remodeling differed between the UCLP and BCLP models. Stresses and strains at the periosteum of the palatal shelf ridges in the absence of compressive forces at the alveolar borders were greater in the UCLP model than the BCLP model. The findings suggest that in newborns with UCLP and BCLP, periosteal distraction by means of a magnetic 5 N attraction force can promote the generation of soft and hard tissues along the cleft edges and rectify the tissue deficiency associated with the malformation.

Hypogonadism: Is It Always Hypogonadotropic in an Adolescent With a Cleft Palate? A Surprising Case of Klinefelter Syndrome.

Pituitary hormone deficiencies may occur in children with midline defects; in these cases, hypogonadism is usually hypogonadotropic. Herein, we report a boy at the age of 13.8 years with mild mental retardation, previously operated for complete cleft palate (isolated) and presented with hypoglycemia due to isolated secondary adrenal insufficiency, who further had a decrease in testicular size with increased follicle-stimulating hormone level (hypergonadotropic hypogonadism) and diagnosed with Klinefelter syndrome. Klinefelter syndrome in childhood is rarely diagnosed and cases are observed in a wide spectrum. Although some regional duplications of the X chromosome also show midline defects such as spina bifida-neural tube defects, mental retardation, hypopituitarism (mostly growth hormone deficiency); coexistence of Klinefelter syndrome and isolated secondary adrenal deficiency/midline defect in our case may also be coincidental. However, to our knowledge, this is the first case in literature with this association in a patient with a 47, XXY karyotype.

Orofacial clefts: treatment based on a multidisciplinary approach

Orofacial clefts: treatment based on a multidisciplinary approach

Incidence of Cleft Lip and Cleft Palate - An Institutional Based Retrospective Study

Cleft lip or the palate is the congenital birth defect with which is characterised by complete or partial cleft lip or palate. The congenital cleft involving the facial structures may vary from trace of notching of the lip to a complete non fusion of lip and the palate. This study was done to determine the incidence of cleft lip and palate. It is a single centered retrospective study. Data was collected from the patient record system used in a private dental institution and following parameters such as gender, type of cleft lip and palate, unilateral or bilateral was recorded. 86000 patient details were analysed between June 2019 to March 2020 out of which 74 patients who fulfilled the inclusion and exclusion criteria were included in the study. The data was statistically analysed using SPSS software. In this study, it was observed that cleft lip was most commonly seen in males and cleft palate in females. Unilateral cleft lip is common in both males and females. Incomplete cleft palate is more common followed by complete cleft palate. Orofacial defects are most commonly seen at the time of birth.

Presurgical Maxillary Orthopedics and Primary Alveolar Closure: Protocol and Long-term Effects on Midfacial Growth in Patients With Complete Unilateral and Bilateral Clefts

BACKGROUND: In a complete cleft lip and palate, a defect exists in the alveolar segment of the maxilla. In order to achieve successful restoration of the maxillary arch, several techniques have been employed with the ultimate goal of achieving continuity and adequate bone stock across the alveolus. Passive orthodontic appliances (POA) and gingivoperiosteoplasty (GPP) are adjuncts utilized by some surgeons with primary cleft lip repair. POA aligns the alveolar segments prior to cleft lip repair, and GPP is utilized to achieve bony union across the cleft at the time of primary lip repair. The use of these treatments remains controversial. Along with the surgical technique of the cleft lip and palate repair, they have the possibility of impacting midface growth. Here, we present our protocol for cleft lip and palate repair utilizing GPP and POA for complete unilateral and bilateral cleft lip and palate patients. We also report preliminary treatment results in complete unilateral and bilateral cleft patients, evaluating midface growth at mixed dentition. METHODS: Ten consecutive complete unilateral and 10 consecutive complete bilateral cleft lip and palate patients were recruited. All presurgical molding was performed by a single individual, and all surgical treatments were performed by the senior author. Patients underwent POA treatment (initiated at 7 days) for 35 weeks. The nasal component was incorporated after 6 weeks. GPP was performed by elevating flaps in the subperiosteal or supraperiosteal plane and closing the alveolar defect. Unilateral cleft patients underwent rotation advancement repair at approximately 6 months, whereas bilateral cleft patients underwent staged repair with a similar technique at approximately 6 and 9 months of age. Cephalometric analysis of lateral radiographs of patients at mixed dentition was performed to evaluate maxillary and mandibular growth (SNA, SNB, ANB) and facial growth relative to the facial axis (facial axis angle). RESULTS: Twenty patients underwent POA, cleft lip closure with GPP and cephalometric analysis. Mean age at time of surgery for all patients was 6.8 months ± 2.6 months of GE with a range of 5–14 months of age. Mean cephalometric values were within age-specific normal values for SNA (80° ± 3.7°), SNB (74° ± 3.4°), ANB (4° ± 1.4°), and the facial axis angle (90° ± 3.5°). One unilateral patient and zero bilateral patients exhibited skeletal Class III malocclusion. CONCLUSION: Although controversy exists regarding the impact of GPP and POA on midface growth in cleft patients, our results demonstrate that GPP and POA do not interfere with maxillary grow or cause a Class III malocclusion at mixed dentition in most patients. POA, combined with GPP at the time of cleft lip repair, leads to normal maxillary development in unilateral and bilateral cleft lip and palate patients at mixed dentition. We feel that the normal maxillary growth justifies continuing the use of GPP and POA, especially when considering the potential advantageous that they can afford at the time of primary cleft lip repair, such as allowing for closure of the alveolus and anterior palate and achieving bony union across the cleft.

Degree of Asymmetry Between Patients With Complete and Incomplete Cleft Lips.

Surgical outcomes for patients with complete cleft lips are not as ideal as those achieved for milder phenotypes. We hypothesized that in addition to the greater width of the cleft, patients with complete cleft lip and palate exhibit a greater degree of hypoplasia and asymmetry. Stereophotographs of 14 infants with unrepaired unilateral complete and 14 with incomplete cleft lips were measured using Vectra imaging software (Canfield Imaging). Unpaired t tests were used to compare measured asymmetry between groups. Measurements included nasion to endocathion, sn-sbal, subnasale to alare (sn-al), subnasale to crista philtra, subalare to crista philtra (sbal-cphi), chelion to crista philtra, lateral lip element fullness, medial lip element fullness (mef), and non-cleft lip fullness. Duplicate measurements allowed Pearson correlation to be used to determine intra-rater reliability. Statistical significance was set at P < .05. Degree of asymmetry of the nasal base, sn-al, and sn-sbal was significantly greater for patients with complete clefts (P = .0001, P = .0001). Hypoplasia of the lateral lip element was seen when comparing lateral and mef (P = .04, P = .004) and lateral lip height (sbal-cphi''; P = .002). The degree of cupid's bow asymmetry did not differ between groups (P = .23). Intrarater reliability was high for all facial measures, ranging from 0.70 to 0.99. More severe, complete cleft lips demonstrate statistically significant greater asymmetry in surgically relevant dimensions. There was greater width of the nasal base. Vertical asymmetry of cupid's bow was unaffected by cleft severity, but that asymmetry was greater in patients with complete clefts due to hypoplasia of the lateral lip element. This may contribute to the less favorable results in these patients.

Modified Presurgical NAM: A Comparative Clinical Evaluation in Complete Unilateral Cleft Lip and Palate Management

Modified Presurgical NAM: A Comparative Clinical Evaluation in Complete Unilateral Cleft Lip and Palate Management

Influence of bone-anchored maxillary protraction on secondary alveolar bone graft status in unilateral complete cleft lip and palate

Our objective was to evaluate the effects of bone-anchored maxillary protraction (BAMP) on the status of the secondary alveolar bone graft in patients with unilateral complete cleft lip and palate (UCLP). The experimental group (EG) comprised 26 patients with UCLP, mean age of 11.9years, submitted to secondary alveolar bone grafting (SABG) with recombinant bone morphogenetic protein, and BAMP therapy, using miniplate-borne Class III intermaxillary elastics. Cone beam computed tomography (CBCT) examinations were taken 6months after SABG and before BAMP (T1) and after 18months of BAMP therapy (T2). The control group (CG) was composed of 24 patients with UCLP submitted only to SABG with recombinant bone morphogenetic protein or autogenous bone from iliac crest without BAMP therapy, matched by initial age and sex with the EG. In the CG, CBCT examinations were performed 6months (T1) and 12months (T2) after SABG surgery. CBCT axial sections were analyzed using Garib scores in both time points. Intra- and intergroup comparisons were performed using Wilcoxon and Mann-Whitney tests, respectively (P<0.05). No intergroup differences were found at T1 and T2. The EG showed significant improvement of graft status from T1 to T2 at the cervical and middle levels of the alveolar cleft. No significant interphase differences were found for graft scores in the CG. Despite loads of intermaxillary elastics applied to the maxilla, no harm to the grafted alveolar bone was observed after BAMP therapy in patients with UCLP.

Effectiveness of a Novel 3D-Printed Nasoalveolar Molding Appliance (D-NAM) on Improving the Maxillary Arch Dimensions in Unilateral Cleft Lip and Palate Infants: A Randomized Controlled Trial.

The aim of the current study was to introduce and measure the effectiveness of a new 3D-printed nasoalveolar molding (D-NAM) appliance on improving the maxillary arch dimensions (MADs) in infants with unilateral complete cleft lip and palate (UCLP) before surgical lip repair. A prospective, balanced, randomized, parallel groups, single-blinded, controlled trial. All the steps of the current study were carried in the Department of Orthodontics, Cairo University in Egypt. Thirty-four, nonsyndromic infants with UCLP. The eligible infants were randomly assigned into either no-treatment (control) or to the new D-NAM groups. In D-NAM group, the maxillary models were 3D scanned into virtual models onto which segmentation and alveolar segments approximation were performed. Approximation movements were divided into 3 models representing 3 activation steps. On each of these models, virtual appliance construction was performed followed by 3D printing of the appliance. Nasal stent was added manually to the appliances of the second and third steps. Horizontal tapes were applied to infants in the D-NAM group only. A Blinded assessors carried all the MADs measurements virtually on digital models collected at the beginning (T1) and after (T2) treatment. Clinically and/or statistically significant improvements in all the measured MADs were recorded in D-NAM group at T2 before surgical lip repair in comparison to control group. The introduced D-NAM/3D-printed appliance is a simple and efficient technique to improve the MADs in infants with UCLP before surgical lip repair.

Speech Outcomes Comparison Between Adult Velopharyngeal Insufficiency and Patients With Unrepaired Cleft Palate.

This study compared the speech outcomes of adult velopharyngeal insufficiency patients and adult cleft palate (ACP) patients, and explored whether there was any difference in the phonological level of these 2 types of patients. Perceptual evaluation was used to assess speech intelligibility, hypernasality and compensatory articulation in 89 adult patients with velopharyngeal insufficiency and 35 adult patients with unrepaired cleft palate. Each group was divided into complete cleft palate and incomplete cleft palate (including submucous cleft palate). The phonological differences were compared between the 2 groups of patients and 2 types of cleft palate. The mean speech intelligibility was 43.04% in velopharyngeal insufficiency group and 32.87% in ACP group. There was a significant difference in speech intelligibility between the 2 groups by T test, t = 2.916 (P < 0.01), speech intelligibility between 2 types of cleft palate was no significant difference. Also, there was a significant difference between the 2 groups in the constitution of hypernasality degree by Chi-Square test, x2 = 31.650 (P < 0.01), compensatory articulation were present in 74.3% ACP patients (26/35) and 47.2% velopharyngeal insufficiency patients (42/89), x2 = 7.446 (P < 0.01), there was a significant difference in incidence of compensatory articulation between the 2 groups. Adult patients with unpaired cleft palate present an even worse speech intelligibility and hypernasality degree than velopharyngeal insufficiency patients after cleft palate repair, regardless of the cleft type. Additionally, patients in ACP group have a higher incidence of compensatory articulation than that in incomplete cleft palate group. In sequenced treatments of cleft lip and palate, evaluation and treatment of speech disorders cannot be ignored.

The Impact of Palatal Fistulae on the Success of Alveolar Bone Grafting.

Palatal fistulae are common complications of cleft palate surgery with a frequency of 5% to 29% and are challenging to repair. Optimal timing to repair palatal fistulae, in a staged fashion before alveolar bone grafting, or at the same time, still remains controversial. The primary aim of this study is to compare outcomes of 2 groups with regard to successful alveolar bone grafting in patients with cleft lip and palate and palatal fistulae. We describe a review of 85 consecutive patients identified as undergoing bone grafting from a single institution craniofacial team during 2003 to 2018. Twenty-eight required palatal fistula repair. All patients had a diagnosis of unilateral or bilateral complete cleft lip and palate. Patients with cleft lip and palate repairs were stratified based on preoperative or simultaneous palatal fistula repair. Panoramic radiographs were reviewed by 2 physicians to evaluate success of bone grafting. Comparison between cohorts was made by statistical analysis. Of the 28 that required palatal fistula repair, 15 (53.6%) patients underwent prebone grafting palatal fistula repair and 13 (46.4%) patients underwent simultaneous bone grafting with palatal fistula repair. Mean age at time of bone grafting and palatal fistula repair were 10.60 years old and 9.39 years old, respectively. Length to follow-up was 54.82 months. The average height of the healed alveolar cleft site for patients in the prebone grafting or simultaneous groups was 10.57 mm and 11.46 mm, respectively. Patients who underwent palatal fistula repair and simultaneous bone grafting had similar outcomes as those with palatal fistula repair preoperatively.