Development and Preliminary Evaluation of A Soft Tissue Microtia Simulator.

Surgical simulation has been used extensively for learning microtia reconstruction and has almost exclusively involved framework creation. However, soft tissue reconstruction in microtia is equally challenging and would benefit from a simulation platform. This study aimed to describe the development and preliminary evaluation of a high-fidelity soft tissue microtia simulator. Three-dimensional modeling software, fused deposition 3-dimensional printing, adhesive techniques, silicones, and polyurethane rubbers were utilized to create a right lobular-type microtia simulator that comprises skin, subcutaneous tissue, and cartilage. Two expert microtia surgeons performed a microtia reconstruction on the simulator and evaluated its value and realism using a Likert-type questionnaire. The surgeons utilized a previously developed synthetic framework and successfully performed the critical steps of the soft tissue reconstruction, including marking, incising, dissection, removal of the cartilage remnant, drain insertion, insertion of the framework, closing of the skin, and demonstration of the soft tissue conforming over the framework using suction. A preliminary assessment of the simulator demonstrated that the simulator is anatomically accurate, realistic, and highly valuable as a training tool. A high-fidelity soft tissue microtia simulator was successfully developed and tested. The simulator provides a valuable training platform for learning a critical component of microtia reconstruction.

Bilateral Cleft lip Simulation.

OBJECTIVE: To evaluate the features, anatomic accuracy, and educational value of a high-fidelity bilateral cleft lip simulator. DESIGN: Evaluation of the simulator by expert cleft surgeons after performing a simulated bilateral cleft lip repair. SETTING: The simulator was evaluated by the surgeons during the Latin American Craniofacial Association meeting. PARTICIPANTS: Eleven experienced cleft surgeons evaluated the simulator. The cleft surgeons were selected based on their availability during the meeting. INTERVENTIONS: The participants performed a simulated bilateral cleft lip repair. They were each provided with a questionnaire assessing the simulator's features, realism and value as a training tool. MAIN OUTCOME MEASURE (S): The main outcome measure are the scores obtained from a Likert-type questionnaire assessing the simulators features, realism and value. RESULTS: Overall, the surgeons agreed with the simulator's realism and anatomic accuracy (average score of 3.7 out of 5). Overall, the surgeons strongly agreed with the value of the simulator as a training tool (average score of 4.6 out of 5). CONCLUSIONS: A high-fidelity bilateral cleft lip simulator was developed that is realistic and valuable as a training tool. The simulator provides a comprehensive training platform to gain hands-on experience in bilateral cleft lip repair before operating on real patients.

Surgery for Velopharyngeal Insufficiency Following Cleft Palate Repair: An Audit of Contemporary Practice and Proposed Schema of Techniques and Variations.

OBJECTIVE: Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed.Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique. RESULTS: Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation. CONCLUSIONS: A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech.

Measuring the Unilateral Cleft Lip Nasal Deformity: Lateral Deviation of Subnasale Is a Clinical and Morphologic Index of Unrepaired Severity.

OBJECTIVE: Objective measurement of pre-operative severity is important to optimize evidence-based practices given that the wide spectrum of presentation likely influences outcomes. The purpose of this study was to determine the correlation of objective measures of form with a subjective standard of cleft severity. DESIGN: 3D images were ranked according to severity of nasal deformity by 7 cleft surgeons so that the mean rank could be used as the severity standard. PATIENTS: 45 patients with unilateral cleft lip and 5 normal control subjects. INTERVENTIONS: Each image was assessed using traditional anthropometric analysis, 3D landmark displacements, and shape-based analysis to produce 81 indices for each subject. MAIN OUTCOME: The correlation of objective measurements with the clinical severity standard. RESULTS: Lateral deviation of subnasale from midline was the best predictor of severity (0.86). Other strongly-correlated anthropometric measurements included columellar angle, nostril width ratio, and lateral lip height ratio (0.72, 0.80, 0.79). Almost all shape-based measurements had tight correlation with the severity standard, however, dorsum deviation and point difference nasolabial symmetry were the most predictive (0.84, 0.82). CONCLUSIONS: Quantitative measures of severity transcend cleft type and can be used to grade clinical severity. Lateral deviation of subnasale was the best measure of severity and may be used as a surrogate of uncoupled premaxillary growth; it should be recorded as an index of pre-operative severity with every cleft lip repair. The correlation of other measures evaluated clarify treatment priorities and could potentially be used to grade outcomes.

The First Hybrid International Educational Comprehensive Cleft Care Workshop.

OBJECTIVE: Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance. DESIGN: Cross-sectional survey-based evaluation. SETTING: International comprehensive cleft care workshop. PARTICIPANTS: Total of 489 participants. INTERVENTIONS: Three-day simulation-based hybrid comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance. RESULTS: The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01). CONCLUSION: Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Sella Turcica Bridging and Tooth Agenesis in Children With Unilateral Cleft Lip and Palate.

AIM: To investigate differences in sella turcica size and bridging in children with unilateral cleft lip and palate (UCLP) with or without concomitant dental anomalies. PATIENTS AND METHODS: A cross-sectional study was carried out looking at 56 children with nonsyndromic UCLP. Lateral cephalograms, taken before alveolar bone grafting, were used to assess sella turcica height, width, area, and bridging. Panoramic radiographs were used to evaluate the presence of dental anomalies in the cleft area including agenesis, supernumerary, and peg-shaped lateral incisors. Differences between sella turcica measurements in the presence or absence of dental anomalies were assessed using t tests. Differences between the prevalence of dental anomalies and sella turcica bridging were assessed using χ2 and Fisher exact tests. Multinomial logistic regression was used to investigate potential associations between sella measurements and dental anomalies. RESULTS: Twenty-six of the 56 children presented with agenesis of the cleft-side lateral incisor, while 7 had a supernumerary, and 19 had a peg-shaped lateral incisor. With regard to sella turcica bridging, 27 children had no calcification, 25 partial and 4 complete calcification. Children with agenesis of the cleft-side lateral incisor showed a shorter sella maximum height (P = .010) and a smaller area (P = .019). When looking at sella turcica bridging, 100% of children with complete calcification showed agenesis of the cleft-side lateral incisor, compared with 52% and 33% of children with partial calcification and no calcification, respectively (P = .034). CONCLUSIONS: Children with UCLP and sella turcica bridging are more likely to present with agenesis of the cleft-side maxillary lateral incisor.

Sella turcica morphometrics in children with unilateral cleft lip and palate.

OBJECTIVE: To use morphometric methods to investigate the size and shape of the sella turcica in children with unilateral cleft lip and palate (UCLP). SETTING AND SAMPLE POPULATION: Fifty-six healthy children with non-syndromic UCLP, from a major paediatric teaching hospital, with lateral cephalograms taken prior to alveolar bone grafting, were compared with an age- and sex-matched control group of healthy children without orofacial clefts, with lateral cephalograms taken prior to orthodontic treatment. MATERIALS AND METHODS: In this cross-sectional study, conventional measurements were performed on the sella turcica to measure width, height and area on lateral cephalograms. Sella shape was also analysed using 11 points defining the sella turcica contours, using geometric morphometrics. Procrustes superimposition was used to register all sella contour tracings to calculate average sella shape. Principal component analysis was applied to the residuals of the point coordinates, and principal components (PCs) of shape were extracted. RESULTS: Statistically significant differences between the UCLP and control groups were found for sella posterior height, midpoint height, maximum height and area, where all of these were smaller in children with UCLP. Principal component analysis revealed that the first two PCs accounted for 84.7% of total shape variance. There was a statistically significant difference in sella shape between children with UCLP and control children. CONCLUSIONS: In children with UCLP, the sella turcica is shorter and with a smaller surface area when compared to matched non-cleft children. Moreover, sella turcica shape, when disregarding size, seems to differ to that of non-cleft children.

Assessing Performance in Simulated Cleft Palate Repair Using a Novel Video Recording Setup.

OBJECTIVE: To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance. DESIGN: Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed. RESULTS: The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions. CONCLUSIONS: The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair.

Comparison of dental outcomes in patients with nonsyndromic complete unilateral cleft lip and palate who receive secondary alveolar bone grafting before or after emergence of the permanent maxillary canine.

INTRODUCTION: For patients with complete unilateral cleft lip and palate (CUCLP), secondary alveolar bone grafting (SABG) can be performed before or after the emergence of the cleft side permanent canine (pre-CE and post-CE, respectively). The controversy regarding dental outcomes related to the timing of SABG remains unsettled. The objective of this study was to evaluate dental survival and specific dental outcomes of cleft-adjacent teeth in children with CUCLP who received either pre-CE or post-CE SABG. METHODS: The permanent maxillary canines and the central and lateral incisors of 21 pre-CE and 23 post-CE SABG subjects with nonsyndromic CUCLP and all cleft-related surgeries performed by the same surgeon were analyzed retrospectively. Intraoral radiographs and clinical chart notes were collected at age 7 years, at the time of the SABG, and approximately 4 years after the grafting. Dental survival, spontaneous canine eruption, planned prosthetic replacement, root development, and root resorption were analyzed. RESULTS: Dental outcomes on the noncleft side were better than those on the cleft side. On the cleft side, dental survival of the cleft-adjacent teeth was not significantly different between the pre-CE and post-CE SABG groups (P >0.05). Most teeth completed root development after grafting, and the cleft side canine root development in the pre-CE SABG group appeared to accelerate after SABG. Trends showed that the pre-CE SABG group suffered less root resorption (16.28%; post-CE: 22.73%; P >0.05) and received fewer planned prosthetic replacements (14.29%; post-CE: 26.01%; P >0.05) but required a greater number of canine exposures (33.33%; post-CE: 4.55%; P = 0.02). CONCLUSIONS: Pre-CE SABG showed better dental outcomes in patients with CUCLP, with fewer adverse dental outcomes than post-CE SABG.

Economy of Hand Motion During Cleft Palate Surgery Using a High-Fidelity Cleft Palate Simulator.

OBJECTIVE: The objectives of this study were to assess economy of hand motion of residents, fellows, and staff surgeons using a high-fidelity cleft palate simulator to (1) stratify performance for the purpose of simulator validation and (2) to estimate the learning curve. DESIGN: Two residents, 2 fellows, and 2 staff surgeons performed cleft palate surgery on a high-fidelity cleft palate simulator while their hand motion was tracked using an electromagnetic hand sensor. The time, number of hand movements, and path length of their hands were determined for 10 steps of the procedure. The magnitude of these metrics was compared among the 3 groups of participants and utilized to estimate the learning curve using curve-fitting analysis. RESULTS: The residents required the most time, number of hand movements, and path length to complete the procedure. Although the number of hand movements was closely matched between the fellows and staff, the overall total path length was shorter for the staff. Inverse curves were fit to the data to represent the learning curve and 25 and 113 simulation sessions are required to reach within 5% and 1% of the expert level, respectively. CONCLUSION: The simulator successfully stratified performance using economy of hand motion. Path length is better matched to previous level of experience compared to time or number of hand movements.

Recreational use in dispersed public lands measured using social media data and on-site counts.

Outdoor recreation is one of many important benefits provided by public lands. Data on recreational use are critical for informing management of recreation resources, however, managers often lack actionable information on visitor use for large protected areas that lack controlled access points. The purpose of this study is to explore the potential for social media data (e.g., geotagged images shared on Flickr and trip reports shared on a hiking forum) to provide land managers with useful measures of recreational use to dispersed areas, and to provide lessons learned from comparing several more traditional counting methods. First, we measure daily and monthly visitation rates to individual trails within the Mount Baker-Snoqualmie National Forest (MBSNF) in western Washington. At 15 trailheads, we compare counts of hikers from infrared sensors, timelapse cameras, and manual on-site counts, to counts based on the number of shared geotagged images and trip reports from those locations. Second, we measure visitation rates to each National Forest System (NFS) unit across the US and compare annual measurements derived from the number of geotagged images to estimates from the US Forest Service National Visitor Use Monitoring Program. At both the NFS unit and the individual-trail scales, we found strong correlations between traditional measures of recreational use and measures based on user-generated content shared on the internet. For national forests in every region of the country, correlations between official Forest Service statistics and geotagged images ranged between 55% and 95%. For individual trails within the MBSNF, monthly visitor counts from on-site measurements were strongly correlated with counts from geotagged images (79%) and trip reports (91%). The convenient, cost-efficient and timely nature of collecting and analyzing user-generated data could allow land managers to monitor use over different seasons of the year and at sites and scales never previously monitored, contributing to a more comprehensive understanding of recreational use patterns and values.

Reliability of Oronasal Fistula Classification.

OBJECTIVE: Oronasal fistula is an important complication of cleft palate repair that is frequently used to evaluate surgical quality, yet reliability of fistula classification has never been examined. The objective of this study was to determine the reliability of oronasal fistula classification both within individual surgeons and between multiple surgeons. DESIGN: Using intraoral photographs of children with repaired cleft palate, surgeons rated the location of palatal fistulae using the Pittsburgh Fistula Classification System. Intrarater and interrater reliability scores were calculated for each region of the palate. PARTICIPANTS: Eight cleft surgeons rated photographs obtained from 29 children. RESULTS: Within individual surgeons reliability for each region of the Pittsburgh classification ranged from moderate to almost perfect (κ = .60-.96). By contrast, reliability between surgeons was lower, ranging from fair to substantial (κ = .23-.70). Between-surgeon reliability was lowest for the junction of the soft and hard palates (κ = .23). Within-surgeon and between-surgeon reliability were almost perfect for the more general classification of fistula in the secondary palate (κ = .95 and κ = .83, respectively). CONCLUSIONS: This is the first reliability study of fistula classification. We show that the Pittsburgh Fistula Classification System is reliable when used by an individual surgeon, but less reliable when used among multiple surgeons. Comparisons of fistula occurrence among surgeons may be subject to less bias if they use the more general classification of "presence or absence of fistula of the secondary palate" rather than the Pittsburgh Fistula Classification System.

Measuring recreational visitation at U.S. National Parks with crowd-sourced photographs.

Land managers rely on visitation data to inform policy and management decisions. However, visitation data is often costly and burdensome to obtain, and provides a limited depth of information. In this paper, we assess the validity of using crowd-sourced, online photographs to infer information about the habits and preferences of recreational visitors by comparing empirical data from the National Park Service to photograph data from the online platform Flickr for 38 National Parks in the western United States. Using multiple regression analysis, we find that the number of photos posted monthly in a park can reliably indicate the number of visitors to a park in a given month. Through additional statistical testing we also find that the home locations of photo-takers, provided voluntarily on an online profile, accurately show the home origins of park visitors. Together, these findings validate a new method for measuring recreational visitation, opening an opportunity for land managers worldwide to track and understand visitation by augmenting current data collection methods with crowd-sourced, online data that is easy and inexpensive to obtain. In addition, it enables future research on how visitation rates change with changes in access, management or infrastructure, weather events, or ecosystem health, and facilitates valuation research, such as travel cost studies.

Preoperative Cleft Lip Measurements and Maxillary Growth in Patients With Unilateral Cleft Lip and Palate.

OBJECTIVE: Maxillary growth in patients with cleft lip and palate is highly variable. The authors' aim was to investigate associations between preoperative cleft lip measurements and maxillary growth determined cephalometrically in patients with complete unilateral cleft lip and palate (cUCLP). DESIGN: Retrospective cross-sectional study. PATIENTS: Children with cUCLP. METHODS: Preoperative cleft lip measurements were made at the time of primary cheiloplasty and available for each patient. Maxillary growth was evaluated on lateral cephalometric radiographs taken prior to any orthodontic treatment and alveolar bone grafting (8.5 ± 0.7 years). The presence of associations between preoperative cleft lip measurements and cephalometric measures of maxillary growth was determined using regression analyses. RESULTS: In the 58 patients included in the study, the cleft lateral lip element was deficient in height in 90% and in transverse width in 81% of patients. There was an inverse correlation between cleft lateral lip height and transverse width with a ß coefficient of -0.382 (P = .003). Patients with a more deficient cleft lateral lip height displayed a shorter maxillary length (ß coefficient = 0.336; P = .010), a less protruded maxilla (ß coefficient = .334; P = .008), and a shorter anterior maxillary height (ß coefficient = 0.306; P = .020) than those with a less deficient cleft lateral lip height. CONCLUSIONS: Patients with cUCLP present with varying degrees of lateral lip hypoplasia. Preoperative measures of lateral lip deficiency are related to later observed deficiencies of maxillary length, protrusion, and height.

Presurgical Unilateral Cleft Lip Anthropometrics and the Presence of Dental Anomalies.

OBJECTIVE: To investigate associations between cleft lip anthropometrics and dental anomalies in the permanent dentition in unilateral cleft lip patients. DESIGN: Retrospective cross-sectional study. PATIENTS: Children with unilateral clefts of the lip, with or without cleft palate. METHODS: Anthropometric lip measurements, made immediately prior to lip repair, were available for each patient. The presence of dental anomalies in the permanent dentition was assessed radiographically. The presence of associations between anthropometric lip measurements and prevalence rates of different dental anomalies were determined using logistic regression analyses. RESULTS: In the 122 included patients, the cleft lateral lip element was deficient in height in 80% and in transverse length in 84% of patients. Patients with more deficient cleft side lateral lip height and less deficient cleft side lateral lip transverse length were more likely to present with cleft side maxillary lateral incisor agenesis. On the other hand, patients with a less deficient cleft side lateral lip height and more deficient cleft side lateral lip transverse length were more likely to present with a cleft side supernumerary maxillary lateral incisor. When looking only at incomplete clefts, the cleft side lateral lip transverse length deficiency was more predictive of the presence of supernumerary maxillary lateral incisors (P = .030), while for complete clefts, the cleft side lateral lip height deficiency was more predictive of the presence of maxillary lateral incisor agenesis (P = .035). CONCLUSIONS: In patients with unilateral clefts, cleft lip anthropometrics have a predictive role in determining the occurrence of dental anomalies.

Presurgical cleft lip anthropometrics and dental arch relationships in patients with complete unilateral cleft lip and palate.

OBJECTIVE: To investigate associations between anthropometric lip measurements and dental arch relationships in patients with complete unilateral cleft lip and palate (CUCLP). DESIGN: Retrospective cross-sectional study. PATIENTS: Children with CUCLP. METHODS: Anthropometric lip measurements, made immediately prior to lip repair, were available for each patient. The dental arch relationships were evaluated on dental study casts (8.6 ± 0.9 years) taken prior to any orthodontic treatment and prior to alveolar bone graft, using the modified Huddart and Bodenham (MHB) scoring system. The presence of associations between anthropometric lip measurements and dental arch relationships was determined using linear regression analysis. RESULTS: In the 63 patients included in the study, the cleft lateral lip element was deficient in height in 87% and in transverse width in 86% of patients. Patients with more deficient cleft-side lateral lip height were more likely to present with more negative MHB scores (r = .443; P < .001). Conversely, patients with more deficient cleft-side lateral lip transverse width more often presented with more positive MHB scores (r = .281; P = .025). CONCLUSIONS: In patients with CUCLP, there is a wide variability in the degree of deficiency of the cleft-side lateral lip element, both in the vertical and in the transverse dimension. The extent of this deficiency may, in part, predict the resulting dental arch relationships.

State of the art: The Unilateral Cleft lip and Nose Deformity and Anatomic Subunit Approximation.

The anatomic subunit approximation approach to unilateral cleft lip repair was developed over 20 years ago. While the underlying principles of the repair are unchanged, its description has been simplified, additional landmarks and creases have been added, and objective analysis of perioperative changes have provided better clarity regarding goals and desired alterations. We review recent insights regarding the deformity; describe the repair in a simplified manner; and link a stepwise approach to foundation-based primary rhinoplasty as a part of the avenue to creating nasolabial balance and harmony.

L'approximation de la sous-unité anatomique pour réparer la fissure palatine unilatérale a été mise au point il y a plus de 20 ans. Les principes fondamentaux de la réparation n'ont pas changé, mais la description est simplifiée et des repères et des plis ont été ajoutés, sans compter qu'une analyse objective de la malformation et des changements chirurgicaux ont permis de mieux comprendre les objectifs ainsi que les modifications souhaitées. Les auteurs analysent la malformation dans le contexte de récentes études objectives, décrivent la réparation selon des concepts contemporains et relient une approche graduelle à la rhinoplastie primaire fondamentale dans le cadre de la trajectoire visant à créer une harmonie et un équilibre nasolabiaux.

Evaluation of a high-fidelity cleft alveolar bone graft simulator.

INTRODUCTION: Cleft alveolar bone graft surgery is technically challenging to perform as well as difficult to learn and teach. A high-fidelity cleft alveolar bone graft simulator was previously developed. However, further evaluation of the simulator is necessary to assess its efficacy. METHODS: Two cleft simulation workshops were conducted in which participants were led through a simulated cleft alveolar bone graft. The first simulation workshop involved six plastic surgery trainees. The second workshop involved 43 practicing cleft surgeons. The participants were provided with a Likert-type questionnaire assessing the simulators' features, realism, and value as a training tool. The change in self-reported confidence was assessed by providing each participant with a pre- and post-simulation confidence questionnaire. RESULTS: There was overall agreement in the realism of the simulators' features (average score of 4.67 and 3.80 out of 5 for the trainees and surgeons, respectively). There was overall agreement to strong agreement in the simulators value as a training tool (average score of 5 and 4.43 out of 5 for the trainees and surgeons, respectively). The self-reported confidence increased for all questionnaire items for both the trainees and surgeons. This was significant (p < 0.05) for five out of eight and all questionnaire items for the trainees and surgeons, respectively. The magnitude of the confidence increase was generally greater for less experienced participants. CONCLUSION: The cleft alveolar bone graft simulator was found to be realistic and valuable as a training platform. Use of the simulator improved self-reported confidence in cleft alveolar bone graft surgery.

Root development differences between cleft-adjacent teeth on the cleft side in comparison to their analogs on the noncleft side in patients with nonsyndromic cleft lip and palate who received secondary alveolar bone grafting.

OBJECTIVE: To assess differences in root development between the cleft side (CS) and noncleft side (NCS) for permanent maxillary central incisor and canine longitudinally in patients with nonsyndromic complete unilateral cleft lip and palate (cUCLP) who received secondary alveolar bone grafting (SABG) and to evaluate the effects of SABG on the acceleration of root development of these teeth. MATERIALS AND METHODS: Permanent maxillary central incisors and canines of 44 subjects with nonsyndromic cUCLP who had all their cleft-related surgeries performed by the same surgeon were analyzed retrospectively from chart notes and radiographs. Panoramic and periapical radiographs at time point 1 (T1) (age, 7.55 years), at SABG (time point 2 [T2], 10.13 years), and a minimum of 2 years after SABG were studied. Root development rating scores on the NCS and CS were compared using paired t-tests and analyses of proportions. RESULTS: Mean root development score differences (NCS - CS) for canines and central incisors were greatest at T2 but diminished at time point 3 (T3). A larger proportion of teeth on the CS trailed the teeth on the NCS by at least 1 point at T2 than at T1 or T3, with the smallest proportion being observed at T3. The change in root development scores from T1 to T2 and from T2 to T3 showed relative CS acceleration from T2 to T3, indicating a catch-up of root development of cleft-adjacent teeth after SABG. CONCLUSIONS: Root development of cleft-adjacent central incisors and canines is slow in comparison with their noncleft analogs. Root development of these teeth accelerates following SABG.

Development and Evaluation of a High-Fidelity Rhinoplasty Simulator.

SUMMARY: Rhinoplasty is a challenging procedure with a steep learning curve. Surgical simulators provide a safe platform to gain hands-on experience without compromising patient outcomes. Therefore, rhinoplasty is an ideal procedure to benefit from an effective surgical simulator. A high-fidelity rhinoplasty simulator was developed using three-dimensional computer modeling, three-dimensional printing, and polymer techniques. The simulator was tested by six surgeons with experience in rhinoplasty to assess realism, anatomic accuracy, and value as a training tool. The surgeons performed common rhinoplasty techniques and were provided a Likert-type questionnaire assessing the anatomic features of the simulator. A variety of surgical techniques were performed successfully using the simulator, including open and closed approaches. Bony techniques performed included endonasal osteotomies and rasping. Submucous resection with harvest of septal cartilage, cephalic trim, and tip suturing, as well as grafting techniques including alar rim, columellar strut, spreader, and shield grafts, were performed successfully. Overall, there was agreement on the simulator's anatomic accuracy of bony and soft-tissue features. There was strong agreement on the simulator's overall realism and value as a training tool. The simulator provides a high-fidelity, comprehensive training platform to learn rhinoplasty techniques to augment real operating experience without compromising patient outcomes.