Presurgical Orthopedics Research Articles

A Dual-Layered 3D-Printed Appliance for Pre-Surgical Orthopedics in Infants with Cleft Lip and Palate

A Dual-Layered 3D-Printed Appliance for Pre-Surgical Orthopedics in Infants with Cleft Lip and Palate

Early functional restoration in cleft patients by presurgical infantile orthopedics with follow up

Cleft lip and palate present significant surgical challenges, particularly in cases of extensive clefts associated with severe nasolabial deformities. This case series focuses on the role of presurgical naso alveolar molding (PNAM) in improving surgical outcomes by reducing cleft deformities and enhancing facial symmetry. PNAM, combined with nasal stenting and presurgical orthopedics, aids in aligning the segments of the alveolar cleft and correcting nasal cartilage asymmetry. The study involved bilateral and unilateral cleft repairs, utilizing the Randall's modification of tennison triangular flap for unilateral cases and the Millard-Mulliken procedure for bilateral full clefts. Precise preoperative marking, meticulous tissue rearrangement, and multi-layer closure were key to achieving optimal results. Postoperative care included close monitoring, with skin sutures removed on the fifth day. The results align with existing literature, demonstrating the effectiveness of PNAM in narrowing the cleft and achieving nasal symmetry. This case series highlights the importance of early intervention and the application of PNAM plates in the comprehensive treatment of cleft lip and palate, contributing to favorable outcomes in reconstructive surgery.

A Modified 270 Degree Closure Technique to Address the Prominent or Locked-Out Premaxilla in Bilateral Cleft Palate Repair.

The bilateral cleft deformity with a prominent or 'locked-out' premaxilla presents one of the most challenging repairs in cleft surgery. Despite its relative frequency, traditional hard palate repair techniques fail to fully address this deformity and expose surgeons to the risk of development of a large anterior fistula when flaps cannot approximate the premaxilla. This greatly increases morbidity for the patient and creates unnecessary challenges during fistula repair or alveolar cleft bone graft later in childhood. The 270° closure technique extends the nasal closure 270° around the premaxilla, continuing the hard palate repair through the alveolar clefts. This technique has been performed on 41 patients with mean follow up of 10.8 years. The repair was successful in 93% of patients with 3 patients developing palatal fistulae, all posterior to the 270° closure. The 270° cleft palate repair around the prominent premaxilla fills a void in the literature for managing the immense challenge of this deformity. When presurgical orthopedics are not a viable option, this approach can minimize the risk of large or complex fistula formation posterior to the premaxilla.

Assessment of knowledge, awareness, and attitude about the current treatment protocols for newborns with cleft lip and palate among obstetrician-gynecologists and radiologists – A questionnaire survey

This study aimed to assess the knowledge, awareness, and attitudes of Obstetricians-gynaecologists and radiologists regarding current treatment regimens for CLP and their perspectives on elective termination of pregnancy for the same cause. A 15-question survey was conducted among 68 gynaecologists and 52 radiologists who were registered with the Medical Council of India. The questionnaire, distributed via social network, contained 19 questions, including knowledge, awareness, and attitude regarding CLP, presurgical orthopaedics, and pregnancy termination. Spearman rank correlation was used to assess construct validity, and a Chi-square test with a significance level of 0.05 was used to compare the responses between both groups. The study showed that about 89% of gynaecologists and 92.3% of radiologists can identify CLP during the initial assessment of the foetus using ultrasound technique, whereas 30.90% of gynaecologists and 36.50% of radiologists have encountered elective termination of pregnancy due to CLP. While 89.70% of gynaecologists and 88.50% of radiologists do not know pre-surgical orthopaedic procedures for CLP. No statistically significant difference existed in the knowledge level about CLP and its treatment regimens among both groups. The awareness and attitude among the OB-GYNs, and radiologists on prenatal detection of CLP was found to be highly significant. At the same time, there was limited knowledge among these specialists about CLP and its management.

Model analysis through two-dimensional evaluation of alveolar changes of untreated unilateral cleft lip and palate infants

The primary objective of therapeutic interventions for unilateral cleft lip and palate (UCLP) is to reestablish typical role and anatomy. The efficacy of nasoalveolar molding relies on the age at which it is initiated, thus early initiation is recommended. Evaluating the success of presurgical orthopedics involves assessing the after-treatment maxillary arch form and proportions in UCLP infants and comparing them to age-matched infants without clefts. Untreated UCLP cases exhibit various changes in the transverse and angular dimensions of the alveolar segment. Utilizing digital analysis of UCLP plaster casts through Photoshop software (version 24.0.0) can serve as an alternative method to predict changes in cleft width, arch width, and angular measurements in untreated cases.

3D nasoalveolar moulding: A complete digital workflow model

Nasoalveolar moulding (NAM) is a paradigm shift from the presurgical orthopaedics used extensively over the past 20 years in infants with cleft lip and palate. It has been proposed that the gap between the clefted segments be filled up before surgical repair via presurgical nasoalveolar moulding. To attain the best practical and aesthetic results, it is a straightforward yet effective treatment that must be started at the appropriate age and time. In order to enhance treatment outcomes, convenience of use, compliance, and cost-effectiveness, recent developments in NAM therapy have focused on implementing changes to the nasal stent or intraoral moulding plate. Specifically, 3D technology has been used to improve the efficiency of NAM device design and develop standardised, objective methods of determining progressive morphological changes during therapy. The article discusses various methods that use 3D printing technology to produce tangible components from a virtual therapeutic strategy. It also looks at how developments in computational methods and printing materials could open up novel opportunities for computer-assisted NAM therapy.

Digital nasoalveolar molding through presurgical orthopedics in newborns/infants with cleft lip and palate: A comprehensive review and case study.

This study aims to provide a comprehensive review and case study about the advantages and disadvantages of the application of digital technologies in presurgical orthopedics in newborns/infants with cleft lip and palate (CLCP). Positive changes in the nasal anatomy, maxillary arch, and cleft width could be achieved. Three representative cases of newborns/infants with CLCP were managed using the presurgical newborn/infant orthopedics (PSIO) approach. The patients were diagnosed and treated. Detailed descriptions of the impression procedures and PSIO appliance construction and placement were provided for each case. Case 1 utilized traditional impression techniques, Case 2 employed a semi-digitalized approach with intraoral digital scanning, and Case 3 utilized a completely digitalized method for appliance construction. Positive changes in maxillary arch dimensions and cleft width reduction were observed in all cases. The management of CLCP in newborns and infants poses a complex challenge with profound implications. The PSIO approach not only facilitates reconstructive surgery but also enhances overall quality of life. Digital tools, like specialized optical scanners and 3D printing, revolutionize the PSIO process, making it more efficient and patient-friendly. Clinical benefits include improved facial morphology, esthetics, feeding, speech, and optimized future surgical results. Despite ongoing efficacy debates, global adoption as the initial surgical approach underscores its value. The integration of digital technologies offers new hope for patients and families, promising a brighter future for those affected by this congenital condition.

Dental Arch Relationships of Saudi Children with Unilateral Cleft Lip and Palate.

To determine dental arch relationships of Saudi children born with nonsyndromic complete unilateral cleft lip and palate (UCLP). This is a retrospective cohort study that comprised dental study models of 74 UCLP Saudi children aged 8-10 years who were recruited from 14 referral cleft centers. All participants had their cleft lip and palate repaired with no history of alveolar bone graft or any orthodontic treatment. Dental arch relationships of UCLP patients were assessed using the Great Ormond Street, London, and Oslo (GOSLON) Yardstick-a clinical tool that categorizes dental relationships of UCLP children into five discrete grades from I to V. The reliability of the rating was assessed with weighted kappa (κ) statistics. Three children (4.1%) had excellent surgical outcomes (grade I), 18 children (24.3%) filled into grade II (good outcome), 22 subjects (29.7%) had grade III (fair outcome), 27 children (36.5%) had grade IV (poor outcome), and 4 subjects (5.4%) were ranked as having very poor outcomes (grade V). The mean GOSLON score was 3.39. Intrarater and interrater agreements were high indicating good reproducibility. Based on the dental arch relationships, the treatment outcome of UCLP Saudi children was unsatisfactory, with a mean GOSLON score of 3.39. Delayed palate repair and the use of presurgical orthopedics may be considered in the future for cleft deformity management. To address the effect of particular cleft surgical protocol on dental arch relationships of UCLP patients. How to cite this article: Alforaidi S, Zreaqat M, Hassan R. Dental Arch Relationships of Saudi Children with Unilateral Cleft Lip and Palate. J Contemp Dent Pract 2023;24(12):987-990.

Presurgical orthopedics in patient with cleft lip and palate without cheiloplasty at one year of age.

Introduction. Cleft lip/palate (CLP) occurs due to failure of fusion of facial processes at an early stage of embryonic development. The use of pre-surgical orthopedics helps us to correct the bone collapse that patients with CLP may present, as well as stimulate the growth of the palatal segments, with use beginning in the first hours of life. Due to the pandemic caused by COVID, many patients did not receive care, generating a need for treatment focused on their characteristics. Aim. Generate transversal development in a 1-year-old male patient and rotate the left maxillary segment to conform the arch, and thus, favor the prognosis of surgery for the patient with cleft lip and palate without cheiloplasty at one year of life. Description of the case. Male patient with cleft lip and palate without cheiloplasty at one year of age presents to cleft lip and palate clinic YOU HAVE TO SMILE, JOIN EFFORTS. He refers to having been treated with pre-surgical orthopedics. Clinically, a cleft lip and palate is observed, in addition to the collapsed left maxillary segment, generating a lack of continuity and arch perimeter. The treatment phase consisted of a removable plate joined in its central part by three helixes, to rotate the left maxillary segment. Results. An adequate maxillary development was generated and the arch was shaped. conclusions. It is important to highlight the characteristics of each case in order to generate a treatment plan suitable for the needs of the patient, since this improves the prognosis and post-surgery.

The use of Korat-modified nasoalveolar molding devices in patients with unilateral complete cleft lip and palate with a 5-year follow-up

The nasoalveolar molding (NAM) appliance has been the appliance of choice for pre-surgical orthopedics to improve nasal and lip morphology, and optimally align the alveolar segments before cheiloplasty. However, the appliance has some limitations, including its complexity and long clinical chair time for appliance adjustments. In this case report, we present a patient treated for a right complete cleft lip and palate using three types of Korat modification for NAM with a 5-year follow-up. This study demonstrated that the Korat-NAM improved the aforementioned issues and was suitable for patients at different stages before and after lip and palate repair.

Perception and Attitude of Parents of Children With Orofacial Clefts Regarding the Use of Presurgical Orthopedics and Feeding Obturators.

This study aims to evaluate the parents' attitude and their perception regarding the management of orofacial cleft (OFC) children with presurgical nasoalveolar molding (PNAM), DynaCleft and/or feeding obturators. A cross-sectional, descriptiveand observational retrospective survey-based study was conducted among parents of OFC children treated with PNAM, DynaCleft and/or feeding obturators who attended a primary dental health care center in Al-Madinah, Saudi Arabia, from 2019 to 2023. A validated questionnaire was used after translating it from English to Arabic. The questionnaire consisted of 32 questions divided into two sections. The first section covers parents' sociodemographic data and OFC risk factors. The second section evaluates the parents' perception regarding the use of presurgical orthopedics (PSO) for OFC repair. The questionnaire was completed through telephone interviews carried out by two investigators with the parents of OFC children. Out of 142 parents of OFC children, only 40 parents and their children met the inclusion criteria of the study. Most parents (95%) reported their satisfaction with the treatment and stated that they would encourage other parents of OFC children to use PSO. This study concluded that parents of OFC children had a positive attitude towardPSO treatment. Based on the positive outcomes of PSO treatment reported in the current study and previous literature, PSO should be considered as a routine treatment in the early management of orofacial clefts.

The Effects of NAM on the Symmetry of the Face and Maxillary Arch in Babies With Unilateral Cleft.

The study aimed to evaluate the effect of nasoalveolar molding (NAM) therapy through reverse engineering, or its absence, to obtain symmetry of the face and maxillary arch. Twenty-six babies with unilateral cleft lip and palate received treatment with NAM, and 12 babies with unilateral cleft lip and palate without presurgical orthopedics (control group). Patients were molded and photographed in 2-stages: the first month of life (T1/pre) and after the use of NAM/before the cheiloplasty (T2/post). In the digital models, the analyses performed were arch perimeter, arch length, and labial frenulum angle. The photographs allowed us to analyze nasal width, mouth width, columella angle, and nostril area. The results demonstrated that there was an increase in arch perimeter and arch length in control and NAM groups in the T2 period in comparison to T1. Labial frenulum angle was reduced in the NAM group compared to the NAM-T1 and control-T2 periods. Treatment with NAM yielded a reduction in nasal width in the period of T2 compared with T1. Columella angle was enhanced after NAM use in T2 and, was different from control group. The nostril area was reduced in the NAM group in T2 compared with control group. Nasoalveolar molding therapy reduced the labial frenulum angle, contributing to a reduction in the extension of the cleft. The NAM protocol improved facial symmetry, mainly through nasal effects, whereas the absence of orthopedic therapy yielded a commitment to the face and maxillary arch symmetry.

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.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity.

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP). A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP. Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery. Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol. Therapeutic, III.

Comparative Study of Maxillary Growth in Patients With Unilateral Cleft Treated With and Without Pre-Surgical Orthopedics.

Compare the maxillary growth of patients with Unilateral Cleft treated with pre-surgical Functional Maxillary Orthopedic (FMO) and that of who underwent a surgical procedure with no previous use of appliances. Prospective study, the patients were divided into 2 groups. G1, was composed of 12 patients who received no pre-surgical intervention and cheilorhinoplasty at 6 months of age and G2, included 12 patients treated using Pre-Surgical Funtional Maxilary Orthopedic; they underwent no surgery during the study. Measurements were taken at three times: before the first month of life, at 6 months and between 9-12 months of age. Cleft distance (anterior, medium and posterior), maxillary width (anterior, medium and posterior) and minor and major segment width were analyzed. Alveolar Cleft decrease was 79.82% in G1 and 52% in G2. Posterior Cleft decrease was 24.1% in G1 and 41.77% in G2. Greater Segment Width increase was 24.53% for the patients in G1, and 37.47% for the patients in G2. As for Inter Canine Width, a decrease of 5.16% in G1 and an increase of 9.19% in G2 were found. Medium Arch Width only increased in a statistically significant manner in G2 9.02%. Surgery allowed for the closure of the alveolar cleft. FMO made it possible to close the anterior and the posterior clefts through the growth of the maxillary segments, increased the transverse growth of the maxilla and could prevent maxillary collapse. Each team must individually evaluate whether to indicate or not the use of preoperative orthopedics.

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.

A Point-of-Care Digital Workflow for 3D Printed Passive Presurgical Orthopedic Plates in Cleft Care.

Cleft lip and palate are one of the most common congenital craniofacial malformations. As an initial treatment, presurgical orthopedics is considered standard treatment at many cleft centers. Digital impressions are becoming feasible in cleft care. Computer-aided design (CAD) and three-dimensional (3D) printing are manufacturing standards in dentistry. The assimilation of these technologies has the potential to alter the traditional workflow for the fabrication of customized presurgical orthopedic plates. We present a digital workflow comprising three steps: 3D digital image acquisition with an intraoral scanner, open-source CAD modeling, and point-of-care 3D printing for the fabrication of personalized passive presurgical plates for newborns with cleft lip and palate. The digital workflow resulted in patient-related benefits, such as no risk of airway obstruction with quicker data acquisition (range 1–2.5 min). Throughput time was higher in the digital workflow 260–350 min compared to 135 min in the conventional workflow. The manual and personal intervention time was reduced from 135 min to 60 min. We show a clinically useful digital workflow for presurgical plates in cleft treatment. Once care providers overcome procurement costs, digital impressions, and point-of-care 3D printing will simplify these workflows and have the potential to become standard for cleft care.

Bilateral Cleft Lip Repair: Lessons from History

After studying this article, the participant should be able to: 1. Describe the bilateral cleft lip and nasal deformity and associated anatomical variations. 2. Understand the history and evolution of the bilateral cleft lip repair. 3. Understand the key principles of the surgical repair. This article describes characteristics of the bilateral cleft lip and nasal deformity and its management, including presurgical orthopedics, operative techniques, and postsurgical care.

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

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. 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. 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. 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.

Nasoalveolar molding: A review

Nasoalveolar molding represents a paradigm shift from the traditional presurgical orthopedics in cleft lip and palate patients which has been applied increasingly in the past two decades. Nasoalveolar moulding (NAM) is a nonsurgical way to reshape and align the gingiva, lip and nostrils to reduce the severity of the cleft before the conventional cleft lip and palate surgery. It requires an interdisciplinary approach for achieving the best results. This article is a review of recent literature apropos of objectives, technique, appliance design and adjustments and complications of this technique.