Using "Real-World Data" to Study Cleft Lip/Palate Care: An Exploration of Speech Outcomes from a Multi-Center US Learning Health Network.

OBJECTIVE: To assess the ability of a cleft-specific multi-site learning health network registry to describe variations in cleft outcomes by cleft phenotypes, ages, and treatment centers. Observed variations were assessed for coherence with prior study findings. DESIGN: Cross-sectional analysis of prospectively collected data from 2019-2022. SETTING: Six cleft treatment centers collected data systematically during routine clinic appointments according to a standardized protocol. PARTICIPANTS: 714 English-speaking children and adolescents with non-syndromic cleft lip/palate. INTERVENTION: Routine multidisciplinary care and systematic outcomes measurement by cleft teams. OUTCOME MEASURES: Speech outcomes included articulatory accuracy measured by Percent Consonants Correct (PCC), velopharyngeal function measured by Velopharyngeal Competence (VPC) Rating Scale (VPC-R), intelligibility measured by caregiver-reported Intelligibility in Context Scale (ICS), and two CLEFT-Q™ surveys, in which patients rate their own speech function and level of speech distress. RESULTS: 12year-olds exhibited high median PCC scores (91-100%), high frequency of velopharyngeal competency (62.50-100%), and high median Speech Function (80-91) relative to younger peers parsed by phenotype. Patients with bilateral cleft lip, alveolus, and palate reported low PCC scores (51-91%) relative to peers at some ages and low frequency of velopharyngeal competency (26.67%) at 5 years. ICS scores ranged from 3.93-5.0 for all ages and phenotypes. Speech Function and Speech Distress were similar across phenotypes. CONCLUSIONS: This exploration of speech outcomes demonstrates the current ability of the cleft-specific registry to support cleft research efforts as a source of "real-world" data. Further work is focused on developing robust methodology for hypothesis-driven research and causal inference.

Aesthetic Outcomes in Cleft Care: Exploring Patterns in Patient-Reported Outcomes Across Adolescence.

BACKGROUND: For patients with cleft lip/palate, adolescence is a time of maxillofacial growth and complex psychosocial stressors. The personal significance of facial differences may change, making patient-reported outcomes measures (PROMs) invaluable. In this study, we use several scales from CLEFT-Q™ and FACE-Q™ to explore how aesthetic outcomes differ by age and by sex among patients with unilateral cleft lip/palate. MATERIALS AND METHODS: This was a multi-center, cross-sectional study that prospectively collected CLEFT-Q™ and FACE-Q™ data across six cleft treatment centers during clinical appointments from 2019-2022. Subjects were aged 8-22y with unilateral cleft lip, alveolus, and palate who had not undergone tertiary operative care (maxillary advancement or septorhinoplasty) at the time of survey response. Data cross-sections were prepared by age (8-10y, 11-13y, 14y+), by sex, and by age and sex together. RESULTS: Older age groups reported poorer aesthetic outcomes and worse appearance-related distress compared to younger groups. Although male and female subjects reported similar aesthetic outcomes, female subjects reported more appearance-related distress. When considered simultaneously, age and sex appear to have an intersectional impact on perceived aesthetic outcome and appearance-related distress during adolescence. CONCLUSIONS: This exploratory project suggests that patients with cleft lip/palate may perceive worsening of facial aesthetic throughout the course of adolescence, the exact pattern of which may be dependent on sex. Future work will evaluate this hypothesis using longitudinal cohorts. It will be important to investigate psychosocial factors that may impact these outcomes, and also to quantify the impact of tertiary operative care on these outcomes.

Unilateral mydriasis after maxillary osteotomy: a case series and review of the literature.

PURPOSE: To present 4 cases of unilateral mydriasis associated with orthognathic surgery and to review the differential diagnosis and management related to this condition. MATERIALS AND METHODS: Four cases of unilateral mydriasis associated with orthognathic surgery were identified from the authors' institutional experience. All maxillary osteotomies performed by the authors' department from 2001 to 2013 were identified based on Current Procedural Terminology codes; 4 cases of unilateral mydriasis were found. Cases are presented and the literature is reviewed. RESULTS: Two male and 2 female patients with an age range of 16 to 34 years developed unilateral mydriasis after maxillary osteotomy; the estimated prevalence is 0.004%. Although the precise cause can be difficult to determine, in this series 1 case was attributable to swelling affecting contents of the superior orbital fissure, 1 was related to edema or medications, and 2 were pharmacologically induced. CONCLUSION: Although rare, a review of the differential diagnosis for and management of unilateral mydriasis associated with orthognathic surgery is pertinent to those who perform corrective jaw surgery.

Multimodal protocol reduces postoperative nausea and vomiting in patients undergoing Le Fort I osteotomy.

PURPOSE: To assess the impact of a multimodal antiemetic protocol on postoperative nausea and vomiting (PONV) after Le Fort I osteotomy. MATERIALS AND METHODS: Consecutive patients undergoing Le Fort I osteotomy with or without additional procedures at a single academic institution were recruited as the intervention cohort for an institutional review board-approved prospective clinical trial with a retrospective comparison group. The intervention cohort was managed with a multimodal antiemetic protocol, including total intravenous anesthesia; prophylactic ondansetron, steroids, scopolamine, and droperidol; gastric decompression at surgery end; opioid-sparing analgesia; avoidance of morphine and codeine; prokinetic erythromycin; and fluids at a minimum of 25 mL/kg. The comparison group consisted of consecutive patients from a larger study who underwent similar surgical procedures before protocol implementation. Data, including occurrence of PONV, were extracted from medical records. Data were analyzed in bivariate fashion with the Fisher exact and Wilcoxon rank-sum tests. Logistic regression was used to compare the likelihood of nausea and vomiting in the 2 cohorts after controlling for demographic and surgical characteristics. A P value less than .05 was considered significant. RESULTS: The intervention (n = 93) and comparison (n = 137) groups were similar in gender (58% and 65% female patients; P = .29), race (72% and 71% Caucasian; P = .85), age (median, 19 and 20 years old; P = .75), proportion of patients with known risk factors for PONV (P = .34), percentage undergoing bimaxillary surgery (60% for the 2 groups), and percentage for whom surgery time was longer than 180 minutes (63% and 59%; P = .51). Prevalence of postoperative nausea was significantly lower in the intervention group than in the comparison group (24% vs 70%; P < .0001). Prevalence of postoperative vomiting was likewise significantly lower in the intervention group (11% vs 28%; P = .0013). The likelihood that patients in the comparison group would develop nausea was 8.9 and that for vomiting was 3.7 times higher than in the intervention group. CONCLUSION: This multimodal protocol was associated with substantially decreased prevalence of PONV in patients undergoing Le Fort I osteotomy.

Pain with pericoronitis affects quality of life.

PURPOSE: To assess the association between patients' pericoronitis pain symptoms and quality-of-life (QOL) outcomes for lifestyle and oral function. PATIENTS AND METHODS: Subjects (American Society of Anesthesiologists health risk assessment level I or II) with mild symptoms of pericoronitis were enrolled in a study approved by the institutional review board and asked to complete a QOL instrument specifically for third molar problems covering lifestyle, oral function, and pain. Subjects assessed lifestyle and oral function using a 5-point Likert-type scale, ranging from "no trouble" (score, 1) to "lots of trouble" (score, 5), and worst and average pain using a 7-point Likert-type scale, ranging from "no pain" (score, 1) to "worst pain imaginable" (score, 7). Pain levels reported at enrollment were compared with QOL outcomes for lifestyle and oral function using Spearman correlation coefficients. Correlations of at least 0.6 were considered clinically quite important, and correlations of at least 0.4 were considered clinically important. Associations between these outcome measurements were considered statistically significant at a P value less than .05. RESULTS: Most of the 113 subjects were Caucasian (51%), women (56%), 23 years old or younger (58%), and well educated (91% with at least some college). Mean pain levels ± standard deviation were low (worst pain, 3.3 ± 1.5; average pain, 2.4 ± 1.2). All pain outcomes were significantly associated with items in the lifestyle and oral function domains (P < .01). Clinically important correlations were seen between pain outcomes and daily routine, social life, eating a regular diet, chewing food, and talking (P < .0001). CONCLUSIONS: Clinically important correlations existed between subjects' pericoronitis pain and lifestyle and oral function, associations not often considered by clinicians or policy makers.

Monitoring for periodontal inflammatory disease in the third molar region.

PURPOSE: To assess changes at 2-year intervals in the periodontal status of the third molar region in participants enrolled with asymptomatic third molars and no clinical evidence of third molar region periodontal pathology. PARTICIPANTS AND METHODS: The included participants who presented with a healthy periodontal status (all probing depths [PDs], <4 mm) in the third molar region, defined as distal of second molars and around adjacent third molars, were from a larger longitudinal study of participants with asymptomatic third molars. Full-mouth periodontal PD data from 6 sites per tooth were obtained clinically at enrollment and at subsequent 2-year intervals. Data were aggregated to the patient level. Outcome variables were the presence or absence of periodontal pathology, defined as at least 1 PD of at least 4 mm in the third molar region. RESULTS: One hundred twenty-nine participants had a third molar region PD shallower than 4 mm at enrollment. Most participants were Caucasian (85%), women (60%), younger than 25 years (62%), educated beyond high school (84%), and with good oral health habits. At 6 years, excluding the 61 participants lost to follow-up, 47% participants had had third molars removed, 21% had developed at least 1 PD of at least 4 mm in the third molar region since enrollment, and 32% retained the periodontal status at enrollment (all PDs in third molar region, <4 mm). Demographic characteristics were not statistically different for participants followed for 6 years compared with those lost to follow-up. CONCLUSIONS: Although not all participants could be followed for 6 years after enrollment or chose to retain third molars, one third of participants maintained the third molar region periodontal status assessed at baseline for 6 years after enrollment; no clinical evidence of pathology developed over time.

Effect of Class III bone anchor treatment on airway.

OBJECTIVES: To compare airway volumes and minimum cross-section area changes of Class III patients treated with bone-anchored maxillary protraction (BAMP) versus untreated Class III controls. MATERIALS AND METHODS: Twenty-eight consecutive skeletal Class III patients between the ages of 10 and 14 years (mean age, 11.9 years) were treated using Class III intermaxillary elastics and bilateral miniplates (two in the infra-zygomatic crests of the maxilla and two in the anterior mandible). The subjects had cone beam computed tomographs (CBCTs) taken before initial loading (T1) and 1 year out (T2). Twenty-eight untreated Class III patients (mean age, 12.4 years) had CBCTs taken and cephalograms generated. The airway volumes and minimum cross-sectional area measurements were performed using Dolphin Imaging 11.7 3D software. The superior border of the airway was defined by a plane that passes through the posterior nasal spine and basion, while the inferior border included the base of the epiglottis to the lower border of C3. RESULTS: From T1 to T2, airway volume from BAMP-treated subjects showed a statistically significant increase (1499.64 mm(3)). The area in the most constricted section of the airway (choke point) increased slightly (15.44 mm(2)). The airway volume of BAMP patients at T2 was 14136.61 mm(3), compared with 14432.98 mm(3) in untreated Class III subjects. Intraexaminer correlation coefficients values and 95% confidence interval values were all greater than .90, showing a high degree of reliability of the measurements. CONCLUSION: BAMP treatment did not hinder the development of the oropharynx.

Difference in maxillary sinus volumes of patients with cleft lip and palate.

BACKGROUND AND OBJECTIVE: Sinus disease is noted to be common in patients with cleft lip and palate. Many have wondered if anatomic differences are a cause or at least a contributor of this. In this sense, comparisons of sinus volumes of patients with different craniofacial clefts may be helpful to determine possible differences from normal. Thus, the present study aimed to evaluate and compare the maxillary sinus volume of patients with unilateral (UCLP) and bilateral (BCLP) cleft lip and palate to control, i.e. non-cleft patients, using cone beam computed tomography (CBCT) images. METHODS: The sample consisted of 30 subjects with UCLP, 15 with BCLP and 15 control individuals (non-cleft). Each maxillary sinus was assessed three-dimensionally, segmented and its volume was calculated. The comparison between right and left sinus was performed by Student t-test, and the differences between the control and cleft groups were calculated using ANOVA. RESULTS: No statistical differences were found when the sides were compared (p>0.05). In relation to the assessment among groups, all comparisons had statistically significant differences (p<0.05), with the UCLP group presenting the lowest sinus volume. CONCLUSION: UCLP individuals present maxillary sinuses with smaller volumes, without differences found between the cleft and non-cleft side. BCLP subjects also present a reduction in the volume when compared to a control sample, but the average sinus volume is larger than in UCLP patients.

Orbital anatomy for the surgeon.

An anatomic description of the orbit and its contents and the eyelids directed toward surgeons is the focus of this article. The bone and soft tissue anatomic nuances for surgery are highlighted, including a section on osteology, muscles, and the orbital suspensory system. Innervation and vascular anatomy are also addressed.

Craniofacial and orbital dermoids in children.

Dermoid cysts are congenital lesions that commonly arise from nondisjunction of surface ectoderm from deeper neuroectodermal structures. They tend to be found along planes of embryonic closure. Classification by site is helpful for diagnostic planning and surgical treatment. A distinction can be made between frontotemporal, orbital, frontoethmoidal, and calvarial lesions. The risk of extension into deeper tissues must be determined before surgical intervention. Simple lesions are amenable to direct excision. Deeper lesions often require a coordinated surgical approach between a neurosurgeon and craniofacial surgeon after thorough radiographic imaging. Follow-up through the developmental years is recommended for complex dermoid lesions.

Changes over time in the periodontal status of young adults with no third molar periodontal pathology at enrollment.

PURPOSE: To assess changes in periodontal status over time in subjects with all third molar region periodontal probing depths (PDs) of less than 4 mm at enrollment. PATIENTS AND METHODS: Subjects were a subsample of young adults enrolled with 4 asymptomatic third molars in an institutional review board-approved longitudinal study. Full-mouth periodontal PD data, 6 sites per tooth, were measures of periodontal status. Data were aggregated to subject and jaw levels. A PD of 4 mm or greater was considered an indicator variable for periodontal pathology. Subjects were classified according to PD at follow-up: all PDs of less than 4 mm or at least 1 PD of 4 mm or greater. The demographic differences and the third molar anatomic position at baseline were compared to assess whether enrollment factors were related to the changes in periodontal pathology. The level of significance was set at .05. RESULTS: One hundred six subjects had all third molar region PDs of less than 4 mm at enrollment and were aged 25 years on average. Of these, 38% had a change in third molar region periodontal status, with at least 1 third molar region PD of 4 mm or greater detected at a median follow-up of 4.1 years (interquartile range, 2.4-5.9 years). A PD of at least 4 mm was detected significantly more often in the mandibular third molar region than in the maxillary third molar region (P < .01). No significant differences in age, gender, education, or length of follow-up were detected between the 40 subjects with a change in periodontal status in the third molar region and the 66 subjects who remained periodontally healthy (P > .05). At follow-up, 50% of subjects with at least 1 PD of 4 mm or greater in the third molar region had at least 1 PD of 4 mm or greater in non-third molar regions as compared with 15% of subjects with all third molar region PDs of less than 4 mm (P < .01). CONCLUSIONS: Periodontal pathology developing over time in healthy young adults was significantly more likely in the mandibular third molar region and mandibular non-third molars.

Cutaneous cysts of the head and neck.

PURPOSE: This article reviews the types of cutaneous cysts in patients referred to the Facial Lesion Clinic at John Peter Smith Hospital in Fort Worth, TX, and proposes effective treatment modalities based on lesion and patient variables. Cyst variables included proper identification, size of the lesion, and acute or chronic processes. Patient considerations included age, skin type, and location. Medical and social histories were not noted. PATIENTS AND METHODS: Eighty-two patients who had 1 or more cysts removed over the 5-year period from July 15, 1998 to July 14, 2003 were reviewed for age, gender, histologic diagnosis, anatomic location of the lesion, and complications. RESULTS: Patients with epidermal inclusion cysts (79%), followed by pilar cysts (9%), hidrocystomas and dermoid cysts (3% each), and multiple other diagnoses (less than 2%) were treated. Neither complications nor recurrent infections were reported during the 5-year interval. There were no recurrent cyst formations noted by return appointment. CONCLUSION: Cystic lesions of the head and neck may be treated effectively as long as they are correctly identified and treated in a specific manner.