Presurgical Orthopedic Treatment Research Articles

Caregivers' Experience with Lip Taping as a Presurgical Orthopedic Treatment for Cleft Lip and Palate Defects.

This study aimed to assess caregivers' experiences and perceptions of applying lip taping as presurgical orthopedic therapy (PSO) for infants with a cleft lip and palate. A retrospective survey was conducted, inviting parents to respond to a series of structured questions between September 2022 and June 2023. The questionnaire focused on evaluating parents' experience with lip taping, a crucial component of PSO. Descriptive statistics and the Chi-square test were employed to analyze relationships between categorical variables. Of the 157 participants, overall, 122 completed the survey, forming the dataset for analysis. A majority (90.0%) reported sufficient experience in using lip taping and no major difficulties with lip taping application. Caregivers with higher education levels exhibited a significantly positive correlation (p = 0.015). Additionally, 93.4% confirmed the efficacy of lip taping for premaxillary segment retraction, with this outcome being correlated with caregivers' knowledge and education (p = 0.008). Interestingly, caregivers' age also demonstrated a substantial association (p = 0.020). While a vast majority expressed positive experiences with lip taping as a presurgical treatment, continuous, tailored education on cleft lip and palate is imperative. This education should be directed towards caregivers and individuals offering direct support to parents of children with CLP, ensuring optimal care and preparation for surgical treatment.

Comparative study on cleft palate morphology after passive presurgical plate therapy in unilateral cleft lip and palate

Presurgical plate therapy has been widely accepted as a treatment prior to palatal cleft closure. The effects of passive presurgical plate therapy on cleft morphology prior to single-stage unilateral cleft lip and palate (UCLP) repair were quantified. We compared the dimensions of cleft width and cleft area (true cleft and palatal cleft) measured preoperatively at 2 European cleft centers. Center A performed single-stage UCLP repair in 8-month-old infants without any presurgical orthopedic treatment. Center B initiated passive presurgical plate therapy immediately after the birth of the neonates, followed by single-stage UCLP repair at 8 months of age. We included 28 patients with complete UCLP from Center A and 12 patients from Center B. The average anterior width of the true cleft before surgery was significantly smaller in infants at Center B than that in Center A (p=0.001) with 95% confidence interval of (1.8, 5.7) mm, but the average posterior width was similar in the 2 groups. The mean presurgical true cleft area amounted to 106.8mm2 (SD=42.4mm2) at Center A and 71.9mm2 (SD=32.2mm2) at Center B, with a confidence interval for the difference being (9.8, 60.1) mm2. This corresponded to a 32.7% reduction of the true cleft area when passive presurgical plate therapy was used for the first 8 months of the infants' life. Passive presurgical plate therapy in UCLP significantly reduced the cleft area. Implications for the subsequent surgical outcome might depend on the surgical technique used.

Chirurgische behandeling lip- en verhemeltespleet

Surgical treatment of cleft lip and palate Children with cleft lip and/or palate often undergo multiple surgical procedures to repair the lip and/or palate. The lip closure is usually done between the ages of 3 and 6 months, which may or may not be preceded by presurgical orthopedic treatment. The techniques used for cleft lip repair vary between different teams and surgeons. In addition to a correct alignment of the lip parts, the restoration of the continuity of the orbicularis oris muscle and the correct positioning of the base of the nostril are important. The timing and sequence of the hard and soft palate repair vary and are a trade-off between the beneficial effect of early palate repair on the velopharyngeal function and speech development, and the possible negative effect of palate repair on maxillary growth. The hard and soft palate can be closed simultaneously or in 2 operating times. Again, several techniques are available, always with the aim of achieving a complete closure of the mucosa without oronasal fistulas and with a functional velopharyngeal sphincter. For the latter, repositioning the palatine levators and restoring their continuity are crucial.

Three-Dimensional Printable Open-Source Cleft Lip and Palate Impression Trays: A Single-Impression Workflow.

Documenting complex three-dimensional (3D) cleft lip and palate malformation with plaster casts based on maxillary impressions is standard care. Presurgical orthopedic treatment also requires an impression. Digital impression-taking in patients with cleft lip and palate is feasible, but procurement costs hinder clinical implementation. Individualized impression trays allow for a precise impression, limiting airway risk. The authors present an open-source impression tray library with scalable impression trays not requiring 3D modeling knowledge. The cleft lip and palate impression tray library is accessible on Open Science Framework. Different shapes are available, and the tray size is selected based on the tuber distance. This allows 3D printing with biocompatible material at the point of care complying with local regulations. The open-source cleft tray library presented offers a hybrid solution for cleft centers, pending the implementation of digital impression.

Effect of Pre-Surgical Orthopedic Treatment on Hard and Soft Tissue Morphology in Infants with Cleft Lip and Palate

The frequency of cleft lip and palate births in Japan is approximately 0.146%. The study aimed to compare the effects of NAM on restoring nasal morphology and improving extraoral nasal morphology in children with cleft lip and palate in the first stage of treatment using 3D imaging and oral model analysis. The subjects were five infants (37.6 ± 14.4 days old) with unilateral cleft lip and palate. The images taken with the 3D analyzer and oral model used for constructing the NAM at the first examination (baseline) and at the completion of the pre-surgical orthodontic treatment (157.8 ± 37.8 days old) were analyzed. The cleft distance was measured at the upper, middle, and lower points on the 3D images. On the model, the cleft jaw width at the maximum protrusion of the healthy and affected sides of the alveolar bone was measured. After the pre-surgical orthopedic treatment, the measured value on the model decreased significantly by a mean of 8.3 mm from baseline, and the cleft lip width narrowed by an average of 2.8 ± 2.2, 4.3 ± 2.3, and 3.0 ± 2.8 mm at the upper, middle, and lower points of the cleft, respectively. Pre-surgical orthopedic treatment using NAM can help narrow the width of the cleft jaw and lip. The sample size is stated at the study limit in the paper.

The Impact of Pre-surgical Orthopedics Appliances (PSOAs) in Bilateral Cleft Lip and Palate (BCLP) Patients

INTRODUCTION: Acceptable maxillary growth in bilateral cleft lip and palate (BCLP) is difficult to achieve. Pre-surgical orthopedic treatment aims at the reduction of cleft size by guiding growth and functional rehabilitation. The objective of this study was to evaluate the impact of Pre-surgical Orthopedics Appliances (PSOAs) on facial growth in BCLP. MATERIALS AND METHODS: Consented subjects were patients who were treated in Hospital Universiti Sains, Malaysia, and Hospital Raja Perempuan Zainab II. Ages of patients ranged from 7 to 21 years of age with non-syndromic cleft and no associated anomalies. A lateral cephalogram was taken and data collected was analyzed to compare the facial growth of BCLP with and without PSOA and between active and passive PSOA. RESULTS: The study sample comprised of 52 BCLP patients with 26 having PSOA and 26 did not having PSOA. Among these patients, those who had PSOA had significant shorter length of PNS-ANS (3.69 mm; p= 0.04) and Co-A (8.38 mm; p=0.04) compared to those who did not have PSOA. However, there were no significant difference in the length measurements between passive and active PSOA users. CONCLUSION: The usage of PSOA gives a shorter maxillary length in the facial growth of bilateral cleft patients. This study proved the effectiveness of PSOA on facial growth of cleft patients in local population.

Digital impressions from newborns to preschoolers with cleft lip and palate: A two-centers experience

Documenting cleft lip and palate morphology prior to surgery is standard care. Presurgical orthopedic treatment also requires a 3D cleft model. Endangering the airway, conventional impressions require additional safety measures and resources. We investigate the implementation and risks of digital impressions for the youngest patients with orofacial clefts. We report a retrospective cohort study of patients with cleft lip and palate, aged up to 6 years, treated at two cleft centers in Europe (Basel (A), Warsaw (B)). We scanned with the Medit i500 (Medit Corp, Seoul, South Korea). Center A for presurgical orthopedics and prior surgery from June 2020 to March 2022. Center B prior surgery from December 2020 to May 2021. Scanning data were analyzed for adverse events and adverse device effects, scanning duration, and number of images according to cleft type and age. We analyzed 342 digital impressions in 190 patients (center A: 71, B: 119). The median age was 8.7 months with a range from the first day of birth (presurgical orthopedics) to six years of life (early alveolar bone grafting). No adverse events or adverse device effects were observed. The median scan duration was 85.5s for cleft palate and 50s for cleft lip and nose (IQR 56s and 39s, respectively). Digital impressions with intraoral scanners are safe in patients with cleft lip and palate from newborn to preschool age. Given the funding to purchase an intraoral scanner, interfaces to electronic patient records, and point-of-care 3D printing, cleft centers can successfully implement this technology.

Obstetrician-Gynecologists' Knowledge and Awareness on Nasoalveolar Molding in Newborns with Cleft Lip and Palate.

This study aimed to determine the level of knowledge and awareness of obstetrician-gynecologists (OB-GYNs) about the presurgical orthopedic treatment of newborns with cleft lip and palate (CLP). We conducted a 12-question survey by email to 532 OB-GYNs who were members of the Turkish Obstetricians and Gynaecologists Association. The participants were asked about their years in practice, region of practice, and knowledge of CLP and nasoalveolar molding (NAM). A total of 141 OB-GYNs agreed to participate and completed the survey. Fifty-nine (42%) of 141 OB-GYNs had never heard of NAM treatment in newborns with CLP. Twenty-seven percent had information about NAM, and 23% referred newborns with CLP for NAM. No statistically significant difference existed in the knowledge level about the preoperative treatment of newborns with CLP between experienced and inexperienced OB-GYNs (P > .05). The knowledge levels of OB-GYNs about NAM were insufficient. We hope that this study will provide more effective results in OB-GYNs referring newborns with CLP for NAM.

Presurgical Orthopedic Treatment of a 3-Year-Old Child with Unoperated Complete Bilateral Cleft Lip and Palate and Protruding Premaxilla.

Unoperated patients with bilateral complete cleft lip and palate (BCCLP), who do not receive orthopedic treatment in infancy and present with significant sagittal excess of the premaxilla, are among the most difficult patients to treat. Delay in primary reconstruction reduces the elastic characteristics of the tissues. The resulting rigidity of bony structures accompanied by the wide alveolar and palatal clefts associated with sagittal excess of the premaxilla pose a great challenge for both surgeon and orthodontist. There is no unique protocol for treatment of these conditions. This paper describes the use of orthopedic treatment in an unoperated 3-year-old male child with BCCLP and a protrusive premaxilla whose appearance and function were both severely affected. A modified Meazzini technique, as described in operated BCCLP patients with a downward-displaced premaxilla, was used. The device itself consists of the 2 independent components mutually connected by a 17 × 25 steel arch. The first is an active fan-type expander. The second consists of an acrylic cap covering the premaxilla and 3 brackets used for the steel arch application. They are connected by a rectangular steel 17 × 25 archwire. Reduction of the premaxillary sagittal excess of is carried out with an elastic chain. The use of this orthopedic appliance is a reliable and valuable presurgical treatment in the therapy of children with BCCLP and protrusive premaxilla whose orthopedic and surgical treatment have been delayed.

Nasal molding prevents relapse of nasal deformity after primary rhinoplasty in patients with unilateral complete cleft lip: An outcomes-based comparative study of palatal plate alone versus nasoalveolar molding.

ObjectivesIn recent years, many studies have reported that the presurgical nasoalveolar molding method improves the nose morphology; however, the reason for its effectiveness after surgery has never been understood. We evaluated the effect of nasoalveolar molding by comparing it with a passive orthopedic method without a nasal stent and focusing on the nostril morphology after primary cheiloplasty using various measurement methods. We then analyzed the essential factors.Materials and methodsThe patients involved were 31 infants with unilateral complete cleft lip and palate treated with primary cheiloplasty at the University of Tsukuba Hospital from 2004 to 2011. Of the 31 infants, 16 received nasoalveolar molding treatment and 15 received passive orthopedic treatment as controls. Photographic facial measurements were performed for all patients immediately and 7 months after primary cheiloplasty. The esthetics of the nostrils were assessed according to the left–right nostril symmetry, as measured by the Hausdorff distance, area ratio, perimeter ratio, and aspect a/u (the aspect ratio of the affected side)/(the aspect ratio of the unaffected side) ratio. In addition, the inclination of the nasal ridge was assessed using anthropometric measurements (Grc‐Grn∠midline and midline∠columellar axis).ResultsThe area ratio, perimeter ratio, and Grc‐Grn∠midline were significantly greater in the nasoalveolar molding group immediately after surgery (p = 0.00062, 0.016, and 0.048, respectively) than in the control group. However, the Hausdorff distance and aspect a/u ratio were more favorable (p = 0.0018 and 0.0039, respectively) in the nasoalveolar molding group after 7 months.ConclusionsThe results of our study suggested that using nasoalveolar molding as a presurgical orthopedic treatment could improve the shape of the nasal cartilage with surgeon's corrections.

Mothers' knowledge and experience concerning presurgical orthopedic management for infants with cleft lip and palate.

OBJECTIVES:The present study aimed to assess the level of mothers’ knowledge toward cleft lip and palate and their experience concerning presurgical orthopedic management.MATERIALS AND METHODS:This was a cross-sectional study where the mothers were invited to complete a self-administered validated and reliable questionnaire. The questionnaire included questions that aimed to assess mother's knowledge related to the most prevalent aspects of cleft lip and palate anomaly itself and additionally, questions associated with presurgical orthopedic treatment as an adjunct therapy. Descriptive statistics were used to define the characteristics of the study variables. Chi-square test was utilized to assess relationships between categorical variables.RESULTS:Totally, 145 mothers completed the survey (response rate was 73%). Forty-six (46%) of the mothers provided an incomplete or improper definition of the anomaly and 35 (24%) claimed that they know the cause of the anomaly. The majority of mothers did not identify family history as a risk factor; consanguinity was identified in 29% (n = 42). Of the total, 58 mothers (40%) agreed that dental management of CLP requires teamwork and the majority (n = 126, 87%) recognized the plastic surgeon as the most important specialist. Mothers aged 20-30 years old (n = 42, 53%), and those who are university graduates (n = 38, 48%), as well as employed mothers (n = 52, 66%) have in general a higher degree of knowledge regarding cleft lip and palate (P < 0.001). More than half of the mothers (n = 70, 57%) reported that presurgical orthopedic treatment was useful and needed for their infants.CONCLUSIONS:Most of the mothers reported a high level of knowledge about cleft lip and palate and they experienced the usefulness of the orthopedic appliances for their infants. However, there was uncertainty in some parts such as definition, diagnosis, causes, and risk factors for cleft lip and palate. Therefore, understanding the causes of cleft lip and palate, as well as comprehensive education concerning the essential role of the orthopedic appliances to improve cleft lip and palate are crucial for mothers to improve their infants’ quality of life.

Presurgical orthopedic treatment of children with unilateral cleft lip and palate with a sequential splints method: indications and long-term results

To justify the use of the Sequential Splints Method of presurgical orthopedic treatment for children with unilateral cleft lip and palate depending on extent of initial deformation and to estimate long-term results. The method was applied in 17 unilateral cleft lip and palate infants who received treatment at the age from 4 days to 3 months. There was a control group of 28 cleft lip and palate patients operated with no early orthodontics. Average age in both groups at the time of research was 3.8±0.9 years. Comparative assessment was conducted before the beginning of the post-operative orthodontic treatment for the following parameters: residual width of the alveolar process cleft, presence of lateral incisor's bud, the extent of the nose deformation on the cleft side. It was found that residual width of the alveolar process cleft was, on average, 5.95 mm in the main group and 12.6 mm in the control group. The percentage of the lateral incisor adentia was 28% in the main group and 66% in the control group. The mean score of alar nose deformation was 3.9 and 3.1 points, correspondingly. According to obtained results patients who did not receive the presurgical orthopedic treatment were more likely to have residual deformations and larger residual width of the alveolar process cleft. There was higher risk of teeth germs loss in the control group. The Sequential Splints Method of presurgical orthopedic treatment is recommended as a necessary part of the treatment for the unilateral cleft lip and palate.

Evaluation of a Digital Protocol for Pre-Surgical Orthopedic Treatment of Cleft Lip and Palate in Newborn Patients: A Pilot Study.

The aim of this study was to evaluate the accuracy, invasiveness and impact on clinical results of a digital oral impression protocol in the pre-surgical orthopedic treatment (PSOT) of newborn cleft lip and palate (CLP) patients undergoing primary alveolar surgical repair. Six patients were divided, according to impression technique used, into a digital (intraoral scanner (IOS)) and a non-digital (tray and putty (T&P)) group. Parents considered IOS impressions to be less invasive, compared to T&P impressions. The clinician that took all the impressions considered the IOS to be less stressful compared to the T&P method. In two T&P patients, the impression was repeated because some important anatomical details were missing, in one case due to patient regurgitation during the first attempt. No impression was repeated, and any adverse event was reported in the IOS group. There were no significant differences between these two protocols in pre-surgical alveolar gap reduction and surgical challenge. The study results indicate that this digital protocol can accelerate the production process of the passive molding plate with an instantaneous transmission of the digital impression to the dental lab, maintaining the same accuracy level and clinical outcomes of classical techniques and reducing the invasiveness of impression taking, avoiding any risk of impression material ingestion or inhalation.

Fabrication of Nasoalveolar Molding Devices for the Treatment of Cleft Lip and Palate, Using Stereolithography Additive Manufacturing Processes and Computer-Aided Design Manipulation Software.

Nasoalveolar molding (NAM) is a presurgical orthopedic treatment modality that attempts to reorient misaligned bony and soft tissue structures in patients with clefting of the lip and palate. The NAM devices are implemented prior to surgical intervention in order to minimize the gap across the cleft and thereby reduce tension across the eventual repair. Currently, NAM devices are fabricated in a laboratory and then refined chairside by the provider. The present article describes the potential of three-dimensional (3D) printing and computer-aided design (CAD) software for the fabrication of NAM devices. A workflow was developed to demonstrate the use of 3D printing and CAD software to design NAM devices. This workflow encompasses scanning an impression into CAD software, performing a series of manipulations, and then printing the digital model. To test the workflow, a cleft palate plaster model was scanned into CAD software. Through a series of linear and angular freeform manipulations of the body, the model was modified to display a cleft with a reduced alveolar gap. Sequential molding devices were produced which would gradually apply pressure to targeted areas of hard and soft tissue until the cleft is minimized. The resulting devices are printed using a stereolithography printer. The use of 3D printing and CAD software shows promise in improving the accuracy, speed, and cost-effectiveness of designing NAM devices. The accuracy and flexibility from digitally visualizing the manipulations made to an appliance before its creation can result in a more personalized device for the patient.

Presurgical Orthopedic Treatment Using Modified Nostril Retainers in Patients With Unilateral Cleft Lip With or Without Cleft Palate.

This study aimed to present a new technique for presurgical orthopedic treatment of patients with unilateral cleft lip with or without cleft palate (UCL±P) by means of modified nostril retainers manufactured using a special mold with soft acrylic or orthodontic acrylics material. Nasal molding with the modified nostril retainer is considerably effective and comfortable for the patient.

Presurgical cleft lip and palate orthopedics: an overview.

Patients with cleft lip and/or palate go through a lifelong journey of multidisciplinary care, starting from before birth and extending until adulthood. Presurgical orthopedic (PSO) treatment is one of the earliest stages of this care plan. In this paper we provide a review of the PSO treatment. This review should help general and specialist dentists to better understand the cleft patient care path and to be able to answer patient queries more efficiently. The objectives of this paper were to review the basic principles of PSO treatment, the various types of techniques used in this therapy, and the protocol followed, and to critically evaluate the advantages and disadvantages of some of these techniques. In conclusion, we believe that PSO treatment, specifically nasoalveolar molding, does help to approximate the segments of the cleft maxilla and does reduce the intersegment space in readiness for the surgical closure of cleft sites. However, what we remain unable to prove equivocally at this point is whether the reduction in the dimensions of the cleft presurgically and the manipulation of the nasal complex benefit our patients in the long term.

Morphological alveolar changes with pre-surgical orthopedic treatment of the unilateral cleft lip and palate

Morphological alveolar changes with pre-surgical orthopedic treatment of the unilateral cleft lip and palate

Nasoalveolar Morphology Following Presurgical Orthopedic Treatment in Unilateral Cleft Lip Alveolus and Palate Infants

Nasoalveolar Morphology Following Presurgical Orthopedic Treatment in Unilateral Cleft Lip Alveolus and Palate Infants

Evaluation of a Three-Dimensional Stereophotogrammetric Method to Identify and Measure the Palatal Surface Area in Children With Unilateral Cleft Lip and Palate.

To assess a three-dimensional (3D) stereophotogrammetric method for area delimitation and evaluation of the dental arches of children with unilateral cleft lip and palate (UCLP). Obtained data were also used to assess the 3D changes occurring in the maxillary arch with the use of orthopedic therapy prior to rhinocheiloplasty and before the first year of life. Within the collaboration between the Università degli Studi di Milano (Italy) and the University CES of Medellin (Colombia), 96 palatal cast models obtained from neonatal patients with UCLP were analyzed using a 3D stereophotogrammetric imaging system. The area of the minor and greater cleft segments on the digital dental cast surface were delineated by the visualization tool of the stereophotogrammetric software and then examined. "Trueness" of the measurements, as well as systematic and random errors between operators' tracings ("precision") were calculated. The method gave area measurements close to true values (errors lower than 2%), without systematic measurement errors for tracings by both interoperators and intraoperators (P > .05). Statistically significant differences (P < .05) were noted for alveolar segment and time. Maxillary segments have the potential for growth during presurgical orthopedic treatment in the early neonatal period. The cleft segment delimitation on digital dental casts and area measurements by the 3D stereophotogrammetric system revealed an accurate (true and precise) method for evaluating the stone casts of newborn patients with UCLP.

Prevalence and management of natal/neonatal teeth in cleft lip and palate patients.

Objective:The aim of this study was to determine the prevalence and distribution of natal/neonatal teeth in infants with cleft lip and palate (CLP) according to gender, involving jaw and side and to show the management of some cases.Materials and Methods:A retrospective study was carried out on medical history and photographic records of 69 infants with CLP, who were treated at the CLP clinic of Yeditepe University between years 2014–2015. The presence of neonatal teeth was determined, and if present the gender, type of cleft, and position were recorded. Statistical analysis was performed.Results:Neonatal teeth were observed in 7% of the study group. No significant differences were found between cleft types and gender (P > 0.05). The prevalence of neonatal teeth in bilateral, unilateral and isolated cleft type was 16.5%, 6.5%, and none, respectively. All neonatal teeth were located in the maxilla and on the cleft-side (100%).Conclusion:The presence of natal/neonatal teeth in infants with CLP was not rare. In all of these cases the teeth were located adjacent to the cleft region. In isolated palatal cleft, where the alveolar region including the teeth buds are away from the cleft, no neonatal teeth were observed. It may be concluded that neonatal teeth in infants with CLP are frequently present and located inside the borders of the presurgical orthopedic treatment (POT) plate. Therefore, if possible, immediate extraction of the neonatal teeth is advised or if not possible because of systemic health reasons, modifications of the plate are required.