Mandibulotomy Technique and Permanent Molar Injury After Mandibular Distraction Osteogenesis in Infants.

OBJECTIVE: The risk that mandibular distraction osteogenesis (MDO) poses to the developing mandibular dentition is well-known; however, less is understood about how the choice of instrumentation used for mandibular osteotomy might affect the development of permanent molars. METHODS: Retrospective chart review examining infants with micrognathia who underwent MDO from 2010 to 2018 at a single tertiary care children's hospital using external, multivector devices. The first and second permanent mandibular molars were radiographically examined years after surgery to determine whether osteotomy cutting techniques affect the risk of injury to the permanent dentition. RESULTS: Thirty-seven infants and children underwent MDO from 2010 to 2018. Follow-up dental radiographs were available for 17 patients; 6 patients were excluded based on the use of preoperative computed tomography, utilization of virtual surgical planning technology, use of buried internal distractors, or older age at the time of distraction surgery. This yielded a total of 11 patients who underwent MDO with external hardware without virtual surgical planning representing 22 osteotomies. Sixteen osteotomies were performed using a side-cutting burr and 6 with a piezoelectric saw. The median age at distraction surgery was 3 weeks. The rate of an abnormal permanent first or second mandibular molar finding per osteotomy was 88% (14/16) in the side-cutting group versus 17% (1/6) with the piezoelectric technique (P = 0.004). CONCLUSION: Mandibular distraction osteogenesis risks injury to the mandibular molars; however, this study suggests a significant risk reduction in molar injury if the piezoelectric device is utilized.

Quality of Life and Psychosocial Outcomes Among Children With Cleft Differences.

Introduction Velopharyngeal insufficiency (VPI) and craniofacial differences can lead to diminished speech and swallowing function resulting in communication and social challenges throughout childhood. To monitor changes in patients' psychosocial health and velopharyngeal function, the Pediatric Symptom Checklist (PSC) and Velopharyngeal Insufficiency Effects on Life Outcomes (VELO) survey tools can be utilized. This study aimed to investigate the relationship between VPI quality-of-life outcomes and psychosocial disturbances through a comparative analysis of PSC and VELO parental surveys among children followed by a craniofacial team. Methods A retrospective chart review was completed using data from a single, multidisciplinary cleft and craniofacial team. Previously completed parental survey responses between 2010 and 2022 were collated and results were analyzed using a Spearman's rank correlation test (rs). Results There were 89 subjects who completed both surveys on the same day (n = 148 survey pairs (s)). Patients aged three to five years old (s = 88) had a mean VELO of 17.9 (0-65) and a mean PSC of 7.9 (0-27), while patients aged six to eight years old (s = 60) had a mean VELO of 16.6 (0-74) and a mean PSC of 12.0 (0-37). The strongest correlation observed for both age groups was between the total PSC and VELO Speech Limitations sub-scores (three to five years old: rs = 0.537, p < 0.001; six to eight years old: rs = 0.330, p = 0.010). Similarly, children in the six- to eight-year-old group with cleft lip and palate showed a correlation between the total PSC and VELO Speech Limitations (rs = 0.583, p < 0.001). Conclusion This study suggests a relationship between PSC and VELO scores among children ages three to eight years old with cleft differences and demonstrates that specific domains within the VELO questionnaire should be considered as being associated with a higher risk for psychosocial impairment. Specifically, higher VELO Speech Limitations sub-scores may portend a greater risk for poor psychosocial outcomes supporting the importance of early interventions in this group.

Is Postoperative Nasal Stenting Necessary After Primary Cleft Lip and Nose Repair?

The repair of an infant with cleft lip includes treatment of the nasal deformity using surgical repositioning of the nasal cartilages. In some cases, the nose is molded before surgery, termed nasoalveolar molding, and in others, postoperatively with nostril stents for a variable amount of time. This best practice evaluation fails to make a definitive evidence-based conclusion, yet the benefits of stenting seem to outweigh the risks.

Update on using buccal myomucosal flaps for patients with cleft palate and velopharyngeal insufficiency: primary and secondary interventions.

PURPOSE OF REVIEW: This review aims to examine the indications and anatomical circumstances for when to optimally incorporate buccal myomucosal flaps (BMFs) into palatal surgical reconstruction. RECENT FINDINGS: Studies examining outcomes following primary cleft palate repair with incorporation of BMF have demonstrated excellent speech outcomes and low rates of fistula. Furthermore, some reports cite an association of buccal flap use with reduced midface hypoplasia and the need for later orthognathic surgery. When used for secondary speech surgery, BMFs have been shown to lead to speech improvements across multiple outcome measures. Advantages of BMF techniques over conventionally described pharyngeal flap and pharyngoplasty procedures include significant lengthening of the velum, favorable repositioning of the levator muscular sling, and lower rates of obstructive sleep apnea. SUMMARY: Although the published data demonstrate excellent outcomes with use of BMFs for primary and secondary palatal surgery, there are limited data to conclude superiority over the traditional, more extensively investigated surgical techniques. The authors of this review agree with the evidence that BMF techniques can be useful in primary palatoplasty for congenitally wide clefts, secondary speech surgery for large velopharyngeal gaps, and/or in individuals with a predisposition for airway obstruction from traditional approaches.

Publishing Trends in International Humanitarian Cleft Lip and Palate Care: A Systematic Review.

Background: Humanitarian outreach delivers essential cleft lip and palate (CLP) care in low- and middle-income countries. Objective: To review the literature regarding humanitarian CLP care and determine if a shift toward more sustainable care delivery is observed. Methods: A systematic review was performed on articles describing CLP repair in humanitarian settings from 1985 to 2020. Publications were categorized into trip reports, outcomes, teaching, and public health. Articles were stratified into three 12-year intervals (T1-T3) for analysis. Results: A total of 246 publications were included. Average annual publications increased 15.4-fold from T1 to T3 (p < 0.001). Among publications focused on delivering CLP-related care, descriptive trip report articles trended downward (58% in T1 vs. 42% in T3), whereas outcome-focused publications trended upward (42% in T1 vs. 58% T3). Public health research represented the greatest percentage of publications in T3 (50%). There were 22 teaching-related publications in T3 and only one in prior years. Conclusion: Research trends demonstrate a shift away from focusing solely on the number of surgical cases completed and toward more sustainable models of care delivery that address barriers to receiving longitudinal care.

Longitudinal Anatomic Analysis of Primary Cleft Lip Rhinoplasty Outcomes.

Background: The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges. Objectives: Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair. Methods: This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models. Results: Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2-12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and -0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2-4, 5-7, 8-12, 13-24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015-0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair. Conclusions: In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

Quality Assurance Standards for Outreach Cleft Lip and Cleft Palate Repair Programs in Low-Resource Settings.

BACKGROUND: Comprehensive cleft care is a multidisciplinary team endeavor. While untreated craniofacial conditions have multiple undue repercussions, cleft care in outreach settings can be fraught with significant perioperative morbidity risks. AIM: Propose updated quality assurance standards addressing logistic and operational considerations essential for the delivery of safe and effective cleft lip and /or palate (CL/P) care in low and middle-income countries (LMICs) settings. METHODS: Based on American Cleft Palate-Craniofacial Association (ACPA) quality standards, published literature, published protocols by Global Smile Foundation (GSF), and the senior author's three-decade experience, updated standards for outreach cleft care were synthesized. RESULTS: Ten axes for safe, effective, and sustainable cleft lip and palate care delivery in underserved settings were generated: 1) site assessment, 2) establishment of community partnerships, 3) team composition and credentialing, 4) team training and mission preparation, 5) implementation of quality assurance guidelines, operative safety checklists, and emergency response protocols, 6) immediate and long-term postoperative care, 7) medical record keeping, 8) outcomes evaluation, 9) education, and 10) capacity building and sustainability. Subsequent analysis further characterized essential components of each of those ten axes to delineate experience derived and evidence-based recommendations. DISCUSSION: Quality assurance guidelines are essential for the safe delivery of comprehensive cleft care to patients with CL/P in any setting. Properly designed surgical outreach programs relying on honest community partnerships can be effectively used as vehicles for local capacity building and the establishment of sustainable cleft care ecosystems.

Feeding Performance and Outcomes in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis.

To describe perioperative feeding performance in infants with Robin sequence (RS) who underwent mandibular distraction osteogenesis (MDO).A retrospective study of infants that underwent MDO from May 2010 to December 2019.Tertiary pediatric hospital.A total of 40 patients underwent MDO and 20 met inclusion criteria. Of the included infants, 6 had an associated syndrome and 80% were male.Time to full oral feeds, rate of G-tube placement, and change in weight percentile following MDO.Average oral intake prior to MDO was 22.1% of individual goal feeds. Among the 15 (75%) children that did not require G-tube placement, mean time to full oral feeds after MDO was 11 days ± 5.7 days, with 80% of infants reaching full oral feeds within 2 weeks after extubation. The proportion of G-tube placement in patients with a syndrome was higher than in isolated RS (-0.6; 95% CI: -1.0, -0.2). Mean percentages of weight-for-age percentile decreased during the first 3 months after the procedure. This was followed by a mean upturn in weight starting after the third month after MDO with a recovery to preoperative mean weight-for-age percentiles by 6 months after surgery.This study suggests that infants with RS may achieve full oral feeds despite poor feeding performance before MDO. Infants with syndromic RS are more likely to require G-tube. These findings may be used to inform G-tube discussion and offer a timeline to work toward goal oral feeds for infants with RS after MDO.

Masseteric-to-facial nerve transfer for treatment of pediatric facial paralysis: An initial report.

OBJECTIVES: The indications and outcomes of masseteric-to-facial nerve transfer in pediatric patients with short-term facial paralysis is incompletely understood as compared to its use in adult patients. This report aims to retrospectively quantify outcomes with both clinician-based measurements and objective facial analysis software. METHODS: Retrospective case series at a single institution. The Sunnybrook Facial Grading System was used for clinician-based measurements and Emotrics software for objective measurements. RESULTS: Four pediatric patients underwent masseteric-to-facial nerve transfers from 2016 to 2018. The mean patient age at the time of surgery was 4.5 years (range = 2-7) and the mean time from paralysis onset to surgical intervention was 12.9 months (range = 10.0-16.2). The mean follow-up was 18.3 months (range = 14.5-23.6). With regards to the Sunnybrook resting nasolabial fold symmetry, 3 of the 4 patients improved from 2 (absent nasolabial fold) to 1 (less pronounced nasolabial fold). Per the Emotrics analysis, the pre- and post-operative mean absolute differences for commissure excursion between the normal functioning and paralyzed sides were 11.8 mm and 6.7 mm, respectively (p = 0.04). CONCLUSION: The masseteric-to-facial nerve transfer technique leads to an objective improvement in dynamic smile function in select pediatric patients.

Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database.

OBJECTIVES: This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO). DESIGN: Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012. SETTING: Inpatient database from the United States. PARTICIPANTS: Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic. INTERVENTIONS: Mandibular distraction osteogenesis. MAIN OUTCOME MEASURES: Length of hospital stay, adjunct airway and nutritional interventions and disposition. RESULTS: The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32). CONCLUSIONS: Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.

Metanalysis of alloplastic materials versus autologous fat for injection augmentation pharyngoplasty treatment of velopharyngeal insufficiency.

BACKGROUND: Velopharyngeal insufficiency (VPI) can cause resonance, speech and feeding problems. While reconstructive palatoplasty and surgical pharyngoplasty techniques are the mainstay of treatment for severe VPI, injection augmentation pharyngoplasty offers a minimally invasive approach in patients with mild-to-moderate VPI. METHODS: We conducted a systematic review of the literature available on PubMed and Embase from 1990 to 2019 including studies that addressed VPI, incompetence, or dysfunction managed with injection augmentation. Patient demographics, etiology of VPI, injection material, volume of injection, number of injections, complications and both subjective and objective outcomes were recorded. RESULTS: Twenty-nine studies met our inclusion criteria encompassing 587 patients, ages 3-75 years (mean = 16) who underwent injection pharyngoplasty. Injection materials included glutaraldehyde cross-linked (GAX) collagen (n = 5), calcium hydroxyapatite (n = 36), dextranomer and hyaluronic acid (n = 72) and autologous fat (n = 471). Follow-up averaged 15.4 months (range = 2-60 months). Functional improvements in nasality were recorded in a large proportion of patients (0.79, 95% CI 0.75 to 0.82). However, a greater proportion of patients in the synthetic materials group demonstrated either reduced or resolved hypernasality compared with those receiving autologous fat injections (χ2 = 7.035, n = 91/103 vs. 255/338, p = 0.008). Complete velopharyngeal gap closure post-injection was achieved at a higher frequency with injection of synthetic materials compared with autologous fat (χ2 = 11.270, n = 61/69 vs. 58/91 p = 0.001).r CONCLUSION: Injection pharyngoplasty offers a minimally invasive alternative intervention for treatment of VPI secondary to small velopharyngeal gaps. Patients treated with synthetic materials experienced a greater improvement in velopharyngeal closure and a corresponding improvement in resonance balance.

Cleft Palate in Newborns Diagnosed With Prematurity.

OBJECTIVE: Cleft lip and/or palate (CLP) is the most common major congenital malformation of the head and neck. Although numerous genetic features, syndromes, nutritional deficiencies, and maternal exposures have been implicated in the etiology of CLP, the impact of prematurity on the pathogenesis remains incompletely understood. This study seeks to evaluate the associations between prematurity and the development of CLP in the United States. STUDY DESIGN: Cross-sectional. SETTING: Academic medical center. METHODS: The Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of prematurity or CLP. Demographic information was obtained. Odds ratios were used to determine associations between prematurity and CLP. RESULTS: Among patients included in our data set, 8.653% (n = 326,147) were preterm; 0.136% (n = 5115) had CLP; and 0.021% (n = 808) were preterm and had CLP. Preterm infants had 1.90 times the odds (95% CI, 1.74-2.07) of developing CLP when compared with the nonpreterm population. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.83 (95% CI, 1.66-2.01) for the association between prematurity and CLP. CONCLUSION: Infants who are born preterm are more likely to have CLP than full-term infants. The current results will allow for improved risk stratification, maternal counseling, and interventions in the case of prematurity. LEVEL OF EVIDENCE: 4.

Cleft Lip and Palate in Newborns Diagnosed With Neonatal Abstinence Syndrome.

OBJECTIVE: Cleft lip and/or cleft palate (CLP) is the most common major congenital malformation of the head and neck. Previous studies suggested an association between fetal opioid exposure and CLP. This study seeks to evaluate the associations between CLP and neonatal abstinence syndrome (NAS) in the United States. STUDY DESIGN: Population-based inpatient registry analysis. SETTING: Academic medical center. SUBJECTS AND METHODS: Kids' Inpatient Database (2016) was used to identify weighted in-hospital births with diagnoses of CLP or NAS. Demographic information was obtained. RESULTS: Among 3.8 million weighted in-hospital births, prevalence rates of CLP in the NAS and non-NAS populations were 3.13 and 1.35 per 1000, respectively. The odds ratios for patients with NAS developing CLP, isolated cleft palate, isolated cleft lip, and cleft lip and palate when compared with the reference population were 2.33 (95% CI, 1.87-2.91; P < .001), 4.97 (95% CI, 3.84-6.43; P < .001), 1.01 (P = .98), and 0.80 (P = .46). Independent predictors of CLP within the NAS population included median household income for patients' zip code, race, hospital region, payment method, and maternal use of tobacco or other drugs of addiction. The binary logistic regression model accounting for possible confounding variables produced an odds ratio of 1.74 (95% CI, 1.36-2.23; P < .001) for the association between NAS and CLP. CONCLUSION: Our study found an association between NAS and CLP, specifically isolated cleft palate, suggesting that prenatal exposure to opioids may be an environmental risk factor in the development of CLP.

Neonatal tooth infection resulting in subperiosteal orbital abscess: A case report.

Neonatal orbital infections are quite rare, and are most often attributed to ethmoid sinusitis. This report describes a case of subperiosteal orbital abscess in a neonate secondary to an infected neonatal tooth. Although there have been two cases reported in the literature describing odontogenic infection resulting in orbital abscess in neonates, these cases were due to infected tooth buds rather than an infected neonatal tooth. We discuss workup and surgical management of this patient, including tooth extraction and intraoral approach to the orbit for abscess drainage.

Outcomes Assessment of Multi-Level Sleep Surgery in Syndromic Versus Non-Syndromic Children.

OBJECTIVES: Analyze the differences in length of stay, cost, disposition, and demographics between syndromic and non-syndromic children undergoing multi-level sleep surgery. METHODS: Children with sleep disordered breathing or obstructive sleep apnea that had undergone sleep surgeries were isolated from the 1997 to 2012 editions of the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Children were then classified as syndromic or non-syndromic and stratified by level of sleep surgery (tonsillectomy & adenoidectomy, tonsillectomy & adenoidectomy plus other site surgery, other site surgery). Length of stay and cost were reported with Kruskal-Wallis one-way analysis of variance, disposition with binomial logistic regression, and demographics with chi-square. RESULTS: Syndromic children compared to non-syndromic children were more likely to have surgery beyond just tonsillectomy & adenoidectomy and also had a longer length of stay, higher total cost and non-routine disposition (all P < .001). Syndromic children undergoing tonsillectomy and adenoidectomy plus other site surgery had a longer length of stay compared to syndromic children undergoing tonsillectomy & adenoidectomy (6.00 days vs 3.63 days, P < .001). However, no similar statistically significant difference in length of stay was found in non-syndromic children (2.01 days vs 2.87 days, P > .05). CONCLUSION: The potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not.

Publishing trends in velopharyngeal insufficiency.

OBJECTIVE: This study seeks to describe publishing trends for VPI over a 33-year span with regard to treating specialty, methods of assessment, related diagnoses, and methods of treatment for each specialty. METHODS: A PubMed search was performed on "velopharyngeal insufficiency" using medical subject headings terms from 1985 to 2017. Publisher specialty, method(s) of VPI assessment, associated diagnosis/diagnoses, and method(s) of VPI treatment per specialty and combined across specialties were analyzed. Respective publications were totaled in 11-year intervals and two-way analysis of variance was used to compare change over time within specialties and across specialties. RESULTS: 763 publications were included for analysis. The total number of publications on VPI increased from a total of 6 in 1985 to a peak of 67 in 2015. The specialties that showed the largest increase in relative frequency of publication were Otolaryngology (p < 0.001), Plastic Surgery (p < 0.001), and Multidisciplinary (p < 0.001). Publications on endoscopic (p < 0.001) evaluation of VPI have significantly increased over time relative to magnetic resonance imaging and lateral cephalometry. Across all specialties, publications that feature pharyngoplasty (p < 0.001), palatoplasty (p < 0.001), and pharyngeal flap (p < 0.001) as methods of VPI treatment have significantly increased over time. CONCLUSION: There is a trend towards endoscopy for diagnostics and a multidisciplinary approach when managing patients with VPI. The specialty that showed the largest increase in the relative frequency of publication was Otolaryngology. Surgical methods of treatment continue to be described at increasing frequency relative to more conservative treatments.