Longitudinal Follow-Up of Facial Growth of Patients With Unilateral Cleft Lip and Palate Following Modified Veau-Wardill-Kilner Palatoplasty.

OBJECTIVE: To evaluate facial growth after modified Veau-Wardill-Kilner/pushback (PB) palatoplasty from childhood to adulthood in patients with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective longitudinal study. SETTING: Single center. PATIENTS: Sixty-two (29 males and 33 females) consecutive patients with nonsyndromic UCLP. INTERVENTIONS: Pushback palatoplasty and subsequent cleft palate treatment. MAIN OUTCOME MEASURES: Lateral and posterior-anterior cephalograms were taken at 3 different phases: phase 1 (before first-stage orthodontic treatment; N = 58; average age, 4.9 ± 1.1 years), phase 2 (before second-stage orthodontic treatment; N = 58; 15.9 ± 1.1 years), and phase 3 (after orthodontic retention; N = 51; 22.1 ± 3.2 years). RESULTS: The majority of patients had skeletal class III morphology in all 3 phases due to retrognathic maxilla. Maxillary growth did not improve in phase 2 despite first-stage orthodontic treatment in phase 1. Maxillary morphology improved in phase 3 but retardation occurred, although 77.42% of patients received orthognathic surgery during second-stage orthodontic treatment. Mandibular growth was slightly reduced in phases 1 and 2 and the mandible remained retrognathic in phase 3, following mandibular setback orthognathic surgery. The horizontal occlusal cant was slightly upward and toward the cleft side with respect to the reference plane, and the upper midline was deviated to the cleft side in phases 1 and 3. CONCLUSIONS: Patients with UCLP who undergo phased PB palatoplasty, orthodontic treatment, and orthognathic surgeries do not maintain skeletal class I facial morphology.

Histologic Aspect of the Curved Vomerine Mucosa in Cleft Lip and Palate.

BACKGROUND: Common surgical techniques aim to turn the entire vomerine mucosa with vomer flaps either to the oral side or to the nasal side. The latter approach is widely performed due to the similarity in color to the nasal mucosa. However, we lack a histologic description of the curved vomerine mucosa in cleft lip and palate malformations. METHODS: We histologically examined an excess of curved vomerine mucosa in 8 patients using hematoxylin-eosin, periodic acid-Schiff, Elastin van Gieson, and Alcian blue stains. Tissue samples were obtained during surgery at 8 months of age. RESULTS: Our histological analysis of the mucoperiosteum overlying the curved vomer revealed characteristics consistent with those of an oral mucosa or a squamous metaplasia of the nasal mucosa, as exhibited by a stratified squamous epithelium containing numerous seromucous glands. Some areas showed a palisaded arrangement of the basal cells compatible with metaplasia of respiratory epithelium, but no goblet cells or respiratory cilia were identified. Abundant fibrosis and rich vascularity were present. CONCLUSION: The vomer mucosa showed no specific signs of nasal mucosa. These findings should be considered in presurgical cleft orthopedics and palatal surgery for further refinement. Shifting the vomer mucosa according to a fixed physiologic belief should not overrule other important aspects of cleft repair such as primary healing and establishing optimal form and function of palatal roof and nasal floor.

The biomechanical evaluation of magnetic forces to drive osteogenesis in newborn's with cleft lip and palate.

This study examined the potential for dental magnets to act as a driving force for osteogenesis in the palate of newborns with a unilateral cleft lip and palate. In the first part of the study dental magnets were arranged in a set up mimicking a distraction device and the curves of the magnetic attraction force versus gap distance curves generated, with and without the presence of palatal rugae tissue in between both sides of the distraction device. The attraction forces ranged from 1 to 12 N depending on the gap distance and the presence of soft tissue in the gap. In the second part of the study these forces were used as input for a 3D finite element model of the palate of a newborn affected by unilateral cleft lip and palate. In the analysis of load transfer, it was found that the strains generated by a magnetically induced distraction exceed 1,500 µstrain suggesting that bone locally is submitted to mild overload leading to bone apposition.

Comparative study on cleft palate morphology after passive presurgical plate therapy in unilateral cleft lip and palate.

BACKGROUND: Presurgical plate therapy has been widely accepted as a treatment prior to palatal cleft closure. The effects of passive presurgical plate therapy on cleft morphology prior to single-stage unilateral cleft lip and palate (UCLP) repair were quantified. PATIENTS AND METHODS: We compared the dimensions of cleft width and cleft area (true cleft and palatal cleft) measured preoperatively at 2 European cleft centers. Center A performed single-stage UCLP repair in 8-month-old infants without any presurgical orthopedic treatment. Center B initiated passive presurgical plate therapy immediately after the birth of the neonates, followed by single-stage UCLP repair at 8 months of age. RESULTS: We included 28 patients with complete UCLP from Center A and 12 patients from Center B. The average anterior width of the true cleft before surgery was significantly smaller in infants at Center B than that in Center A (p = 0.001) with 95% confidence interval of (1.8, 5.7) mm, but the average posterior width was similar in the 2 groups. The mean presurgical true cleft area amounted to 106.8 mm2 (SD = 42.4 mm2) at Center A and 71.9 mm2 (SD = 32.2 mm2) at Center B, with a confidence interval for the difference being (9.8, 60.1) mm2. This corresponded to a 32.7% reduction of the true cleft area when passive presurgical plate therapy was used for the first 8 months of the infants' life. CONCLUSION: Passive presurgical plate therapy in UCLP significantly reduced the cleft area. Implications for the subsequent surgical outcome might depend on the surgical technique used.

Cleft lip and palate surgery simulator: Open source simulation model.

Objective: Cleft lip and palate is the most common craniofacial birth anomaly and requires surgery in the first year of life. However, craniofacial surgery training opportunities are limited. The aim of this study was to present and evaluate an open-source cleft lip and palate hybrid (casting and three-dimensional (3D) printing) simulation model which can be replicated at low cost to facilitate the teaching and training of cleft surgery anatomy and techniques. Design: The soft tissue component of the cleft surgery training model was casted using a 3D printed 5-component mold and silicone. The bony structure was designed to simulate the facial anatomy and to hold the silicone soft tissue. Setting: Two groups, one group of trainees and one group of expert surgeons, at University Hospital Basel in Switzerland and Pontifical Catholic University of Chile in Santiago, Chile, tested the cleft lip and palate simulation model. Participants completed a Likert-based face and content validity questionnaire to assess the realism of the model and its usefulness in surgical training. Results: More than 70 % of the participants agreed that the model accurately simulated human tissues found in patients with unilateral cleft lip and palate. Over 60 % of the participants also agreed that the model realistically replicated surgical procedures. In addition, 80-90 % of the participants found the model to be a useful and appropriate tool for teaching the anatomy and surgical techniques involved in performing unilateral cleft lip and palate repair. Conclusion: This open-source protocol provides a cost-effective solution for surgeons to introduce the cleft morphology and surgical techniques to trainees on a regular basis. It addresses the current financial barrier that limits access to commercially available models during the early stages of surgeon training prior to specialization in the field.

Automated and data-driven plate computation for presurgical cleft lip and palate treatment.

PURPOSE: Presurgical orthopedic plates are widely used for the treatment of cleft lip and palate, which is the most common craniofacial birth defect. For the traditional plate fabrication, an impression is taken under airway-endangering conditions, which recent digital alternatives overcome via intraoral scanners. However, these alternatives demand proficiency in 3D modeling software in addition to the generally required clinical knowledge of plate design. METHODS: We address these limitations with a data-driven and fully automated digital pipeline, endowed with a graphical user interface. The pipeline adopts a deep learning model to landmark raw intraoral scans of arbitrary mesh topology and orientation, which guides the nonrigid surface registration subsequently employed to segment the scans. The plates that are individually fit to these segmented scans are 3D-printable and offer optional customization. RESULTS: With the distance to the alveolar ridges closely centered around the targeted 0.1 mm, our pipeline computes tightly fitting plates in less than 3 min. The plates were approved in 12 out of 12 cases by two cleft care professionals in a printed-model-based evaluation. Moreover, since the pipeline was implemented in clinical routine in two hospitals, 19 patients have been undergoing treatment utilizing our automated designs. CONCLUSION: The results demonstrate that our automated pipeline meets the high precision requirements of the medical setting employed in cleft lip and palate care while substantially reducing the design time and required clinical expertise, which could facilitate access to this presurgical treatment, especially in low-income countries.

The Effect of Ligature Type on Lateral Tooth Movement during Orthodontic Treatment with Lingual Appliances-An In Vitro Study.

(1) Background: One of the most challenging parts in lingual orthodontics is the control and correction of the tip of anterior teeth, due to the occlusal open vertical slot of the incisors in lingual systems. The presented experimental in-vitro study was performed to determine the maximal tipping moment of the anterior teeth between two types of lingual brackets, the Incognito™ Appliance System (Incognito, TOP-Service, Bad Essen, Germany) and Tip-Bar™ system (Incognito, TOP-Service, Bad Essen, Germany). Furthermore, twelve different ligation methods and two different ligature materials were investigated. (2) Methods: The measurement was performed by assessing the stiffness and ultimate strength of the ligature in a uniaxial material testing machine (Instron, Norwood, MA, USA) using a 0.025 × 0.018 inch stainless steel wire. (3) The results showed that the highest precision for control tipping of anterior teeth was determined for the 0.010 inch Stainless Steel Tie (Pelz and Partner). Furthermore, the Tip-Bar™ brackets increased the maximal moment by 33.8% for elastic and steel ligatures. (4) Conclusions: The lateral tooth movement is highly dependent on the type of ligature and applied material during orthodontic treatment with lingual appliances. The use of 0.010 inch steel ligatures and the Tip-Bar™ bracket design results in better alignment in the anterior teeth segment.

Three-dimensional analysis of aligner gaps and thickness distributions, using hard x-ray tomography with micrometer resolution.

Purpose: The morphology of a polymer aligner, designed according to an orthodontic treatment plan, determines clinical outcomes. A fundamental element of orthodontic tooth movement with aligner treatment is the fit of the aligner's surface to the individual teeth. Gaps between the aligner and teeth do occur because current aligner fabrication is not capable of completely reproducing the complex anatomy of the individual denture. Our study aims at a quantitative three-dimensional assessment of the fit between optically transparent aligners placed on a polymeric model of the upper dental arch for two thermofoil thicknesses at preselected thermoforming temperatures. Approach: Using an intraoral scan of a subject's upper dental arch, eight models were printed using a stereolithographic system. A series of eight NaturAligners® was manufactured with a pressure molding process, using thermofoils with thicknesses of 550 and 750 µ m and preselected process temperatures between 110°C and 210°C. These aligners placed on the corresponding models were imaged by an advanced micro computed tomography system. The aligners and the models were segmented to extract the gaps and aligners' local thicknesses as a function of the processing temperature for the two foil thicknesses. Results: The results indicate that the aligners show a better fit when the foils are processed at higher temperatures. Nevertheless, processing temperatures can be kept below 150°C, as the gain becomes negligible. Thermal processing reduces the average thickness of the aligners to 60% with respect to the planar starting foil. These thickness distributions demonstrate that the aligners are generally thicker on the occlusal surfaces of molars and premolars but thinner around the incisors and buccal as well as on oral surfaces. Conclusions: Hard x-ray tomography with micrometer resolution is a powerful technique employed to localize the gaps between aligners and teeth, and it also enables film thickness measurements after thermoforming. The thicker film on the occlusal surfaces is most welcome because of aligner abrasion during wear. The NaturAligner® surfaces consist of a 25 - µ m -thin cellulose layer, and thus the microplastics released via abrasion of less than this thickness are expected to be substantially less critical than for other commercially available, optically transparent aligners.

Continuous circular closure in unilateral cleft lip and plate repair in one surgery.

The study aims at assessing wound healing and safety of single-stage two-layers continuous closure in patients with unilateral cleft lip and palate (UCLP). In this retrospective, descriptive cohort study, we assessed wound healing without fistula formation at 1, 3, and 6 months after a single-stage two-layer UCLP repair, in which the midline suture is continuously circular all along the oral and nasal sides. We examined lengths of hospital stay and the incidence of intra- and postoperative adverse events. Furthermore, we compared the cleft width at birth and on the day of surgery, after presurgical orthopaedics. Eleven UCLP patients underwent one cleft surgery between July 2016 and June 2018 at the age of 8-9 months. Full primary healing occurred in all patients without fistulas. Median length of post-operative hospital stay was 5 days (range = 4-9 days). No intra- or postoperative adverse events above Grade I (according to ClassIntra and Clavien-Dindo, respectively) occurred. Median and interquartile range (IQR) of the palatal cleft width decreased significantly from birth to surgery, i.e., from 12.0 mm (10.8-13.6 mm) to 5.0 mm (4.0-7.5 mm) anteriorly and from 14.0 mm (11.5-15.0 mm) to 7.3 mm (6.0-8.5 mm) posteriorly (p = 0.0033 in both cases). Given these preliminary results, the concept of single-stage continuous circular closure in UCLP has potential for further investigation. However, it remains to be proven that there are no relevant adverse effects such as inhibition of maxillary growth. Registered in clinicaltrials.gov:NCT04108416.

Digital impressions from newborns to preschoolers with cleft lip and palate: A two-centers experience.

BACKGROUND: 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. METHODS: 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. RESULTS: 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 85.5 s for cleft palate and 50 s for cleft lip and nose (IQR 56 s and 39 s, respectively). CONCLUSION: 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.

Craniofacial Growth at Age 6-11 Years after One-Stage Cleft Lip and Palate Repair: A Retrospective Comparative Study with Historical Controls.

BACKGROUND: Primary alveolar bone grafting inhibits craniofacial growth. However, its effect on craniofacial growth in one-stage cleft lip and palate protocols is unknown. This study investigated whether primary alveolar bone grafting performed during one-stage unilateral cleft lip and palate repair negatively affects growth up to 6-11 years old. METHODS: The craniofacial growth, dental arch relationship and palatal morphology at 6-11 years old in children with unilateral cleft lip and palate were compared retrospectively. Two cohorts after a one-stage protocol without (Group A) and with (Group B) primary bone grafting at the same center were compared. Further, cephalometric measurements for growth were compared with an external cohort of a one-stage protocol and a heathy control. RESULTS: Group A comprised 16 patients assessed at 6.8 years (SD 0.83), and Group B comprised 15 patients assessed at 9 years (SD 2.0). Cephalometric measurements indicated similar sagittal maxillary growth deficits and a significant deviation in maxillary inclination in both groups compared to the healthy group. Moderate to severe changes in palatal morphology were observed in 70% of the members in both groups. CONCLUSION: Omitting primary alveolar bone grafting under the one-stage protocol with two-flap palatoplasty studied did not improve growth at 6-11 years. The results implicate two-flap palatoplasty with secondary healing as having greater adverse effects on growth than primary alveolar bone grafting. Dental and palatal morphology was considerably compromised regardless of primary alveolar bone grafting.

Evaluation of accuracy and reliability of OneCeph digital cephalometric analysis in comparison with manual cephalometric analysis-a cross-sectional study.

INTRODUCTION: Lateral cephalometric analysis continues to be one of the gold standard diagnostic aids in orthodontics, with various software available to enhance this. AIM: This study was done to evaluate the accuracy and reliability of linear and angular measurements obtained from OneCeph digital cephalometric tracing and manual tracings in lateral cephalometry. METHODOLOGY: This is a cross-sectional study done on twenty pre-treatment lateral cephalometric radiographs of subjects who reported to the postgraduate orthodontic clinic for orthodontic treatment over one month. Cephalometric tracings were done using OneCeph digital software and manual tracing method to evaluate nine parameters of Steiner's cephalometric analysis. An Independent T-sample test was done between the mean values of manual and OneCeph tracing. Intra operator reliability was evaluated by paired T-test after a week. RESULTS: No significant statistical difference was observed as the p-value was greater than 0.05 for all the parameters in the two groups. CONCLUSION: The reliability and accuracy of OneCeph software application was found to be at par with manual cephalometric tracing.

Paediatric dental care during and post-COVID-19 era: Changes and challenges ahead.

BACKGROUND: COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus is transmitted through respiratory droplets and by physical contact from contaminated surfaces to the mucosa. Its route of transmission has caused a significant challenge in medical and dental healthcare. OBJECTIVE: This article aims to review the literature and information available on the provision of paediatric dental treatment during and post-pandemic and to provide specific recommendations on the safe provision of paediatric dental care. RESULTS: Children infected by SARS-CoV-2 have no or milder COVID-19 symptoms and are potential vectors in spreading the disease. Routine dental treatment is suspended in many countries because of the increased risk of cross-infection in dental practices. Only emergency dental care is provided for urgent conditions. It is necessary to gradually reinstate regular dental care to paediatric patients and maintain their good oral health. To control the disease transmission and maintain the oral health of the population, minimally intervention techniques that minimise or eliminate aerosol generation, plus comprehensive oral health preventive measures should be practised to safeguard safety at dental practices in this unprecedented time. CONCLUSIONS: Robust infection control guidelines should be implemented in dental clinics to minimise the risk of infection and to ensure the safety of patients and staff during the pandemic. Three levels of preventive care should be practised to prevent oral diseases and improve children's oral health in this COVID-19 era. Treatment should be prioritized to patients in urgent needs and aerosol-generating procedures should be minimized.

A Comparison of Craniofacial Characteristics between Two Different Adult Populations with Class II Malocclusion-A Cross-Sectional Retrospective Study.

The dental, skeletal, and soft-tissue characteristics of a particular malocclusion can differ based on ethnicity, race, age, sex and geographical location with Class II malocclusion being one of the most prevalent malocclusions encountered in orthodontic clinical practice. The broad understanding of the characteristics of vertical skeletal and dental parameters in patients with Class II malocclusion can help clinicians to identify patterns and variations in the expression of this phenotype for better treatment outcomes. Hence, we compared the craniofacial characteristics of skeletal and dental Class II malocclusion traits from Indian and Vietnamese individuals to analyze the vertical skeletal and dental patterns in both population groups. The sample comprised of lateral cephalograms from 100 young adults with Class II malocclusion, of which fifty (25 males and 25 females) were from South India and the other 50 age- and sex-matched adults from Vietnam. The lateral cephalometric radiographs were digitized into anonymous image files and were traced and assessed for 16 vertical skeletal and dental parameters. The ANB angle was greater in males (+1.4 deg; p < 0.001) and females (+1.9 deg; p < 0.001) in the South Indian population. The Vietnamese males had a larger mandibular plane angle, articular angle, anterior facial height and lower anterior facial height compared to the Indian males. The Vietnamese females had larger mandibular plane and articular angles compared to the Indian females. The skeletal class II malocclusion was more severe in the South Indian compared to the Vietnamese adults. The Vietnamese sample showed a generalized tendency towards a more vertical skeletal growth pattern and in males this pattern seemed to be due to the dentoalveolar component. The Vietnamese females showed a tendency towards a vertical growth pattern, but without apparent contribution by the dentoalveolar component.

Three-Dimensional Morphological Changes of the True Cleft under Passive Presurgical Orthopaedics in Unilateral Cleft Lip and Palate: A Retrospective Cohort Study.

The aim of this cohort study was to quantify the morphological changes in the palatal cleft and true cleft areas with passive plate therapy using a new analysis method based on three-dimensional standardized reproducible landmarks. Forty-five casts of 15 consecutive patients with complete unilateral cleft lip and palate were laser scanned and investigated retrospectively. The landmarks and the coordinate system were defined, and the interrater and intrarater measurement errors were within 1.0 mm. The morphological changes of the cleft palate area after a period of 8 months of passive plate therapy without prior lip surgery are presented graphically. The median decrease in cleft width was 38.0% for the palatal cleft, whereas it was 44.5% for the true cleft. The width of the true and palatal cleft decreased significantly over a period of 8 months. The true cleft area decreased by 34.7% from a median of 185.4 mm2 (interquartile range, IQR = 151.5-220.1) to 121.1 mm2 (IQR = 100.2-144.6). The palatal cleft area decreased by 31.5% from a median of 334 mm2 (IQR = 294.9-349.8) to 228.8 mm2. The most important clinical considerations are the reproducibility and reliability of the anatomical points, as well as the associated morphological changes. We propose using the vomer edge to establish a validated measuring method for the width, area, and height of the true cleft.

Influence of different storage temperatures on the mechanical properties of NiTi, Cu-NiTi and SS orthodontic archwires: An in vitro study.

OBJECTIVE: Due to their exceptional temperature sensitivity, the mechanical properties of Nickel-titanium and Copper Nickel-titanium wires may be influenced by their storage temperature. This in turn may have clinical implications and may also affect the outcomes. This study analyzed the influence of storage temperatures on the mechanical properties of orthodontic wires in a laboratory setting. MATERIALS AND METHODS: Stainless steel (SS), Nickel-Titanium (NiTi), and three variants of Copper-NiTi (Cu-NiTi 27°C, 35°C and 40°C), 0.017×0.025 inches in size were analysed using a three-point bending test in a pre-heated chamber at 36°C. The orthodontic wires were stored for twenty-four hours before the mechanical testing at four different temperatures (5°, 22°, 36° and 60°C). RESULTS: The obtained results showed that the mechanical forces exerted by 27°C Copper-NiTi exhibit the most stable behaviour after having been stored at different temperatures, whereas 35°C Copper-NiTi showed the highest variability. As to be expected, Stainless steel shows no changes in its bending mechanical properties. CONCLUSION: Furthermore, the results of this investigation reflect the importance of controlling the storage temperature of orthodontic NiTi and Copper-NiTi wires tested in a research environment in order to avoid unexpected bias.

The effect of pacifier sucking on orofacial structures: a systematic literature review.

BACKGROUND: Non-nutritive sucking habits may adversely affect the orofacial complex. This systematic literature review aimed to find scientific evidence on the effect of pacifier sucking on orofacial structures. METHODS: A search on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases was conducted to find all pertinent articles published from inception until February 2018, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the studies was evaluated using the risk of bias judgements in non-randomized studies of interventions (ROBINS-I). RESULTS: Among the 2288 articles found, 17 articles met the selection criteria: seven prospective cohort studies, nine cross-sectional studies, and one randomized clinical trial. Using ROBINS-I, 12 studies were evaluated to have a serious overall risk of bias and five, a moderate one. These studies claimed a strong association between a pacifier sucking habit and the presence of an anterior open bite and posterior crossbite. Functional/orthodontic pacifiers were shown to cause significantly less open bites than the conventional ones. CONCLUSIONS: High level of evidence of the effect of sucking habits on orofacial structures is missing. The available studies show severe or moderate risk of bias; hence, the findings in the literature need to be very carefully evaluated. There is moderate evidence that the use of pacifier is associated with anterior open bite and posterior crossbite, thus affecting the harmonious development of orofacial structures. Functional/orthodontic pacifiers reduce the prevalence of open bite when compared to the conventional ones, but evidence is needed concerning the effects on posterior crossbite. Well-designed randomized controlled trials are needed to further analyze the effects of functional/orthodontic and conventional pacifiers on orofacial structures.