Patient and parent reported outcome measures in cleft lip and palate patients before and after secondary alveolar bone grafting.

European and Northern American healthcare authorities increasingly encourage the use of Patient Reported Outcome Measures (PROMs) that complement clinical and laboratory assessments to help holistically evaluate reconstructive outcomes. This is the first study to evaluate PROMs in cleft lip/palate patients who have, or have not, undergone secondary alveolar bone grafting (SABG).A PROMs study was conducted; 40 consecutive consenting cleft lip/palate children between 8 and 14 years old were included. Twenty patients did, and 20 patients did not, have SABG. PROMs scores from children and parents in the 2 groups were compared.Forty patients completed the trial. No significant differences in total score from the Chang Gung Short Form-15 (CGSF-15) were found between children and their parents. Children with SABG reported no more oral-nasal regurgitation than children without SABG, but tended to report more nasal obstruction. There were no statistically significant differences in parent reported outcomes between the 2 groups.Cleft lip/palate patients who underwent SABG reported significantly less nasal regurgitation and more nasal obstruction compared to those patients who did not undergo SABG.

Difference in the Surgical Outcome of Unilateral Cleft Lip and Palate Patients with and without Pre-Alveolar Bone Graft Orthodontic Treatment.

Presurgical orthodontic treatment before secondary alveolar bone grafting (SABG) is widely performed for cleft lip/palate patients. However, no randomized controlled trial has been published comparing SABG outcomes in patients with, and without, presurgical orthodontic treatment. This randomized, prospective, single-blinded trial was conducted between January 2012 and April 2015 to compare ABG volumes 6 months postoperatively between patients with and without presurgical orthodontic treatment. Twenty-four patients were enrolled and randomized and 22 patients completed follow-up. Patients who had presurgical orthodontics before SABG had significantly improved inclination (p < 0.001) and rotation (p < 0.001) of the central incisor adjacent to the defect, significantly improved ABG fill volume (0.81 ± 0.26 cm(3) at 6 months compared to 0.59 ± 0.22 cm(3); p < 0.05) and less residual alveolar bone defect (0.31 ± 0.08 cm(3) at 6 months compared to s 0.55 ± 0.14 cm(3); p < 0.001) compared to patients who did not have presurgical orthodontic treatment. In conclusion, orthodontic treatment combined with SABG results in superior bone volume when compared with conventional SABG alone.

Long-term comparison of the results of four techniques used for bilateral cleft nose repair: a single surgeon's experience.

BACKGROUND: The purpose of this study was to evaluate progressive changes in surgical techniques and results, aiming for improved nasal shape in primary bilateral cleft rhinoplasty. METHODS: This is an institutional review board-approved retrospective study. Ninety-one consecutive patients with bilateral complete cleft lip underwent primary cheiloplasty with four different techniques of nasal reconstruction from 1992 to 2007 as follows: group I, primary rhinoplasty alone; group II, nasoalveolar molding alone; group III, nasoalveolar molding plus primary rhinoplasty; group IV, nasoalveolar molding plus primary rhinoplasty with overcorrection; and group V, patients without cleft lip. The surgical results were analyzed using photographic records obtained at age 3 years. Four measurements and one angle measurement were obtained. A panel assessment was obtained to grade the appearance of the surgical results. RESULTS: The results are expressed in order from groups I through V. The nostril height-to-width ratio was 0.49, 0.59, 0.62, 0.78, and 0.82, respectively. The nasal tip height-to-nasal width ratio was 0.29, 0.39, 0.49, 0.57, and 0.60. The columella height-to-nasal width ratio was 0.11, 0.18, 0.22, 0.27, and 0.28. The dome-to-columella ratio was 1.88, 1.25, 1.26, 1.14, and 1.10. The nostril area ratio was 1.2, 1.17, 1.13, 1.11, and 1.07. The nasolabial angle was 144.95, 143.98, 121.98, 120.99, and 100.88. Finally, group IV had the best panel assessment. CONCLUSIONS: The results revealed that group IV had the best overall result. Presurgical nasoalveolar molding followed by primary rhinoplasty with overcorrection resulted in a nasal appearance that was closer to the patients without cleft lip.

Smile train: changing the world one smile at a time.

Smile Train was founded with one, clear aim--to help as many children as possible who are needlessly suffering with unrepaired clefts. Its unique "teach-a-man-to-fish" strategy supports local medical professionals to provide free, safe, and high-quality cleft care by offering free education and training opportunities, free equipment, and financial support for cleft treatment. Smile Train is continuing to expand its reach and enhance its ability to serve by developing and implementing new and innovative approaches in the delivery of comprehensive cleft care, so that each and every child born into the world with a cleft has the opportunity to live a full, productive life.

Repair of Tessier no. 3 and no. 4 craniofacial clefts with facial unit and muscle repositioning by midface rotation advancement without Z-plasties.

BACKGROUND: The accepted surgical correction of Tessier no. 3 and no. 4 craniofacial clefts is the use of interdigitating skin flaps along the line of the facial cleft, which frequently results in unsightly facial scars, poor skin color match, and an unnatural facial expression. The authors report their technique of midface rotation-advancement concept to repair these craniofacial clefts. METHODS: Fourteen patients who had undergone Tessier no. 3 and no. 4 cleft repair over a 35-year period (1976 to 2010) at the craniofacial center in Chang Gung Memorial Hospital were retrospectively reviewed. Five patients (group 1) were operated on using Z-plasty principles. Nine (group 2) were operated on using the rotation-advancement technique; six of them had Tessier no. 3 clefts and three had Tessier no. 4 clefts. Seven of those nine patients were primary cases; the other two had secondary or tertiary revisions. Patient photographs were reviewed to assess outcomes. RESULTS: Group 1 had a less overall satisfactory result in terms of scar quality, color matching, or natural facial expression. Overall, a much improved appearance with a higher satisfaction rate was demonstrated in group 2. Patients in group 2 who were surgically treated with the midface rotation advancement technique, though their medial canthus and alar base might not have been well repositioned, still had much better results. CONCLUSIONS: Midface rotation advancement avoided significant scarring with poor skin color matching and unnatural facial expressions. This technique is applicable to either the primary repair or secondary revision of Tessier no. 3 and no. 4 craniofacial clefts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: a single surgeon's experience.

BACKGROUND: This study was the result of a constant evaluation of surgical techniques and results to obtain excellence in primary cleft rhinoplasty. METHODS: This was a retrospective study from 1992 to 2003 comparing the long-term outcomes of four techniques of nasal reconstruction. There were 76 patients divided into four groups: group I (n = 23 patients), primary rhinoplasty alone; group II (n = 16 patients), nasoalveolar molding alone; group III (n = 14 patients), nasoalveolar molding plus primary rhinoplasty; and group IV (n = 23 patients), nasoalveolar molding plus primary rhinoplasty plus overcorrection. The surgical results were analyzed using photographic records obtained at 5 years of age. A ratio of six measurements was obtained comparing the cleft and noncleft sides. A panel assessment was obtained to grade the appearance of the surgical results. All surgery was performed by the senior author (P.K.T.C.). RESULTS: The results are given for groups I to IV, respectively. The nostril height ratio was 0.73, 0.77, 0.81, and 0.95. The nostril width ratio was 1.23, 1.36, 1.23, and 1.21. The one-fourth medial part of nostril height ratio was 0.70, 0.87, 0.92, and 1.00. The nasal sill height ratio was 0.75, 1.02, 1.07, and 1.07. The nostril area ratio was 0.86, 0.89, 0.95, and 1.08. The nostril height-to-width ratio was 0.58, 0.58, 0.71, and 0.92. Finally, group IV had the best panel assessment. CONCLUSIONS: The results revealed that group IV had the best overall result. Overcorrection of 20 percent was necessary to maintain the nostril height. Further technical modifications are necessary to minimize widening of the nostril width.

Establishing a craniofacial center in a developing country.

The establishment of a craniofacial in a developing country is often difficult because of the availability of trained personnel. This requires gradually replacing or training personnel such as speech pathologists. Gradual improvement is possible for a period of 5 to 10 years to train individuals. This requires a dedicated person to achieve the goal of a multidisciplined center for patients with cleft.

Craniofacial morphology in children with complete bilateral cleft lip and palate: does infantile size of the premaxilla predetermine outcome?

OBJECTIVE: To evaluate the possible association between the size of the premaxilla in infants and craniofacial morphology in children with complete bilateral cleft lip and palate (CBCLP) and identify the characteristics of craniofacial morphology in children with CBCLP with median facial dysplasia (MFD). DESIGN: Retrospective study. SETTING: A university hospital craniofacial center. SUBJECTS: Thirty-four patients with nonsyndromic CBCLP, 24 boys and 10 girls, had large premaxilla (LP group). Thirty-six patients with nonsyndromic CBCLP, 16 boys and 20 girls, had small premaxilla (SP group). Thirteen CBCLP patients with MFD, five boys and eight girls (MFD group). MAIN OUTCOME MEASURES: Infant maxillary dental cast at the age of 1 year was used to measure the size of the premaxilla. Cephalometric analysis was used to determine craniofacial morphology in children at the age of 5 years. RESULTS: The size of the premaxilla in infants with CBCLP varied greatly. The LP group tended to have a longer maxilla and a more protruded maxilla, producing a better interjaw relation. The opposite phenomena were observed in the MFD group; the SP group yielded results between those of the LP and the MFD groups. CONCLUSION: The size of the premaxilla in infants with CBCLP can be used to predetermine subsequent craniofacial morphology at the age of 5 years. Children with nonsyndromic CBCLP had craniofacial characteristics that differed significantly from those of children with CBCLP with median facial dysplasia.

Comparison of obstructive sleep apnea syndrome in children with cleft palate following Furlow palatoplasty or pharyngeal flap for velopharyngeal insufficiency.

OBJECTIVE: To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI). PATIENTS: A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI. INTERVENTIONS: An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively. MAIN OUTCOME MEASURES: Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured. RESULTS: In the P group, the mean percentage of stage 2 sleep was lower than the F group (p <.05). The mean RDI and DI were larger in the P group, compared with the F group (p <.001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p <.001 and p = 0.05, respectively). CONCLUSIONS: A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.

Assessment of bilateral cleft lip nose deformity: a comparison of results as judged by cleft surgeons and laypersons.

Reconstruction of bilateral cleft lip nose deformity is difficult and the outcome is inconsistent. This study was conducted to evaluate the gross outcome and the difference in the assessment of nasal appearance as judged by two groups of raters, cleft surgeons and laypersons. Sixty-four patients with bilateral cleft lip were selected for review. The patients' ages ranged from 5 to 30 years. All patients had undergone primary cleft lip repair and secondary nasal reconstruction, and had been followed for at least 6 months. One image for each patient, which included a digitized frontal, lateral, and worm's-eye view, was projected for evaluation by the raters. The raters included five cleft surgeons and five laypersons. A rating scheme was used in which a score of 3 was given for a good, close to normal nasal appearance, 2 for an average result that needed minor revision, and 1 for a poor result that needed major reconstruction. The scores were averaged for each patient in each group and for each group as a whole. The final outcome was judged as good, fair, or poor on the basis of the mean score for each patient. Statistical analysis was performed. The mean score for all patients was 2.08 as assessed by the laypersons and 2.18 as assessed by the cleft surgeon group. There was no statistically significant difference between the two groups. Comparisons on rating scores among different raters revealed a fair agreement on the ratings within each of the two groups. The results were found to be good in 29.7 percent, fair in 64.1 percent, and poor in 6.3 percent of patients when evaluated by the surgeons. When rated by the laypersons, the nasal appearance was found to be good in 26.6 percent, fair in 60.9 percent, and poor in 12.5 percent of patients. This difference in distribution between the two groups was not statistically significant. When comparing the results given by the two groups of assessors, there was agreement on the nasal appearance in 65.6 percent of patients, and a difference in grading in the rest. For the patients who received different grading, the surgeons rated them one grade higher in 63.6 percent and one grade lower in 36.4 percent. There was no difference in grading between any of the evaluators that reflected a two-grade discrepancy in evaluation of results. This study shows that the surgical outcome of bilateral cleft lip nose deformity repair, at the authors' institution, is less than optimal. When assessing bilateral cleft lip nose appearance, the judgment of results by cleft surgeons was similar to that of the laypersons. However, different rating of results existed within each of the two groups, supporting the importance of clearly assessing patient/parent expectations and defining realistic surgical goals.

Effects of cheiloplasty on maxillary dental arch development in infants with unilateral complete cleft lip and palate.

OBJECTIVE: To identify and analyze quantitatively the development of the maxillary dental arch before and after cheiloplasty. DESIGN: Prospective, longitudinal study of maxillary dental arch development at age of 1, 3, 6, and 12 months. SETTING: All patients were treated at a university hospital craniofacial center. PATIENTS: Twenty-seven infants with nonsyndromic, unilateral complete cleft lip and palate. INTERVENTION: Millard's rotation-advancement cheiloplasty was performed between the ages of 3 and 4 months. RESULTS: The anterior portion of the nonclefted segment (I-G), anterior ridge length of the nonclefted segment (I-C), and anterior ridge length of the clefted segment (L-C') continuously increased from 1 to 12 months of age. The anterior cleft width (G-L), anterior arch depth (I perpendicular to CC'), anterior basal angle (angle GC-CC'), and anterior arch curature angle (angle GIC) continuously decreased after the cheiloplasty. CONCLUSIONS: Cheiloplasty could mold the anterior portion of the maxillary dental arch palatally by exerting continuous pressure.

Comparison of craniofacial morphology in patients with bilateral complete cleft of primary versus secondary palate.

OBJECTIVE: To identify and compare the craniofacial morphology of patients with bilateral complete cleft of primary palate (BCCPP) and bilateral complete cleft of secondary palate (BCCSP). In addition, to evaluate the differential effects of lip repair and palatal repair on the craniofacial morphology in cleft patients. SUBJECTS: Twenty-four children, 10 boys and 14 girls, mean age of 5.8 years, with BCCPP (BCCPP group). Twenty-five children, 10 boys and 15 girls, mean age of 5.6 years, with BCCSP (BCCSP group). DESIGN: Retrospective analysis. MAIN OUTCOME MEASURES: Cephalometric analysis was used to determine the craniofacial morphology at about 5 years of age. RESULTS: Compared with the BCCSP group, the BCCPP group demonstrated longer maxillary length, more protruded maxilla, more favorable jaw relation, more severely retroclined maxillary incisors, and larger overjet. CONCLUSIONS: The subjects with BCCPP had craniofacial characteristics that differed significantly from those with BCCSP. It could also be speculated that palatal repair had more adverse effect on the growth of the maxilla in length; however, that repair influenced less the anteroposterior position of maxillary incisors than lip repair did.

A cephalometric study of facial growth in van der Woude syndrome.

OBJECTIVE: To test the hypothesis that maxillary growth and lower lip form in patients with van der Woude syndrome (VDW) is different from patients with non-syndromic cleft lip and palate. DESIGN AND SETTING: Retrospective, case-control study at a tertiary cleft center, Chang Gung Memorial Hospital, Taipei, Taiwan. PATIENTS AND PARTICIPANTS: Records of 53 patients with VDW, who presented for treatment during the years 1968 through 1998 were obtained. Twenty-three of 53 patients had received at least one lateral cephalogram during the course of their treatment. Of these 23, in 17 it was possible to find non-syndromic case controls with identical cleft type, sex, and method of cleft palate repair, with year of birth matching within 1 year of the corresponding VDW patient. For these 17 pairs of VDW and non-syndromic cleft controls, cephalogram acquisition dates were checked to see how well the corresponding pairs matched. A total of 43 pairs of cephalograms were deemed to be acceptably matched because the ages at acquisition differed by less than 15% of the VDW patient's age. MAIN OUTCOME MEASURES: Thirteen measurements were derived from the 11 standard lateral cephalometric landmarks recorded on each cephalogram. The data were classified into five groups according to age at time of cephalogram, and sets of paired non-syndromic cleft and VDW measurements were tested for differences using a Wilcoxon signed rank sum test in two ways, first including all cleft types and then including only those patients with complete bilateral cleft lip and palate. A longitudinal growth analysis considering the movement of the skeletal A and B points was performed on the patients with complete bilateral cleft lip and palate. RESULTS: For the osseous measurements, anteroposterior maxillary length as described by the anterior nasal spine (ANS)-posterior maxillary point distance was statistically significantly shorter in the VDW patients of age 13 years and older, by 5.3 mm. Maxillary height, as described by the nasion-ANS distance was shorter in the VDW patients, closely approaching statistical significance in the age range 7 through 11 years. The lip soft tissue measurements showed significantly greater protrusion over several age ranges in the VDW patients. The longitudinal growth analysis showed a significantly more inferior vertical position of the B point in the controls. CONCLUSIONS: This study demonstrates a few statistically significant differences in maxillary growth and lip conformation between VDW and matching controls. Small sample sizes for each age group hamper the ability to fully interpret or generalize the pattern of these differences.