The Validation of an Innovative Method for 3D Capture and Analysis of the Nasolabial Region in Cleft Cases.

OBJECTIVE: To validate a newly developed method for capturing 3-dimensional (3D) images of the nasolabial region for assessing upper lip scarring and asymmetry in surgically managed unilateral cleft lip and palate (UCLP) cases. DESIGN: Validation study, single cohort. MATERIALS AND METHODS: Eighteen surgically managed UCLP cases were recruited, the nasolabial region of each face was scanned using an intraoral scanner (IOS) to produce 3D images. The images were manually segmented to allow the calculation of surface area of the scar and upper lip asymmetry. Five professionals and 5 lay assessors subjectively evaluated the same images and graded the upper lip scarring and asymmetry at 2 separate occasions. The relationship between the subjective and objective assessments was evaluated. RESULTS: Moderate correlation was found between subjective and objective evaluations of the upper lip scarring and total asymmetry. The captured 3D images were of good quality for the objective measurements of lip asymmetry and residual scarring. Moderate to strong correlations were detected between the 2 panels (T ranging between 0.5 and 0.9) with no significant difference (P > .05) in the mean score of the subjectively evaluated parameters. CONCLUSION: The IOS is a useful tool for the capture of the nasolabial morphology. The captured 3D images are a reliable source for measuring lip asymmetry and scar surface area. The method has sufficient validity for routine clinical use and for objective outcome measures of the surgical repair of cleft lip.

An Innovative Assessment of the Dynamics of Facial Movements in Surgically Managed Unilateral Cleft Lip and Palate Using 4D Imaging.

OBJECTIVE: Assess facial asymmetry during maximum smile in patients with surgically managed unilateral cleft lip and palate (UCLP), using a dynamic 3-dimensional (3D) imaging (4-dimensional) system. DESIGN: Prospective 2 cohort comparative study. METHODS: Twenty-five surgically managed UCLP cases and 75 controls at 8 to 10 years of age were recruited. Facial movements during maximum smile were recorded using video stereophotogrammetry at a rate of 60 3D facial images per second. Maximum smile took approximately 3 seconds and generated 180 3D facial images for the analysis. A generic facial mesh which consists of more than 7000 quasi landmarks was used for the assessment of facial asymmetry at 5 key 3D frames representing the pattern of maximum smile. RESULTS: Statistically significant differences were seen regarding the magnitude of facial asymmetry between the UCLP group and the noncleft controls. Higher average asymmetry in the UCLP group was seen in the 3D frame midway between maximum smile and rest (frame 4) followed by the frame at peak expression of maximum smile (frame 3). The average magnitude of nasolabial asymmetry of the control group was within 0.5 mm in comparison with the UCLP cases which was about 1.8 mm. CONCLUSION: This study provided for the first time, an objective tool for analysis of the dynamics of muscle movements which provided an unprecedented insight into the anatomical basis of the residual dysmorphology. The research demonstrates the limitations of the primary lip repair in achieving symmetrical results and underpins the required refinements to improve the quality of surgical repair of cleft lip.

A multicentre audit to assess the effectiveness of the British Orthodontic Society 'Hold that Smile' retainer videos.

INTRODUCTION: Retention is a crucial part of orthodontic treatment; however, patients often do not wear their retainers as advised. The British Orthodontic Society developed the 'Hold that Smile' campaign in 2017, to improve patient knowledge about retention. Information is provided in two formats: a cartoon and a conventional film. OBJECTIVE: To assess whether patients find the 'Hold that Smile' videos useful and whether they improved patients' intended retainer wear. The gold standard was that 90% of patients should intend to wear their retainers in the long term after watching the videos. DESIGN: National multicentre audit. SETTING: Nine units in the UK. METHODS: Patients aged ⩾ 10 years, in fixed appliances or retention, watched the retainer videos and then completed a questionnaire that was designed specifically for this audit. Each unit collected data for approximately 30 patients. RESULTS: Data were collected for 278 patients in total. The average age was 17.9 years; 64.4% of patients were female and 35.6% were male. Most patients (86.3%) watched both videos and, of these, 44.1% preferred the film, 31.3% preferred the cartoon and 24.6% had no preference. The majority of patients (81.3%) felt that the film provided them with new information, compared with a lower percentage (48.5%) for the cartoon. More patients said they would recommend the film (76.3%) compared with the cartoon (63.3%). Before watching the videos, 77.0% of patients felt they knew about long-term retainer wear and 74.3% of those intended to wear their retainers in the long term. After watching the videos, 96.4% of all patients thought they would now wear their retainers long term. CONCLUSION: After watching the videos, there was a notable increase in the number of patients planning to wear their retainers long term and the gold standard was met. Therefore, these videos may be beneficial in improving understanding and compliance with retention.

The Clinical Application of Recombinant Human Bone Morphogenetic Protein 7 for Reconstruction of Alveolar Cleft: 10 Years' Follow-Up.

PURPOSE: The purpose of this study was to report on a 10-year assessment after the application of recombinant human bone morphogenetic protein 7 (rhBMP-7) for the reconstruction of alveolar clefts. PATIENTS AND METHODS: This study was conducted as a prospective phase II clinical trial on 9 unilateral and 2 bilateral alveolar clefts that received rhBMP-7 (Osigraft; Stryker Biotech, UK). The mean age of the patients at surgery was 10.4 years. At 6 months postoperatively, occlusal radiographs were taken to evaluate bone formation at the cleft site. Patients were followed within the routine cleft care pathway for 10 years to monitor the impact of bone morphogenetic protein 7 on orthodontic treatments and maxillary growth. Radiographs were taken according to the standard cleft care protocol. RESULTS: The radiographic assessment of the unilateral cleft lip and palate cases suggested good bone formation with a Kindelan score of grade 1 or 2. The bilateral alveolar cleft cases had a score of grade 3 or 4, indicating failure or partial failure. The children with successful grafts underwent a routine orthodontic follow-up without incident. The maxillary growth appeared to be similar to that in cases grafted with autogenous bone. No long-term complications and no abnormal pattern of bone formation were detected. CONCLUSIONS: The study provides unique evidence on the long-term safety of rhBMP-7 when applied at the area of skeletal immaturity for the reconstruction of alveolar clefts in children.

Validating the Clinical Use of the Modified Huddart and Bodenham Scoring System for Outcome in Cleft Lip and/or Palate.

OBJECTIVE: The aim of this study was to validate the clinical use of the modified Huddart and Bodenham scoring system for the measurement of maxillary arch constriction in children born with cleft lip and/or palate. DESIGN: The study design consisted of a reliability assessment between clinical and study model scoring. SETTING: The study was carried out in cleft clinics at three hospital-based orthodontic units. PARTICIPANTS: A total of 53 subjects were recruited when attending routine clinic appointments and gave informed consent to participate. INTERVENTION: The modified Huddart and Bodenham scoring system was applied to study models for 53 subjects by all examiners; whereas, one examiner scored 53 subjects clinically, the other two examiners scored 25 and 28 subjects, respectively, on two occasions at least 1 month apart. MAIN OUTCOME MEASURE: Reliability of modified Huddart and Bodenham scoring clinically and on study models was compared. RESULTS: When scoring clinically with the modified Huddart and Bodenham index on two occasions, the intraexaminer and interexaminer intraclass correlation coefficients (ICC) indicated a high level of repeatability and reliability (ICC range, 0.941 to 0.989). The Bland-Altman plots did not show any areas of systematic bias. The ICC between clinical and model scores for each examiner ranged between 0.923 and 0.959. The Bland-Altman plots did not show any areas of systematic bias. The ICC between clinical and model scores for each examiner ranged between 0.923 and 0.959. Canines had lower reliability than molars and incisors. CONCLUSIONS: There was excellent intraexaminer and interexaminer agreement both on study models and in the intraoral scoring using the modified Huddart and Bodenham index. In addition, there was a high degree of correlation between study model and clinical scores using this index.

The role of a dentist in managing patients with dystonia.

UNLABELLED: Oromandibular dystonia is a neurological condition where the muscles of the mouth and jaw contract in involuntary spasms. Dystonia currently has no cure, but there are treatment options to manage symptoms. This case report describes the treatment of a 41-year-old male who presented at University of Glasgow Dental Hospital and School with established oromandibular dystonia. The use of removable appliances as a treatment option for this condition will be discussed. CLINICAL RELEVANCE: This case highlights the potential role of the dental practitioner in providing oromandibular dystonia sufferers with an effective and relatively easy treatment modality in the form of a removable appliance.

The orthodontic management of patients with cleft lip and palate: from birth to the late mixed dentition.

This is the first of two papers outlining the orthodontic management of patients with cleft lip and palate. This paper will review orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. It will emphasise the importance of timing in alveolar bone grafting, the role of the general dental practitioner and the impact of timing on definitive orthodontic outcome.

The orthodontic management of patients with cleft lip and palate: from the permanent dentition and the adult returning to the service.

This is the second of two papers outlining the orthodontic management of patients with cleft lip and palate. The first paper reviewed orthodontic input into children with cleft lip and palate from birth to the late mixed dentition before definitive orthodontics. In this second paper, I will discuss tooth management across the grafted cleft site and its impact on the bone graft itself. I will also discuss the some of the challenges of the adult patient returning to the service.

Surgery-first approach for correction of class III dentofacial deformity with Le Fort I osteotomy; is it advantageous?

The surgery-first approach (SFA) to orthognathic treatment aims to reduce its duration without compromising the outcome. However, the objective assessment of the achieved occlusion has been limited. This study was designed to assess the treatment duration, outpatient appointment number, and quality of occlusal outcomes for two groups of patients; one treated with the SFA and the other with an orthodontics-first approach (OFA). We carried our a retrospective cohort study of case records for twenty consecutive SFA, and 23 consecutive OFA, cases with class III malocclusions, treated with Le Fort I maxillary osteotomy only. Pre-and post-treatment study models were assessed using the Peer Assessment Rating (PAR). Significant differences (p<0.001) were found between the median active treatment durations (10.2 months for the SFA and 32.5 months for the OFA) and appointment numbers (14 for SFA and 24 for OFA). Median absolute PAR reductions were 40 for the SFA and 39 for the OFA. There was no significant difference between the groups regarding quality of occlusal correction. Treatment durations for the SFA group were significantly shorter than for the OFA group, with fewer outpatient appointments. The quality of occlusal outcome for both SFA and OFA groups were satisfactory and comparable.

Cleft lip/palate: incidence of prenatal diagnosis in Glasgow, Scotland, and comparison with other centers in the United Kingdom.

OBJECTIVES: To determine the proportion of children with cleft lip and/or cleft palate diagnosed prenatally between 1999 and 2008 in those referred for treatment to the Royal Hospital for Sick Children in Glasgow, Scotland (RHSC); and to compare the percentage prenatally diagnosed in 2008 versus other cleft treatment centers in the U.K. METHOD: A retrospective study was performed using medical records of the 459 cleft patients born and referred to RHSC between 1999 and 2008. Comparable data for year 2008 were requested from other U.K. units. RESULTS: For the period studied, the percentage of all clefts diagnosed prenatally was 15%. This rose to 28% when only the cases of cleft lip with or without cleft palate (CL ± P) were considered. An increase was seen in prenatal detection of CL ± P from 11% in 1999 to 50% in 2008 (p = .011). Two of the six U.K. units that responded had a significantly higher percentage of CL ± P cases diagnosed prenatally compared with RHSC in 2008 (p < .05). CONCLUSIONS: The percentage of CL ± P cases diagnosed prenatally in this study is consistent with the literature and increased between 1999 and 2008. Routine ultrasound anomaly scanning is shown to significantly improve detection rates compared with scanning of high-risk pregnancies only. Cases of CL ± P where the alveolus or the palate is involved have significantly higher detection rates than those involving only the lip.

The impact of changing cigarette smoking habits and smoke-free legislation on orofacial cleft incidence in the United Kingdom: Evidence from two time-series studies.

BACKGROUND: Both active and passive cigarette smoking have previously been associated with orofacial cleft aetiology. We aimed to analyse the impact of declining active smoking prevalence and the implementation of smoke-free legislation on the incidence of children born with a cleft lip and/or palate within the United Kingdom. METHODS AND FINDINGS: We conducted regression analysis using national administrative data in the United Kingdom between 2000-2018. The main outcome measure was orofacial cleft incidence, reported annually for England, Wales and Northern Ireland and separately for Scotland. First, we conducted an ecological study with longitudinal time-series analysis using smoking prevalence data for females over 16 years of age. Second, we used a natural experiment design with interrupted time-series analysis to assess the impact of smoke-free legislation. Over the study period, the annual incidence of orofacial cleft per 10,000 live births ranged from 14.2-16.2 in England, Wales and Northern Ireland and 13.4-18.8 in Scotland. The proportion of active smokers amongst females in the United Kingdom declined by 37% during the study period. Adjusted regression analysis did not show a correlation between the proportion of active smokers and orofacial cleft incidence in either dataset, although we were unable to exclude a modest effect of the magnitude seen in individual-level observational studies. The data in England, Wales and Northern Ireland suggested an 8% reduction in orofacial cleft incidence (RR 0.92, 95%CI 0.85 to 0.99; P = 0.024) following the implementation of smoke-free legislation. In Scotland, there was weak evidence for an increase in orofacial cleft incidence following smoke-free legislation (RR 1.16, 95%CI 0.94 to 1.44; P = 0.173). CONCLUSIONS: These two ecological studies offer a novel insight into the influence of smoking in orofacial cleft aetiology, adding to the evidence base from individual-level studies. Our results suggest that smoke-free legislation may have reduced orofacial cleft incidence in England, Wales and Northern Ireland.

The clinical application of rhBMP-7 for the reconstruction of alveolar cleft.

In this study, radiographic assessment was performed to find out the effectiveness of bone regeneration following the application of recombinant human bone morphogenetic protein 7 (rhBMP-7) for the reconstruction of alveolar cleft defects in 11 cases: nine unilateral and two bilateral alveolar clefs. Reconstruction of the alveolar cleft was performed by using 3.5 mg of rhBMP-7 (Osigraft OP1) on a type I collagen carrier. Radiographs were taken 6 months post operation using a Gendex Intraoral Unit with Agfa Dentus M2 Comfort occlusal film. The amount of bony infill was graded on a Kindelan four-point scale. The patients were followed up for an average of 6.6 years. Based on the radiographic analysis, eight out of the nine unilateral alveolar cleft cases received a score of grade I and one patient had a grade II score, using the Kindelan scale. In the two bilateral alveolar clefts, only one side had bone formation. The radiographic appearance showed a normal trabecular pattern similar to the adjacent bone. Thus, rhBMP-7 was radiographically and clinically successful in regenerating the bone at the alveolar cleft which resulted in shortening of the operation time, absence of donor-site morbidity and a shorter hospital stay. The promising results of this preliminary study should encourage a phase II trial to compare bone grafts with BMP for the reconstruction of alveolar defects.

Three-dimensional imaging of orthodontic models: a pilot study.

Computer-based digital orthodontic models have been developed that have the potential to replace dental casts. The aim of this study was to examine the accuracy and reproducibility of measurements made on digital models. Ten sets of orthodontic study models were scanned using the Arius3D Foundation System and three-dimensional (3D) images were produced by computer software. Two examiners individually measured 11 parameters on the conventional casts and the digital models on two occasions. The parameters included mesio-distal crown diameter, intercanine and intermolar width, arch length, overjet, and incisor crown height. The measurement techniques were compared using paired t-tests, the coefficient of reliability, and by calculating mean values and the difference between methods. When comparing measurements made on digital models with those on dental casts, systematic errors were detected for five of the 11 parameters at the 10 per cent level. Random errors were a cause of concern for measurements of three parameters. The most accurate and reproducible measurements were lower intercanine width (mean difference between measurements 0.05 +/- 0.32 mm) and overjet (mean difference 0.07 +/- 0.33 mm). Most parameters on the digital models can be reliably measured, and digital models can potentially eliminate the requirement for the production and storage of dental casts, but this will depend on cost.

A study model based photographic method for assessment of surgical treatment outcome in unilateral cleft lip and palate patients.

The aim of this study was to test the reliability of using digital photographs of study models as an alternative to the use of plaster study models in the assessment of surgical treatment outcome in 5-year-old children with unilateral cleft lip and palate (UCLP). Fifty-six dental study models available from the Managed Clinical Network for Cleft Services in Scotland (CLEFTSiS) database of patients aged 5-years with non-syndromic UCLP were employed. An experienced examiner scored the plaster study models using the modified Huddart/Bodenham system. A set of digital photographs stored in the CLEFTSiS electronic patient record database of five different views of the same study models were scored by three examiners to allow calculation of interexaminer reliability. The same examiners repeated the scoring 1 month later under similar conditions to determine intraexaminer reliability and minimize the influence of memory bias on the results. The mean kappa value for the application of the modified Huddart/Bodenham system on photographs of 5-year-old UCLP study models was 0.65 +/- 0.05. The mean kappa value for the measurement of overjet on the digital photographs was 0.68 +/- 0.07. Using the interpretation suggested by Altman, good agreement for both scoring systems was found. Therefore, digital photographs of study models are a reliable alternative to measuring treatment outcome using study models of 5-year-old children with UCLP.