Three-Dimensional Analysis of Craniofacial Structures of Individuals With Nonsyndromic Unilateral Complete Cleft Lip and Palate.

ABSTRACT: Cleft lip and palate (CLP) is one of the most common congenital deformities. Primary surgeries at an early age result in scar formation, which may impede the growth of craniofacial structures of the maxilla. Orthodontist's role in the management of individuals with CLP is important and starts from the time of birth. The knowledge of craniofacial structures in individuals with a cleft is essential for treatment planning. The purpose of this study was to analyze and compare craniofacial structures of cleft and noncleft side of individuals with non-syndromic unilateral complete cleft lip and palate (NSUCCLP) using cone-beam computed tomography (CBCT). CBCT scans of individuals with NSUCCLP (n = 42) were retrieved from the databases of two cleft centers, which followed the same protocols for timing and type of primary surgeries and secondary alveolar bone grafting (SABG). DICOM files of CBCT scans were integrated into Dolphin 3D software, and analysis was carried out in multiplanar views. The craniofacial structures of individuals with NSUCCLP were analyzed using fourteen parameters. Measurements were also recorded between the cleft and noncleft sides for comparison. The volume of the maxilla was generated by isolating it from adjacent structures on a 3D reconstructed model. MAWC, MAWPM1, MAWPM2, MAWM1, and MV of the cleft side was less than noncleft side (P < 0.05). MHP @ N Aper is less on the noncleft side (P < 0.05). There is an asymmetry of structures around the dentoalveolar and nasal region; however, asymmetries were not affected at deeper structures of the craniofacial region of individuals with NSUCCLP.

Morpho-Functional Septorhinoplasty in Adult Patients With Unilateral Cleft Lip Nasal Deformity: A Comprehensive Approach.

PURPOSE: The aim of this study was to introduce a morpho-functional technique of rhinoplasty for correction of defective nasal morphology of the secondary unilateral cleft lip and improvement of air passage through the nose. MATERIALS AND METHODS: The described comprehensive approach follows the rule of 5 R's: relieve, resect, reposition, restructure, and restrengthen. The extended septal graft serves as a columellar strut on the one hand and as a spreader graft on the other hand. RESULTS: The described morpho-functional septorhinoplasty technique is effective for correction of the unilateral cleft lip nasal deformity because it improves the symmetry of the nose, improves the morphology of the alar cartilage, and increases the nasal tip projection. An improvement in breathing occurs as a result of restored symmetry of the ala and nasal vestibule. CONCLUSIONS: Morpho-functional septorhinoplasty is a practical tool to handle adult patients with secondary cleft nasal deformities.

Placement of an antibiotic oral pack on the hard palate after primary cleft palatoplasty: a randomized controlled trial into the effect on fistula rates.

OBJECTIVE: The objective of this study is to determine whether placement of an antibiotic oral pack on the hard palate reduces fistula rates after primary cleft palatoplasty. SUBJECTS AND METHODS: This study was a parallel blocked randomized controlled trial. The study consisted of two groups of 100 patients each with non-syndromic unilateral complete cleft lip, alveolus, and hard and soft palate that underwent primary palatoplasty. Group A had an oral pack placed on the hard palate for 5 days postoperatively while group B did not. Occurrence of fistulae between both groups was tested using odds ratios (OR). RESULTS: In 2% of the patients in group A, a fistula was found 6 months after palatal surgery. In contrast, in 21% of the patients in group B, a palatal fistula could be confirmed. The fistula occurrence in group A was statistically significantly lower than that in group B (OR = 0.0768, CI = [0.02 … 0.34], p < 0.001). CONCLUSION: The findings of this study provide evidence that the rate of fistula formation after primary palatoplasty is significantly reduced if a pack soaked with antibiotic cream is placed on the palate postoperatively for 5 days. CLINICAL RELEVANCE: The use of an antibiotic pack after cleft palate repair can be recommended to prevent occurrence of oronasal fistulae.

Options for the nasal repair of non-syndromic unilateral Tessier no. 2 and 3 facial clefts.

BACKGROUND: Non-syndromic Tessier no. 2 and 3 facial clefts primarily affect the nasal complex. The anatomy of such clefts is such that the ala of the nose has a cleft. Repairing the ala presents some challenges to the surgeon, especially to correct the shape and missing tissue. Various techniques have been considered to repair these cleft defects. AIM: We present two surgical options to repair such facial clefts. MATERIALS AND METHODS: A nasal dorsum rotational flap was used to treat patients with Tessier no. 2 clefts. This is a local flap that uses tissue from the dorsal surface of the nose. The advantage of this flap design is that it helps move the displaced ala of a Tessier no. 2 cleft into its normal position. A forehead-eyelid-nasal transposition flap design was used to treat patients with Tessier no. 3 clefts. This flap design includes three prongs that are rotated downward. A forehead flap is rotated into the area above the eyelid, the flap from above the eyelid is rotated to infra-orbital area and the flap from the infraorbital area that includes the free nasal ala of the cleft is rotated into place. RESULTS AND CONCLUSIONS: These two flap designs show good results and can be used to augment the treatment options for repairing Tessier no. 2 and 3 facial clefts.

Perceptions of family members of children with cleft lip and palate in hyderabad, India, and its rural outskirts regarding craniofacial anomalies: a pilot study.

Objective : This pilot study aimed to understand cultural perspectives on cleft anomalies in the community of Hyderabad, India, and its rural outskirts. Design : Interviews focusing on perceptions of cleft lip and palate were conducted using a 21-item interview guide approved by the director of the Gosla Srinivas Reddy Institute of Craniofacial Surgery (GSR). Settings : Interviews were conducted at GSR, a specialty surgical center located in Hyderabad, India. Patients and Participants : All patients who presented to GSR with either cleft lip, cleft palate, or cleft lip and palate at the time of this study were included. Results : Of the 23 families interviewed, 12 mothers believed the cleft was caused by an eclipse, and two believed the scientific explanation their physician offered. Fourteen families were offered no explanation for the cleft lip and/or palate at the time of their first physician visit. No families practiced non-Western methods for treatment of the cleft. One family identified beliefs held in the community that their child with a cleft lip was bad luck. Conclusion : A commonly held belief in this community in India is that cleft lip, cleft palate, or cleft lip and palate are caused by an eclipse. Physicians appear to be providing families with insufficient education on cleft impairments. Data generated from studies similar to this can be used to design educational protocols that address this gap in community understanding of orofacial clefting.

Ocular Hypertelorism: Principles and Management.

Background: Ocular hypertelorism (OH) was initially considered as un-differentiated congenital cranio-facial deformity, however, I.T Jackson mentioned it as teleorbitism, considering it as increase in the inter-canthal width, inter-pupillary as well as inter-orbital distance as a result of lateralization of the orbital complex in total. Furthermore, Sailer further refined it and included the distance from the lateral orbital wall, i.e. he denoted increased inter-orbital distance along with the distance between lateral orbital walls as true hypertelorism. This condition is rare and is seen in association with midline congenital defects affecting the cranio-facial region. Classification and review of cases: The ideal time for the OH correction is usually between 5 and 8 years of age. However, the management of OH is complex, and several techniques have been described in literature for the same. Here, we describe our classification of OH, along with the evolution of the surgical aspects, the key treatment principles we follow, together with the types of the osteotomies and their indications. Furthermore, we delineate the four main principles that we have set for OH management. Results: Though the improvement in appearance is seen immediately post-surgery, however, this challenging surgery faces a multitude and common postoperative complications which have been represented in this article. The surgeon needs both the technical expertise and an inclination towards aesthetics for the execution of such procedures. Conclusion: It is preferred that the management of OH should be individualized as per the stage of the craniofacial growth and the psychosocial needs of the patient and the parents.

Apical extrusion of debris with root canal instrumentation in primary teeth: A systematic review.

Aim: This study aimed to systematically review available literature of in vitro studies on apical extrusion of debris through rotary instrumentation in comparison to manual instrumentation in pediatric endodontics, and also to perform a comparison between various rotary instrumentation systems for assessment of debris extrusion. Materials and Methods: A comprehensive search was conducted on PubMed, Medline, Cochrane Library, Embase, Scopus, and Google Scholar without any language restriction and year of publication. A planned search strategy was made for PubMed and applied to other databases. After full-text reading, 7 articles were selected for quantitative synthesis. Modified CONSORT checklist of items for reporting in vitro studies of dental materials was used for quality assessment of included studies. Results: Root canal preparation with rotary instrumentation led to lesser apical debris extrusion than manual instrumentation. Self-adjusting file system was associated with the least debris extrusion among all included studies, followed by ProTaper Next, Kedo-S, ProTaper, K3, Mtwo, Revo-S, and Wave One. Conclusion: More apical debris extrusion was seen with manual instrumentation than rotary instrumentation. Furtrhermore, variance in debris extrusion was seen with different rotary file systems.

Reconstruction options in pediatric population with hemi or total mandibulectomy defects: A systematic review.

Purpose: Mandibular pathologies causing extensive defects in pediatrics is relatively rare, and sparse literature is available for the reconstructive options of the same. The main aim is to provide optimum esthetics and function. Materials and methods: PubMed, Cochrane CENTRAL, Embase, MEDLINE and Scopus databases were searched for articles published only in English language up to May 2021, involving reconstruction of hemi or total mandibulectomy defects in patients with the age of 8 years or less, associated with benign or malignant pathology. Primary outcome variable was the success of reconstruction. Qualitative analysis was performed using a microsoft excel-sheet. Results: Of the 2201 articles reviewed, only fourteen were selected for data extraction. 22 patients were included. Fifteen were benign, six were malignant pathologies, and one was not defined. Hemi-mandibulectomy was performed in twenty-one cases, while one underwent total mandibulectomy. Condyle was preserved in five cases, while was removed in nine. Single-stage reconstruction was done in nineteen cases, while second-stage reconstruction was done in the other three. Reconstruction was done with fibular graft in thirteen cases, while CCG was used in others with variable follow-up time. Though minor complications were observed, success was observed in all cases post reconstruction with either fibula or CCG graft, defined either by function, or growth. Conclusion: Irrespective of the age-group, nature of pathology and size of the defect, reconstruction should be considered with either fibula or CCG in single-stage, as they are equally efficacious, with minor complications. Well-defined reconstructive paradigm should be developed for pediatric mandibular reconstruction.

Quantitative analysis of aesthetic outcomes of morphofunctional septorhinoplasty for secondary cleft lip nasal deformity.

The main aim of this study was to assess nasal symmetry after morphofunctional septorhinoplasty, more specifically, symmetry of the alar base and nostrils, and nasal projection, in patients with unilateral and bilateral cleft nasal deformities. Secondary cleft rhinoplasty was performed using morphofunctional septorhinoplasty techniques in 150 patients with unilateral and bilateral cleft lip and nose deformities. Nasal changes were analysed by measuring nasal tip projection, nostril height, nostril width, alar base width, and nasal gap area preoperatively and postoperatively on standard submentovertex view 2-dimensional photographs. In the unilateral cleft group there were statistically significant improvements (p<0.001) in ratios of nasal height and width (p=0.024) and nasal gap area, and in nasal tip projection and alar base width. In the bilateral cleft group there were statistically significant improvements in nasal gap area ratio (p=0.009), nasal tip projection, and alar base width. The morphofunctional septorhinoplasty technique improved aesthetic outcomes.

Nasal symmetry after different techniques of primary lip repair for unilateral complete cleft lip with or without cleft of the alveolus and palate: A systematic review.

The aim of this systematic review was to establish the effect of different surgical repairs for the lip on nasal symmetry. PubMed, Scopus, Embase, Cochrane CENTRAL, and Ovid databases search was performed initially for only English-language articles, in patients with unilateral complete cleft lip with or without cleft alveolus and palate (UCCLAP) who were younger than 1 year of age and undergoing cleft lip repair, and are published from the earliest data available up to December 31, 2020. The primary outcome variable was nasal symmetry, with reported complications being secondary variables. A qualitative synthesis was provided. A total of 19,828 records were obtained, and 17 articles were selected for final review. Assessment of the risk of bias of the included randomized controlled trials (RCTs) (N-1) was done with the Cochrane Risk of Bias 2 (RoB-2) tool, and the ROBINS-I tool was used for non-randomized studies (n = 14). Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to evaluate the quality of the body of evidence. The majority of the included studies compared the triangular repair with the rotation advancement (RA) techniques, and preferred RA or its modifications. In terms of the nasal symmetry, the Fisher repair proved to be superior to the RA technique. Neither RA nor straight line repair was superior to one another. The Delaire technique may be preferred over the modified RA. Also, satisfactory outcomes were observed with simultaneous lip-nose repair. This systematic review examined a plethora of techniques, and the heterogeneity between studies was very high regarding type of surgery, method of nasal symmetry assessment, and length of follow-up, thus producing low-quality evidence; therefore, results should be interpreted with caution. Future research requires RCTs with larger sample sizes and appropriate length of follow-up, and surgeries preferably performed by a single experienced surgeon.

Effect of antibiotic pack on hard palate after fistula closure on nasal airflow and reoccurrence rate.

This parallel blocked randomized controlled trial was done in two groups of 30 patients each to determine if placement of an antibiotic oral pack on the hard palate after hard palatal fistula repair reduces nasal air emission and fistula re-occurrence. Group A had an oral pack on the hard palate for 5 days post-operatively while group B did not. In group A, percentage of nasal air emission was tested using nasometry with and without pack. Paired t-tests were performed to compare nasal emissions for patients with and without pack. Recurrence of fistulas after 6 months between group A and B was tested using odds ratio. Effect of nasal air emission on fistula rates was tested using paired t-tests. There was a significant increase (p < 0.0001) in nasal emission after removal of the pack in group A. Fistula re-occurrence tended to be higher in group B (no pack) than group A but this was not significant (p = 0.242). There was no correlation between nasal air emission and fistula rates. In patients with recurrent fistulae, placement of an oral pack after fistula repair diminishes nasal air emission. Whether this has an impact on re-occurrence of fistulae needs to be investigated further.

Cleft surgery in India - Past, present and future and a model for global knowledge transfer.

This article represents the point of view and philosophy of GSR Institute of Craniomaxillofacial and Facial Plastic Surgery (GSRIFCS) in the management of craniofacial and cleft patients. GSRICFS is a 50 bedded state of art high volume cleft centre in Hyderabad which has accomplished greater than 30000 cleft surgeries. Cleft surgery in India has improved greatly over the last 70 years since the innovations of the Colombo plan to now, resulting in better healthcare facilities, research and transfer of knowledge globally. In this period, the deprivations of the past, due to lack of available, accessible or affordable care or awareness of outpatients and their parentage, of the possibilities, some of cultural origin such as various superstitions leading to isolation and social stigma, have been largely but not completely overcome. There were minimal centres in the past, which provided care, and this was partly due to scarcity of funding, lack of training and non-sustainability of skilled human recourses. Surgery for cleft requires not only a sophisticated infrastructure, but instrumentation, specialized anesthetists and high-end post-operative care along with a multidisciplinary team involving surgeons, anesthetists, paediatricians, psychologists, orthodontists and specialized nurses for optimal outcomes. The article elaborates the vision, mission and plan in establishing the GSRICFS and how it might form a model for the future of cleft care in LMICs.

Assessment of Outcomes of Immediately Loaded Dental Implants in Orofacial Cleft Patients: Protocol for a Single-Arm Clinical Trial.

BACKGROUND: Orofacial cleft, one of the most common congenital deformities, presents with a plethora of defects, subjecting the patient to a multitude of treatments from a young age. Among the oral hard tissue problems, absence of a maxillary permanent tooth in the cleft region either due to congenital absence or extraction due to compromised prognosis is a common finding. Conventionally, the missing tooth is replaced using a removable or fixed partial denture; however, the treatment modality does not satisfactorily meet patient expectations. The most recent decade has seen increasing use of dental implants in the cleft region; however, the outcome of an immediately loaded dental implant is still elusive for orofacial cleft patients. OBJECTIVE: This protocol is for a single-arm clinical trial aimed at determining the treatment outcome of immediately loaded dental implants in patients with a nonsyndromic orofacial cleft. METHODS: Patients meeting the set criteria will be sequentially enrolled until a sample size of 30 dental implants is met and will undergo the proposed treatment according to the predecided protocol. All patients will be followed up at the designated time intervals to record various clinical and radiographic parameters. Implant success will be defined based on the criteria elucidated by Misch et al in the Pisa, Italy Consensus. A quality-of-life assessment questionnaire will also be recorded at the end of patient's follow-up to determine their acceptance of the treatment. RESULTS: A total of 30 dental implants will be placed in patients with a nonsyndromic orofacial cleft. Obtained results will be statistically analyzed to determine the treatment outcomes and success. CONCLUSIONS: This study will help determine the feasibility of immediately loaded dental implants in compromised bone sites such as those presented in cleft patients and will help in generating findings that can be used to fill the lacunae currently present in the holistic treatment of cleft patients. TRIAL REGISTRATION: Clinical Trial Registry of India CTRI/2020/09/027997; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=47659&EncHid=&userName=dental%20implants. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25244.

Relapse and temporomandibular joint dysfunction (TMD) as postoperative complication in skeletal class III patients undergoing bimaxillary orthognathic surgery: A systematic review.

OBJECTIVES: The aim of this study was to determine Relapse and TMD as postoperative complication in skeletal class III patients undergoing bimaxillary orthognathic surgery. MATERIALS AND METHODS: Data was obtained by database searching using The Cochrane Central Register of Controlled Trials (central), PUBMED, SCOPUS, EMBASE, Google scholar, National Medical library, New Delhi. The titles and abstracts of the electronic search results were screened and evaluated by two observers for eligibility according to the inclusion and exclusion criteria. RESULTS: 5261 articles were retrieved for the review. Among these, 3474 duplicate articles were removed. 418 studies were selected based on the eligibility criteria. For the present review, 30 articles were included after elimination according to the inclusion criteria. The Prisma diagram flowchart demonstrates our selection scheme. Quality assessment criteria to evaluate the studies were decided by two review authors in accordance with CONSORT guidelines. Each study was assessed using the evaluation method described in the Cochrane Handbook for Systematic Reviews. Among the 30 studies included in the review, marked degree of relapse in the mandible was noted from 3 months - 1 year postoperatively in 8 studies, 5 studies reported both TMD prevalence and relapse, whereas only 4 studies reported TMD disorder alone. CONCLUSION: Complications of relapse and TMD are associated with bimaxillary orthognathic surgery procedures. More RCTs and CCTs are needed in this regard to get better quality evidence. This review was registered with PROSPERO: CRD42020211342.

Classification and surgical management of temporomandibular joint ankylosis: a review.

The paper reviews various classifications and surgical techniques for the treatment of temporomandibular joint ankylosis. PubMed, EBSCO, Web of Science, and Google Scholar were searched using a combination of keywords. Articles related to classification, resection-reconstruction of the temporomandibular joint, and management of airway obstruction were considered and categorized based on the objectives. Seventy-nine articles were selected, which included randomized clinical trials, non-randomized controlled cohort studies, and case series. Though several classifications exist, most classifications are centered on the radiographic extent of the ankylotic mass and do not include the clinical and functional parameters. Hence there is a need for a comprehensive staging system that takes into consideration the age of the patient, severity of the disease, clinical, functional, and radiographic findings. Staging the disease will help the clinician to adopt a holistic approach in treating these patients. Interpositional arthroplasty (IA) results in better maximal incisal opening compared with gap arthroplasty, with no significant difference in recurrent rates. Distraction osteogenesis (DO) is emerging as a popular technique for the restoration of symmetry and function as well as for relieving airway obstruction. IA, with a costochondral graft, is recommended in growing patients and may be combined with or preceded by DO in cases of severe airway obstruction. Alloplastic total joint replacement combined with fat grafts and simultaneous osteotomy procedures are gaining popularity. A custom-made total joint prosthesis using CAD/CAM can efficiently overcome the shortcomings of stock prostheses.

Silver Diamine Fluoride Versus Atraumatic Restorative Treatment in Pediatric Dental Caries Management: A Systematic Review and Meta-analysis.

INTRODUCTION: The objective was to compare the clinical efficacy of silver diamine fluoride (SDF) and atraumatic restorative treatment (ART) in arresting active caries in primary teeth and first permanent molars in children. MATERIALS AND METHODS: The study protocol was registered in PROSPERO (CRD42020205675). A systematic search was performed in PubMed, Scopus, Embase, Cochrane Library, and gray literature for randomized controlled trials (RCTs) published in English language with a minimum follow-up of 6 months, comparing the caries arrest potential of SDF with ART in primary teeth and first permanent molars in children. The risk of bias and quality assessment of the studies was done using the Cochrane Collaboration Tool and Joanna Briggs Institute Critical Appraisal Tool. Data analysis was performed using RevMan software; the outcomes were summarized in meta-analysis (MA) using the random-effects model, and the odds ratio (OR) at 95% confidence interval (CI) was computed. RESULTS: A total of 1059 studies were identified, out of which 562 remained after removal of duplicates. Eight studies were considered for full-text eligibility, and four studies were included in the qualitative review. Three out of four studies were conducted on primary dentition, whereas one study was done on erupting first permanent molars in children. MA of the two studies compared 30% SDF with ART in primary molars at 12 months and revealed the OR to be 2.02 (95% CI: 0.86-4.71; I 2 = 62%; P = 0.10). CONCLUSION: The current review points to the lack of solid evidence comparing SDF with ART for arresting active caries in primary teeth, especially in the first permanent molars. No statistically significant difference between 30% SDF and ART in primary molars at 12 months was found in the present review. Well-designed RCTs are required to determine a minimum concentration of SDF which is effective and safe for caries arrest in children.

Comparison of piezosurgery and conventional rotatory technique in transalveolar extraction of mandibular third molars: A pilot study.

OBJECTIVES: To compare the postoperative outcomes in impacted mandibular third molar extraction using piezosurgery and conventional rotary technique; and to assess the stress levels in both the techniques by measuring salivary cortisol levels. METHODS: Ten patients with symmetrical impacted lower third molars were included in this split mouth pilot study. Measurements for mouth opening and swelling were taken preoperatively on the day of surgery and 1 week after surgery. Pain was evaluated using Visual Analog Scale (VAS) from first postoperative day for six consecutive days. Saliva collection for analysis of cortisol levels was done at four time intervals - before starting the procedure, immediately after the procedure, 20 min and 1 week later. The mean in two groups was compared using paired t-test/Wilcoxon signed rank test as applicable. Friedman test was used to compare multiple readings of pain and salivary cortisol. RESULTS: Reduction in mouth opening was more in rotary group than piezosurgery group but was not statistically significant (p = 0.092). Increase in facial swelling was more in the rotary group than piezosurgery group with statistically significant values (p = 0.020). Rotary group had higher values for postoperative pain as compared to piezosurgery on all the days and the difference was statistically significant on each day except second postoperative day. Salivary cortisol levels were elevated in both the groups with the mean values higher in group I (rotary) than in group II (Piezosurgery). CONCLUSION: Extraction of impacted lower third molar results in more favourable outcome when carried out by piezosurgery technique. Further studies are needed to compare the salivary cortisol response in rotary and piezosurgery techniques.

Developing and standardizing a center to treat cleft and craniofacial anomalies in a developing country like India.

The range of facial deformities is enormous. All produce some degree of disfigurement and result in the impairment of function to some degree, sometimes even to the point of incompatibility with life. Congenital facial defects in India are associated with considerable superstition, social rejection, and failure to integrate into society.In India, cleft defects occur in 1 in 500 births. Congenital facial defects are a pressing problem in India owing to the limited resources to treat such patients. Poverty is a major factor for parents of such children to get appropriate treatment.Setting up an institute to treat children with cleft and craniofacial deformities in India presents problems with financing treatment for poor patients, procuring the right infrastructure, and employing well-trained human resources.The authors have set up such an institute in Hyderabad in the southern state of Andhra Pradesh in India. The logistics of setting up such a facility in a developing country and the future of funding for cleft treatment are important factors to consider while establishing a center for patients with cleft and craniofacial anomalies.The aim of setting up such centers was to provide quality comprehensive treatment for patients from all sections of society with cleft and craniofacial anomalies.

Three-dimensional assessment of transverse displacement with Facemask and Maxgym in unilateral cleft lip and palate model.

BACKGROUND: Growing patients with cleft lip and palate (CLP) exhibit maxillary deficiency due to early surgical intervention. Maxillary protraction with expansion is the recommended treatment modality for deficient maxilla. Facemask is a conventional protraction appliance, and Maxgym is a new protraction appliance. The purpose of this study is to compare the efficacy of Maxgym with Facemask using finite-element analysis. METHODS: A three-dimensional finite-element model consisting of 49,807 nodes and 185,620 tetrahedral-shaped elements was created using computed tomography scan of a patient with unilateral CLP. F1, F2, and F3 represent different protraction forces of facemask, and M1, M2, and M3 represent different protraction forces of Maxgym. E1 represents slow maxillary expansion (SME) force, and E2 represents rapid maxillary expansion (RME) force. Facemask and Maxgym forces were applied parallel to the occlusal plane from the middle of the clinical crown on the buccal side of the first premolars. The forces E1 and E2 were also applied on the middle of the crown height on the lingual side of the first premolars and the first molars to simulate expansion. The amount of displacement for Maxgym and Facemask forces in transverse direction was analyzed designating specific nodes to represent dental and skeletal structures. RESULTS: The dental and skeletal structures were displaced in transverse direction under all loading conditions. Only expansion or protraction force resulted in transverse displacement of nodes. RME produces greater transverse displacement as compared to SME. Maxgym forces produce greater transverse displacement as compared to facemask. Maxgym with RME produces greater transverse displacement as compared to Maxgym with SME, whereas facemask with RME produces greater transverse displacement as compared to facemask with SME. CONCLUSIONS: Maxgym forces produce greater transverse displacement as compared to facemask with or without expansion.

Assessment of nostril symmetry after primary cleft rhinoplasty in patients with complete unilateral cleft lip and palate.

The aim of this study was to assess the nostril symmetry following primary cleft rhinoplasty done with either a dorsal onlay or columellar strut graft in patients with non-syndromic complete unilateral cleft lip and palate. In this retrospective study 30 consecutive patients treated with autogenous or alloplastic dorsal onlay grafts and 30 consecutive patients treated with autogenous or alloplastic columellar strut grafts for complete unilateral cleft nose reconstruction were analyzed for nasal symmetry. The autogenous grafts used were costo-chondral or septal cartilage and the alloplastic graft used was high density polyethylene (Medpore(®)). Assessment of the nostril symmetry was done using a two-dimensional nasal analysis 24-30 months postoperatively. Ratios between cleft and noncleft side nostril for three parameters were used to assess symmetry namely nostril width, nostril height and nostril gap area. None of the three parameters showed statistically significant changes. A satisfactory, though not statistically significant, difference in symmetrical outcome could be achieved in both the groups with the exception of nostril width symmetry in group treated with dorsal onlay graft.