Enhancing the vermilion in adult secondary cleft lip repair with a continuous V plasty without closure of the donor defect-a case series.

The aim of this paper was to describe a modification to an old method to enhance the vermillion in adult cleft patients. We present ten consecutive patients who requested enhancement of the upper lip vermillion. The technique involves a continuous V plasty within the non-visible mucosa to elevate the vermillion. Each V incision is of a different size to match the defect. Then the V flaps are sutured to one another but the donor defect is left open to epithelialise. Adjunctive procedures are possible at the same time. There were no major complications but one patient was over corrected and needed reduction of mucosa. The technique offers a permanent enhancement of the vermillion and is a safe alternative to other methods of lip augmentation including fillers.

Identifying Predictors of Acquired Velopharyngeal Insufficiency in Cleft Lip and Palate Following Maxillary Osteotomy Using Multiple Regression Analyses.

BACKGROUND: Maxillary osteotomy is typically undertaken to correct abnormal facial growth in cleft lip and palate. The surgery can cause velopharyngeal insufficiency resulting in hypernasality. This study aims to identify valid predictors of acquired velopharyngeal insufficiency following maxillary osteotomy by using a range of perceptual and instrumental speech investigations and multiple regression. METHODS: A prospective study was undertaken consisting of a consecutive series of patients with cleft lip and palate (N = 20) undergoing maxillary osteotomy by a single surgeon. Participants were seen at: 0 to 3 months pre-surgery (T1), 3-months (T2), and 12-months (T3) post-surgery. Hypernasality was rated using the cleft audit protocol for speech-augmented (CAPS-A) and visual analog scales, and nasalance was measured on the Nasometer II 6400. For lateral videofluorosopic and nasendoscopic images, visual perceptual ratings and quantitative ratiometric measurements were undertaken. Multiple regression analyses were undertaken to identify predictors. RESULTS: T3 models with hypernasality as the dependent variable were found to be a good fit and significant (eg, CAPS-A: R2 = 0.920, F(11,7) = 7.303, P = 0.007). Closure ratio (a quantitative ratiometric measurement) and proportion of palate contacting the posterior pharyngeal wall (a visual perceptual rating) were identified as significant predictors for the CAPS-A model (P = 0.030, P = 0.002).

Effect of Maxillary Osteotomy on Speech in Cleft Lip and Palate: Instrumental Outcomes of Velopharyngeal Function.

OBJECTIVE: To investigate the effect of maxillary osteotomy on velopharyngeal function in cleft lip and palate (CLP) using instrumental measures. DESIGN: A prospective study. PARTICIPANTS: A consecutive series of 20 patients with CLP undergoing maxillary osteotomy by a single surgeon were seen at 0 to 3 months presurgery (T1), 3 months (T2), and 12 months (T3) post-surgery. INTERVENTIONS: Nasalance was measured on the Nasometer II 6400. For videofluoroscopy and nasendoscopy data, visual perceptual ratings, for example, palatal lift angle (PLAn), and quantitative ratiometric measurements, for example, closure ratio (CRa), were made using a validated methodology and computer software. Reliability studies were undertaken for all instrumental measures. MAIN OUTCOME MEASURES: Repeated measures analysis of variance (with time at 3 levels) for nasalance and each velar parameter. Planned comparisons across pairs of time points (T1-T2, T1-T3, and T2-T3) including effect sizes. RESULTS: A significant difference over time was found for nasalance (P = .001) and planned comparisons across pairs of time points were significant between T1 and T2 (P = .008), T1 and T3 (P = .002), but not between T2 and T3 (P = .459) providing evidence that maxillary osteotomy can impact on nasalance adversely and that the changes seen are permanent and stable. There were also significant differences over time for PLAn (P = .012) and CRa (P = -.059) and planned comparisons for both velar parameters reflected similar findings to those of nasalance. CONCLUSIONS: Maxillary osteotomy can adversely affect velopharyngeal function in patients with CLP. The study provides evidence for a much earlier post-surgery review even as early as 3 months after surgery.

Orthodontic burden of care for patients with a cleft lip and/or palate.

BACKGROUND: Patients with a cleft lip and/or palate may require multiple episodes of orthodontic treatment, e.g. before alveolar bone grafting, upper arch alignment, orthodontic camouflage and in combination with orthognathic surgery. There is little published regarding the overall orthodontic burden of care for these patients. AIM: To assess the orthodontic burden of care for patients with a cleft lip and/or palate. METHOD: Data were collected retrospectively from all consecutive cleft patients who had completed orthodontic treatment between January 2014 and December 2015 at Great Ormond Street Hospital, London, United Kingdom. RESULTS: Forty-two patients were included in the study: Twenty-three patients with a cleft lip and palate; nine with an isolated cleft palate; eight with cleft lip and alveolus; and two with cleft lip. The mean age of orthodontic treatment commencement was 13.4 years (range = 8.9-18.2 years) with a mean duration of 3.4 years (range = 1.3-8.3 years). An average of 44 appointments were required with an orthodontist (range = 18-98 appointments). CONCLUSION: The orthodontic burden of care for patients with cleft lip and/or palate must not be underestimated. The duration of treatment varies depending on the type of cleft diagnosis and whether orthognathic surgery will be required. From this study, a patient with cleft lip and/or palate required an average of 44 orthodontic appointments and a mean duration of treatment of 3.4 years in order to complete their treatment. This is a considerable burden to patients and their guardians, which they must be informed of before commencement of orthodontic treatment.

Maxillary Growth in Cleft Lip and Palate Patients, With and Without Vomerine Flap Closure of the Hard Palate at the Time of Lip Repair: A Retrospective Analysis of Prospectively Collected Nonrandomized Data, With 10-Year Cephalometric Outcomes.

OBJECTIVE: To assess the midterm effect on maxillary growth of vomerine flap (VF) closure of the hard palate, at the time of lip repair. DESIGN: A retrospective analysis of prospectively collected nonrandomized data. INTERVENTIONS: Consecutive participants with a unilateral cleft lip and palate (UCLP) were operated on, at 3 months of age, by the same surgeon. They were divided into 2 groups, those who had a VF and those who did not (non-VF). SETTING: Participants were treated at 2 hospitals in the United Kingdom. PARTICIPANTS: Twenty-eight participants in the VF group and 24 participants in the non-VF group attended follow-up at 10 years of age. MAIN OUTCOME MEASURES: Standardized lateral cephalometric radiographs were taken at 10 years. Following tracing and digitization, parameters to assess the maxillary growth were analyzed. RESULTS: No statistically significant differences were found in the anterior-posterior or vertical skeletal cephalometric parameters. CONCLUSIONS: The results of this study support the statement that VF repair does not significantly affect maxillary growth in patients with a UCLP, when assessed cephalometrically at 10 years of age. It should be noted that at this age, growth is not yet complete.

An Evaluation of Alveolar Bone Grafting in the UK and Ireland.

OBJECTIVE: To determine the main factors influencing the timing of alveolar bone grafting among cleft teams in the UK and Ireland, to assess the types of radiographs used to evaluate bone grafting sites pre- and postoperatively and the views of the profession on orthodontic expansion prior to grafting. DESIGN: An online survey consisting of 24 questions was compiled and emailed to 53 orthodontists and surgeons in all 12 Cleft Hub Units in the UK and Ireland. RESULTS: All units in the UK and Ireland responded with 51 responses, 39 complete and 12 partial responses, obtained from cleft surgeons and orthodontists. The majority of units are using dental criteria (75%) as a guide to timing alveolar bone grafting. Most units take a postoperative radiograph at 6 months but the view being taken varied. When asked if four cases were ready for grafting based on their radiographs, there was clear agreement by a significant majority for 3 cases but for 1 only a minimal majority (61%). The most common donor site chosen for the graft is the Iliac crest (92.9%). There was excellent agreement for 2 cases asking when to use expansion but poor agreement for one, 55% saying they would expand and 45% saying no. CONCLUSION: Overall there is good agreement among cleft teams in the UK and Ireland about management of alveolar bone grafting; however, a clearer consensus on preoperative orthodontic expansion may be needed.

A Reliable Method to Measure Lip Height Using Photogrammetry in Unilateral Cleft Lip Patients.

There is still no reliable tool to determine the outcome of the repaired unilateral cleft lip (UCL). The aim of this study was therefore to develop an accurate, reliable tool to measure vertical lip height from photographs. The authors measured the vertical height of the cutaneous and vermilion parts of the lip in 72 anterior-posterior view photographs of 17 patients with repairs to a UCL. Points on the lip's white roll and vermillion were marked on both the cleft and the noncleft sides on each image. Two new concepts were tested. First, photographs were standardized using the horizontal (medial to lateral) eye fissure width (EFW) for calibration. Second, the authors tested the interpupillary line (IPL) and the alar base line (ABL) for their reliability as horizontal lines of reference. Measurements were taken by 2 independent researchers, at 2 different time points each. Overall 2304 data points were obtained and analyzed. Results showed that the method was very effective in measuring the height of the lip on the cleft side with the noncleft side. When using the IPL, inter- and intra-rater reliability was 0.99 to 1.0, with the ABL it varied from 0.91 to 0.99 with one exception at 0.84. The IPL was easier to define because in some subjects the overhanging nasal tip obscured the alar base and gave more consistent measurements possibly because the reconstructed alar base was sometimes indistinct. However, measurements from the IPL can only give the percentage difference between the left and right sides of the lip, whereas those from the ABL can also give exact measurements. Patient examples were given that show how the measurements correlate with clinical assessment. The authors propose this method of photogrammetry with the innovative use of the IPL as a reliable horizontal plane and use of the EFW for calibration as a useful and reliable tool to assess the outcome of UCL repair.

Impact of orthodontic appliances on the quality of craniofacial anatomical magnetic resonance imaging and real-time speech imaging.

AIMS: The aim of this work was to investigate the effects of commonly used orthodontic appliances on the magnetic resonance (MR) image quality of the craniofacial region, with special interest in the soft palate and velopharyngeal wall using real-time speech imaging sequences and anatomical imaging of the temporomandibular joints (TMJ) and pituitaries. METHODS: Common orthodontic appliances were studied on 1.5 T scanner using standard spin and gradient echo sequences (based on the American Society for Testing and Materials standard test method) and sequences previously applied for high-resolution anatomical and dynamic real-time imaging during speech. Images were evaluated for the presence and size of artefacts. RESULTS: Metallic orthodontic appliances had different effects on image quality. The most extensive individual effects were associated with the presence of stainless steel archwire, particularly if combined with stainless steel brackets and stainless steel molar bands. With those appliances, diagnostic quality of magnetic resonance imaging speech and palate images will be most likely severely degraded, or speech imaging and imaging of pituitaries and TMJ will be not possible. All non-metallic, non-metallic with Ni/Cr reinforcement or Ni/Ti alloys appliances were of little concern. LIMITATIONS: The results in the study are only valid at 1.5 T and for the sequences and devices used and cannot necessarily be extrapolated to all sequences and devices. Furthermore, both geometry and size of some appliances are subject dependent, and consequently, the effects on the image quality can vary between subjects. Therefore, the results presented in this article should be treated as a guide when assessing the risks of image quality degradation rather than an absolute evaluation of possible artefacts. CONCLUSIONS: Appliances manufactured from stainless steel cause extensive artefacts, which may render image non-diagnostic. The presence and type of orthodontic appliances should be always included in the patient's screening, so the risks of artefacts can be assessed prior to imaging. Although the risks to patients with fixed orthodontic appliances at 1.5 T MR scanners are low, their secure attachment should be confirmed prior to the examination.

A case report of a rare finding of supernumerary primary and permanent canines.

A supernumerary tooth is a tooth that is additional to the normal series of teeth. These can occur anywhere in the primary or permanent dentition and are most commonly found in the anterior maxilla. Supernumerary canines are rare with little available literature and case reports in this area. This case presents a patient with a unilateral maxillary supernumerary deciduous and permanent canine associated with an unusual cleft of the alveolus. How to cite the article: Parker K, Hay N. A case report of a rare finding of supernumerary primary and permanent canines. J Int Oral Health 2014;6(2):129-131.

Early effect of vomerine flap closure of the hard palate at the time of lip repair on the alveolar gap and other maxillary dimensions.

OBJECTIVE: Comparison of the effects of vomerine flap (VF) closure of the hard palate at the time of lip repair with non-closure of the hard palate in subjects with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective, single-blinded, cohort study. SETTING: Study model sets of 40 consecutive, non-syndromic, infants with complete UCLP operated on between 1988 and 1998. PATIENTS: All subjects were operated on by a single consultant plastic surgeon immediately before and after the unit's change of protocol (1993), when VF closure of the hard palate was incorporated at the time of lip repair. Subjects were divided into two groups: VF ( n = 18) and non-VF (n = 22), which acted as a control group. Each subject had maxillary impressions taken before lip repair at 3 months (VF mean age = 11.7 weeks; non-VF mean age = 13.4 weeks) and before palate repair at 6 months (VF mean age = 22.8 weeks; non-VF mean age = 24.0 weeks). MAIN OUTCOME MEASURES: Seven predetermined landmarks and four maxillary dimensions were computed following single-blinded analysis using a reflex microscope. RESULTS: Repeatability tests showed good measurement precision. The operator measurement errors were 0.00018 mm in a horizontal plane (X and Y) and 0.00028 in the vertical plane (Z). The VF group showed significant changes in the alveolar cleft width. There were no statistically significant changes in any arch-form variable between the VF and non-VF groups. CONCLUSION: The decrease of alveolar arch gap width at palate repair (6 months) in the VF group was significantly more than the decrease observed in the non-VF group, and there was no significant decrease in the, anterior and posterior arch width or anteroposterior length of the hard palate in the VF group compared with the non-VF group.