What is the impact of miniscrew-assisted rapid palatal expansion on the midfacial soft tissues? A prospective three-dimensional stereophotogrammetry study.

OBJECTIVES: To evaluate the midfacial soft tissue changes of the face in patients treated with miniscrew-assisted rapid palatal expansion (MARPE). MATERIALS AND METHODS: 3D facial images and intra-oral scans (IOS) were obtained before expansion (T0), immediately after completion of expansion (T1), and 1 year after expansion (T2). The 3D images were superimposed and two 3D distance maps were generated to measure the midfacial soft tissue changes: immediate effects between timepoints T0 and T1 and overall effects between T0 and T2. Changes of the alar width were also measured and dental expansion was measured as the interpremolar width (IPW) on IOS. RESULTS: Twenty-nine patients (22 women, 7 men, mean age 25.9 years) were enrolled. The soft tissue in the regions of the nose, left of philtrum, right of philtrum, and upper lip tubercle demonstrated a statistically significant anterior movement of 0.30 mm, 0.93 mm, 0.74 mm, and 0.81 mm, respectively (p < 0.01) immediately after expansion (T0-T1). These changes persisted as an overall effect (T0-T2). The alar width initially increased by 1.59 mm, and then decreased by 0.08 mm after 1 year, but this effect was not significant. The IPW increased by 4.58 mm and remained stable 1 year later. There was no significant correlation between the increase in IPW and alar width (r = 0.35, p = 0.06). CONCLUSIONS: Our findings indicate that MARPE results in significant but small changes of the soft tissue in the peri-oral and nasal regions. However, the clinical importance of these findings is limited. CLINICAL RELEVANCE: MARPE is an effective treatment modality to expand the maxilla, incurring only minimal and clinically insignificant changes to the midfacial soft tissues.

Super-Resolution of Dental Panoramic Radiographs Using Deep Learning: A Pilot Study.

Using super-resolution (SR) algorithms, an image with a low resolution can be converted into a high-quality image. Our objective was to compare deep learning-based SR models to a conventional approach for improving the resolution of dental panoramic radiographs. A total of 888 dental panoramic radiographs were obtained. Our study involved five state-of-the-art deep learning-based SR approaches, including SR convolutional neural networks (SRCNN), SR generative adversarial network (SRGAN), U-Net, Swin for image restoration (SwinIr), and local texture estimator (LTE). Their results were compared with one another and with conventional bicubic interpolation. The performance of each model was evaluated using the metrics of mean squared error (MSE), peak signal-to-noise ratio (PNSR), structural similarity index (SSIM), and mean opinion score by four experts (MOS). Among all the models evaluated, the LTE model presented the highest performance, with MSE, SSIM, PSNR, and MOS results of 7.42 ± 0.44, 39.74 ± 0.17, 0.919 ± 0.003, and 3.59 ± 0.54, respectively. Additionally, compared with low-resolution images, the output of all the used approaches showed significant improvements in MOS evaluation. A significant enhancement in the quality of panoramic radiographs can be achieved by SR. The LTE model outperformed the other models.

What is the Oral Health-related Quality of Life following Miniscrew-Assisted Rapid Palatal Expansion (MARPE)? A prospective clinical cohort study.

BACKGROUND: Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is a non-surgical orthodontic treatment for transverse maxillary deficiency. This study aimed to investigate the Oral Health-related Quality of Life (OHRQoL) and pain perception of patients undergoing MARPE treatment. METHODS: 42 consecutive patients (9 men, 33 women) from the age of 16 onwards (mean: 27.4 ± 9.3 years; range 17.1-55.7 years) who received a MARPE treatment were included. OHRQoL was assessed with the short form of the Oral Health Impact Profile (OHIP-14) questionnaire. Patients filled out the questionnaire at baseline (T0) and weekly during the expansion phase (P1) and in the post-expansion phase (P2). Pain intensity was assessed with a Visual Analogue Scale (VAS) questionnaire and filled out daily during expansion, along with a question on the intake of analgesics. The mean weekly and total OHIP-score and OHIP-score per domain were calculated at T0, P1 and P2, as well as mean weekly and total VAS-scores for average pain, maximum pain and analgesics intake during P1. Kruskal-Wallis tests were used to test for differences in OHIP between T0, P1 and P2. The level of significance was set at 0.05. RESULTS: The mean OHIP-score was 10.86 ± 9.71 at T0 and increased to 17.18 ± 10.43 during P1 (p < 0.001), after which it returned to pre-expansion levels, 9.27 ± 7.92 (p = 0.907) during P2. At the domain level, there was a statistically significant increase in OHIP-score at P1 for functional limitation, physical pain, psychological discomfort and social disability. The mean VAS-score for average pain during expansion was 16.00 ± 19.73 mm. Both OHIP-score (25.00 ± 10.25), average pain (33.72 ± 16.88 mm), maximum pain (44.47 ± 17.99 mm) and analgesics intake (59%) were highest at initiation of the expansion and decreased by the end of expansion. CONCLUSIONS: MARPE is a generally well-tolerated expansion treatment. A temporary decline in OHRQoL and moderate pain are present at the start of expansion, followed by a recovery of OHRQoL and very mild pain during the rest of treatment. Clinicians should be aware of the effects of MARPE on patients' quality of life and manage the expected discomfort and impediments with adequate communication and patient education.

Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults with the Dutch Maxillary Expansion Device: a prospective clinical cohort study.

OBJECTIVES: To provide a higher degree of evidence on the efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults, thereby applying the Dutch Maxillary Expansion Device (D-MED). MATERIALS AND METHODS: D-MED was developed as an individualized, 3D-designed, and fabricated MARPE appliance supported by 4 palatal miniscrews. Patients from the age of 16 onwards with transverse maxillary deficiency were enrolled consecutively. Pre-expansion and immediate post-expansion CBCTs and intra-oral scans were acquired and measurements of skeletal, alveolar, and dental expansion as well as dental and periodontal side-effects were performed. RESULTS: Thirty-four patients were enrolled (8 men, 26 women) with mean age 27.0 ± 9.4 years. A success rate of 94.1% was achieved (32/34 patients). The mean expansion duration, or mean observation time, was 31.7 ± 8.0 days. The mean expansion at the maxillary first molars (M1) and first premolars (P1) was 6.56 ± 1.70 mm and 4.19 ± 1.29 mm, respectively. The expansion was 60.4 ± 20.1% skeletal, 8.1 ± 27.6% alveolar, and 31.6 ± 20.1% dental at M1 and 92.2 ± 14.5% skeletal, 0.0 ± 18.6% alveolar, and 7.8 ± 17.7% dental at P1, which was both statistically (p < 0.001) and clinically significant. Buccal dental tipping (3.88 ± 3.92° M1; 2.29 ± 3.89° P1), clinical crown height increase (0.12 ± 0.31 mm M1; 0.04 ± 0.22 mm P1), and buccal bone thinning (- 0.31 ± 0.49 mm M1; - 0.01 ± 0.45 mm P1) were observed, while root resorption could not be evaluated. CONCLUSIONS: MARPE by application of D-MED manifested its efficacy in a prospective clinical setting, delivering a high amount of skeletal expansion with limited side-effects in late adolescents and adults. CLINICAL RELEVANCE: Higher quality evidence is supportive of MARPE as a safe and successful non-surgical treatment option for transverse maxillary deficiency.

The role of muscular traction in the occurrence of skeletal relapse after advancement bilateral sagittal split osteotomy (BSSO): A systematic review.

The aim of this systematic review was (i) to determine the role of muscular traction in the occurrence of skeletal relapse after advancement BSSO and (ii) to investigate the effect of advancement BSSO on the perimandibular muscles. This systematic review reports in accordance with the recommendations proposed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic database searches were performed in the databases MEDLINE, Embase and Cochrane Library. Inclusion criteria were as follows: assessment of relapse after advancement BSSO; assessment of morphological and functional change of the muscles after advancement BSSO; and clinical studies on human subjects. Exclusion criteria were as follows: surgery other than advancement BSSO; studies in which muscle activity/traction was not investigated; and case reports with a sample of five cases or fewer, review articles, meta-analyses, letters, congress abstracts or commentaries. Of the initial 1006 unique articles, 11 studies were finally included. In four studies, an intervention involving the musculature was performed with subsequent assessment of skeletal relapse. The changes in the morphological and functional properties of the muscles after BSSO were studied in seven studies. The findings of this review demonstrate that the perimandibular musculature plays a role in skeletal relapse after advancement BSSO and may serve as a target for preventive strategies to reduce this complication. However, further research is necessary to (i) develop a better understanding of the role of each muscle group, (ii) to develop new therapeutic strategies and (iii) to define criteria that allow identification of patients at risk.

Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults: a systematic review and meta-analysis.

BACKGROUND: Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is a non-surgical treatment for transverse maxillary deficiency. However, there is limited evidence concerning its efficacy. OBJECTIVES: This systematic review aims to evaluate the efficacy of MARPE in late adolescents and adults by assessing success rate and skeletal and dental transverse maxillary expansion, as well as treatment duration, dental and periodontal side effects and soft tissue effects. SEARCH METHODS: Seven electronic databases were searched (MEDLINE, Embase, Cochrane Library, Web of Science, Scopus, ProQuest and ClinicalTrials.gov) without limitations in November 2020. SELECTION CRITERIA: Randomized and non-randomized clinical trials and observational studies on patients from the age of 16 onwards with transverse maxillary deficiency who were treated with MARPE and which included any of the predefined outcomes. DATA COLLECTION AND ANALYSIS: Inclusion eligibility screening, data extraction and risk of bias assessment were performed independently in duplicate. When possible, exploratory meta-analyses of mean differences (MDs) with their 95% confidence intervals (CIs) were conducted, followed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis of the evidence quality. RESULTS: Eight articles were included: two prospective and six retrospective observational studies. One study had a moderate risk of bias, whereas seven studies had a serious risk of bias. GRADE quality of evidence was very low. MARPE showed a high success rate (mean: 92.5%; 95%CI: 88.7%-96.3%), resulting in a significant skeletal width increase (MD: 2.33 mm; 95%CI: 1.63 mm-3.03 mm) and dental intermolar width increase (MD: 6.55 mm; 95%CI: 5.50 mm-7.59 mm). A significant increase in dental tipping, a decrease in mean buccal bone thickness and buccal alveolar height, as well as nasal soft tissue change was present (P < 0.05). The mean duration of expansion ranged from 20 to 126 days. LIMITATIONS: One of the main drawbacks was the lack of high-quality prospective studies in the literature. CONCLUSIONS AND IMPLICATIONS: MARPE is a treatment modality that is associated with a high success rate in skeletal and dental maxillary expansion. MARPE can induce dental and periodontal side effects and affect peri-oral soft tissues. Given the serious risk of bias of the included studies, careful data interpretation is necessary and future research of higher quality is strongly recommended. REGISTRATION: PROSPERO (CRD42020176618). FUNDING: No grants or any other support funding were received.

Reliability and Agreement of 3D Anthropometric Measurements in Facial Palsy Patients Using a Low-Cost 4D Imaging System.

The reliability (precision) and agreement (accuracy) of anthropometric measurements based on manually placed 3D landmarks using the RealSense D415 were investigated in this paper. Thirty facial palsy patients, with their face in neutral (resting) position, were recorded simultaneously with the RealSense and a professional 3dMD imaging system. First the RealSense depth accuracy was determined. Subsequently, two observers placed 14 facial landmarks on the 3dMD and RealSense image, assessing the distance between landmark placement. The respective intra- and inter-rater Euclidean distance between the landmark placements was 0.84 mm (±0.58) and 1.00 mm (±0.70) for the 3dMD landmarks and 1.32 mm (±1.27) and 1.62 mm (±1.42) for the RealSense landmarks. From these landmarks 14 anthropometric measurements were derived. The intra- and inter-rater measurements had an overall reliability of 0.95 (0.87 - 0.98) and 0.93 (0.85 - 0.97) for the 3dMD measurements, and 0.83 (0.70 - 0.91) and 0.80 (0.64 - 0.89) for the RealSense measurements, respectively, expressed as the intra-class correlation coefficient. Determined by the Bland-Altman analysis, the agreement between the RealSense measurements and 3dMD measurements was on average -0.90 mm (-4.04 - 2.24) and -0.89 mm (-4.65 - 2.86) for intra- and inter-rater agreement, respectively. Based on the reported reliability and agreement of the RealSense measurements, the RealSense D415 can be considered as a viable option to perform objective 3D anthropomorphic measurements on the face in a neutral position, where a low-cost and portable camera is required.

Non-Syndromic Cleft Lip with or without Cleft Palate: Genome-Wide Association Study in Europeans Identifies a Suggestive Risk Locus at 16p12.1 and Supports SH3PXD2A as a Clefting Susceptibility Gene.

Non-syndromic cleft lip with or without cleft palate (nsCL/P) ranks among the most common human congenital malformations, and has a multifactorial background in which both exogenous and genetic risk factors act in concert. The present report describes a genome-wide association study (GWAS) involving a total of 285 nsCL/P patients and 1212 controls from the Netherlands and Belgium. Twenty of the 40 previously reported nsC/LP susceptibility loci were replicated, which underlined the validity of this sample. SNV-based analysis of the data identified an as yet unreported suggestive locus at chromosome 16p12.1 (p-value of the lead SNV: 4.17 × 10-7). This association was replicated in two of three patient/control replication series (Central European and Yemeni). Gene analysis of the GWAS data prioritized SH3PXD2A at chromosome 10q24.33 as a candidate gene for nsCL/P. To date, support for this gene as a cleft gene has been restricted to data from zebrafish and a knockout mouse model. The present GWAS was the first to implicate SH3PXD2A in non-syndromic cleft formation in humans. In summary, although performed in a relatively small sample, the present GWAS generated novel insights into nsCL/P etiology.

Three-dimensional facial development of children with unilateral cleft lip and palate during the first year of life in comparison with normative average faces.

BACKGROUND: Stereophotogrammetry can be used to study facial morphology in both healthy individuals as well as subjects with orofacial clefts because it shows good reliability, ability to capture images rapidly, archival capabilities, and high resolution, and does not require ionizing radiation. This study aimed to compare the three-dimensional (3D) facial morphology of infants born with unilateral cleft lip and palate (UCLP) with an age-matched normative 3D average face before and after primary closure of the lip and soft palate. METHODS: Thirty infants with a non-syndromic complete unilateral cleft lip, alveolus, and palate participated in the study. Three-dimensional images were acquired at 3, 6, 9, and 12 months of age. All subjects were treated according to the primary surgical protocol consisting of surgical closure of the lip and the soft palate at 6 months of age. Three-dimensional images of UCLP patients at 3, 6 (pre-treatment), 9, and 12 months of age were superimposed on normative datasets of average facial morphology using the children's reference frame. Distance maps of the complete 3D facial surface and the nose, upper lip, chin, forehead, and cheek regions were developed. RESULTS: Assessments of the facial morphology of UCLP and control subjects by using color-distance maps showed large differences in the upper lip region at the location of the cleft defect and an asymmetry at the nostrils at 3 and 6 months of age. At 9 months of age, the labial symmetry was completely restored although the tip of the nose towards the unaffected side showed some remnant asymmetry. At 12 months of age, the symmetry of the nose improved, with only some remnant asymmetry noted on both sides of the nasal tip. At all ages, the mandibular and chin regions of the UCLP patients were 2.5-5 mm posterior to those in the average controls. CONCLUSION: In patients with UCLP deviations from the normative average 3D facial morphology of age-matched control subjects existed for the upper lip, nose, and even the forehead before lip and soft palate closure was performed. Compared to the controls symmetry in the upper lip was restored, and the shape of the upper lip showed less variation after primary lip and soft palate closure. At this early age, retrusion of the soft-tissue mandible and chin, however, seems to be developing already.

Uniform 3D meshes to establish normative facial averages of healthy infants during the first year of life.

Three-dimensional (3D) surface imaging systems are replacing direct anthropometry as the preferred method for capturing facial soft-tissues. Aims of this study were: (1) to develop normative average 3D faces of healthy infants aged 3, 6, 9, and 12 months and (2) to describe normative average 3D facial growth data in infants aged 3 to 12 months. Three-dimensional images of 50 healthy children were acquired at 3, 6, 9, and 12 months of age using the 3dMDcranial system. Four average faces with uniform meshes (3, 6, 9, and 12 months) were developed and registered based on the children's reference frames. Distance maps of growth of the total facial surface and of the nose, upper lip, chin, forehead and cheeks for the intervals 3 to 6 months, 6 to 9 months, and 9 to 12 months of age were calculated. Mean growth of the total facial surface was 3.9 mm (standard deviation [SD] 1.2 mm), 3.5 mm (SD 0.9 mm), and 1.6 mm (SD 0.7 mm) at 3 to 6 months, 6 to 9 months, and 9 to 12 months, respectively. Regarding the selected regions of the face, the mean growth of the nose and upper lip were the largest (3.7 mm and 3.6 mm, respectively) between 6 and 9 months of age. The mean growth of the forehead, cheeks and chin were the largest (5.4 mm, 3.2, and 4.7 mm, respectively) between 3 and 6 months of age. For all facial regions, growth clearly diminished from 9 to 12 months of age. Normative data on the growth of the full face, nose, upper lip, chin, forehead and cheeks are presented. Such data can be used in future studies to identify the effectiveness of treatment of orofacial deformities such as orofacial clefts during the first year of life.

Influence of involuntary facial expressions on reproducibility of 3D stereophotogrammetry in children with and without complete unilateral cleft lip and palate from 3 to 18 months of age.

OBJECTIVES: To assess the influence of involuntary facial expressions on 3D facial stereophotogrammetry reproducibility in children with and without unilateral cleft lip, alveolus and palate (UCLP) aged 3-18 months. MATERIALS AND METHODS: Three to eight 3D facial images per time point were acquired within 10 min of 31 children with UCLP and 50 controls at 3, 12 and 18 months of age. 3D mapping of two 3D facial images per subject per age was performed. Distance kits of the full face and nasolabial area were calculated. RESULTS: In the total subject pool, mean variation between two 3D facial images ranged from 0.38-0.88 mm. There were no significant differences within groups for the various ages. Variation between controls and UCLP subjects did not differ significantly. Variation was higher in the nasolabial area than in the full face. CONCLUSIONS: The influence of involuntary facial expressions on the estimation of facial growth should not be underestimated, especially in the nasolabial region of UCLP subjects aged 3 months. To improve 3D facial imaging reliability, image capturing should be performed by a trained photographer following a meticulous image capturing protocol, including thorough review after capture. CLINICAL RELEVANCE: Facial 3D stereophotogrammetry is a useful tool for monitoring facial growth longitudinally in young children with facial deformities, as no radiation is involved and image capture is easy and fast. It can be performed reliably in children with and without UCLP aged 3-18 months by an experienced photographer utilising a meticulous image capturing protocol.

Effect of One-Stage versus Two-Stage Palatoplasty on Hypernasality and Fistula Formation in Children with Complete Unilateral Cleft Lip and Palate: A Randomized Controlled Trial.

BACKGROUND: Is one-stage or two-stage palatoplasty more effective for preventing fistula formation and hypernasality in patients with complete unilateral cleft lip and palate? METHODS: This parallel blocked randomized controlled trial included 100 patients with nonsyndromic complete unilateral cleft lip and palate with a repaired cleft lip, divided into two equal groups. Group A had one-stage palatoplasty patients at age 12 to 13 months while group B had two-stage palatoplasty patients with soft palatoplasty at age 12 to 13 months and hard palatoplasty at age 24 to 25 months. Presence of a fistula was tested clinically at 3 years and speech was tested using nasometry and perceptual analyses at 6 years. Group C consisted of noncleft controls (n = 20, age 6 years) for speech using nasometry. Fistula rates, hypernasality ratings, and nasalance scores were compared between groups A and B. Nasometry recordings of groups A and B were compared with control group C. RESULTS: There was no difference in fistula rates between groups A and B (p = 0.409; 95 percent CI, 0.365 to 11.9). Mean nasalance scores of group A showed higher nasalance than group B (p = 0.006; 95 percent CI, 1.16 to 6.53). Perceptual analysis showed no difference between groups A and B (p = 0.837 and p = 1.000). Group A showed higher mean nasalance than group C (p = 0.837 and p = 1.000), whereas group B showed no difference (p = 0.088; 95 percent CI, -0.14 to 2.02). CONCLUSIONS: There was no difference in fistula rates between groups. Nasalance was slightly higher in patients in the one-stage palatoplasty group than two-stage palatoplasty group, but the difference was not clinically significant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Validation of 3D documentation of palatal soft tissue shape, color, and irregularity with intraoral scanning.

OBJECTIVES: The purpose of this study was to assess the feasibility of 3D intraoral scanning for documentation of palatal soft tissue by evaluating the accuracy of shape, color, and curvature. MATERIALS AND METHODS: Intraoral scans of ten participants' upper dentition and palate were acquired with the TRIOS® 3D intraoral scanner by two observers. Conventional impressions were taken and digitized as a gold standard. The resulting surface models were aligned using an Iterative Closest Point approach. The absolute distance measurements between the intraoral models and the digitized impression were used to quantify the trueness and precision of intraoral scanning. The mean color of the palatal soft tissue was extracted in HSV (hue, saturation, value) format to establish the color precision. Finally, the mean curvature of the surface models was calculated and used for surface irregularity. RESULTS: Mean average distance error between the conventional impression models and the intraoral models was 0.02 ± 0.07 mm (p = 0.30). Mean interobserver color difference was - 0.08 ± 1.49° (p = 0.864), 0.28 ± 0.78% (p = 0.286), and 0.30 ± 1.14% (p = 0.426) for respectively hue, saturation, and value. The interobserver differences for overall and maximum surface irregularity were 0.01 ± 0.03 and 0.00 ± 0.05 mm. CONCLUSIONS: This study supports the hypothesis that the intraoral scan can perform a 3D documentation of palatal soft tissue in terms of shape, color, and curvature. CLINICAL RELEVANCE: An intraoral scanner can be an objective tool, adjunctive to the clinical examination of the palatal tissue.

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.

Integration of digital dental casts in cone beam computed tomography scans-a clinical validation study.

OBJECTIVES: Images derived from cone beam computed tomography (CBCT) scans lack detailed information on the dentition and interocclusal relationships needed for proper surgical planning and production of surgical splints. To get a proper representation of the dentition, integration of a digital dental model into the CBCT scan is necessary. The aim of this study was to validate a simplified protocol to integrate digital dental models into CBCT scans using only one scan. MATERIALS AND METHODS: Conventional protocol A used one combined upper and lower impression and two CBCT scans. The new protocol B included placement of ten markers on the gingiva, one CBCT scan, and two separate impressions of the upper and lower dentition. Twenty consecutive patients, scheduled for mandibular advancement surgery, were included. To validate protocol B, 3-dimensional reconstructions were made, which were compared by calculating the mean intersurface distances obtained with both protocols. RESULTS: The mean distance for all patients for the upper jaw is 0.39 mm and for the lower jaw is 0.30 mm. For ten out of 20 patients, all distances were less than 1 mm. For the other ten patients, all distances were less than 2 mm. CONCLUSIONS: Mean distances of 0.39 and 0.30 mm are clinically acceptable and comparable to other studies; therefore, this new protocol is clinically accurate. CLINICAL RELEVANCE: This new protocol seems to be clinically accurate. It is less time consuming, gives less radiation exposure for the patient, and has a lower risk for positional errors of the impressions compared to other integration protocols.

Comparison of two- and three-dimensional assessment methods of nasolabial appearance in cleft lip and palate patients: Do the assessment methods measure the same outcome?

OBJECTIVE: For the assessment of the nasolabial appearance in cleft patients, a widely accepted, reliable scoring system is not available. In this study four different methods of assessment are compared, including 2D and 3D asymmetry and aesthetic assessments. METHODS: The data and ratings from an earlier study using the Asher-McDade aesthetic index on 3D photographs and the outcomes of 3D facial distance mapping were compared to a 2D aesthetic assessment, the Cleft Aesthetic Rating Scale, and to SymNose, a computerized 2D asymmetry assessment technique. The reliability and correlation between the four assessment techniques were tested using a sample of 79 patients. RESULTS: The 3D asymmetry assessment had the highest reliability and could be performed by just one observer (Intraclass correlation coefficient (ICC): 0.99). The 2D asymmetry assessment of the nose was highly reliable when performed by just one observer (ICC: 0.89). However, for the 2D asymmetry assessment of the lip more observers were needed. For the 2D aesthetic assessments 3 observers were needed. The 3D aesthetic assessment had the lowest single-observer reliability (ICC: 0.38-0.56) of all four techniques. The agreement between the different assessment methods is poor to very poor. The highest correlation (R: 0.48) was found between 2D and 3D aesthetic assessments. Remarkably, the lowest correlations were found between 2D and 3D asymmetry assessments (0.08-0.17). CONCLUSION: Different assessment methods are not in agreement and seem to measure different nasolabial aspects. More research is needed to establish exactly what each assessment technique measures and which measurements or outcomes are relevant for the patients.

Maxillofacial growth and speech outcome after one-stage or two-stage palatoplasty in unilateral cleft lip and palate. A systematic review.

BACKGROUND: The number of surgical procedures to repair a cleft palate may play a role in the outcome for maxillofacial growth and speech. The aim of this systematic review was to investigate the relationship between the number of surgical procedures performed to repair the cleft palate and maxillofacial growth, speech and fistula formation in non-syndromic patients with unilateral cleft lip and palate. MATERIAL AND METHODS: An electronic search was performed in PubMed/old MEDLINE, the Cochrane Library, EMBASE, Scopus and CINAHL databases for publications between 1960 and December 2015. Publications before 1950-journals of plastic and maxillofacial surgery-were hand searched. Additional hand searches were performed on studies mentioned in the reference lists of relevant articles. Search terms included unilateral, cleft lip and/or palate and palatoplasty. Two reviewers assessed eligibility for inclusion, extracted data, applied quality indicators and graded level of evidence. RESULTS: Twenty-six studies met the inclusion criteria. All were retrospective and non-randomized comparisons of one- and two-stage palatoplasty. The methodological quality of most of the studies was graded moderate to low. The outcomes concerned the comparison of one- and two-stage palatoplasty with respect to growth of the mandible, maxilla and cranial base, and speech and fistula formation. CONCLUSIONS: Due to the lack of high-quality studies there is no conclusive evidence of a relationship between one- or two-stage palatoplasty and facial growth, speech and fistula formation in patients with unilateral cleft lip and palate.

Accuracy of virtually 3D planned resection templates in mandibular reconstruction.

OBJECTIVE: Since reconstruction of composite defects in the head and neck region is a challenging and demanding problem for head and neck surgeons, surgical aids have been sought for decades. The purpose of this study was to evaluate the accuracy of prefabricated surgical resection templates used in mandibular segmental resections in comparison to the virtual surgical plan. MATERIALS AND METHODS: A prospective study was performed in 11 consecutive patients, with a primary T4 oral squamous cell carcinoma or osteoradionecrosis of the mandible. Preoperatively, a CBCT scan was acquired to delineate the size and extension of tumor invasion; a virtual patient-specific resection template was designed based on this information. Intraoperatively, the resection template was positioned on the mandible and secured using four fixation screws. Postoperatively, a CBCT scan was acquired. This scan was superimposed on the preoperative scan. Positioning of the resection template and inclination of the resection planes were evaluated on the virtual head model. In order to test the interobserver reliability of these new measurement methods, two different observers executed all measurements. RESULTS: The mean shift of the proximal resection templates was 3.76 mm (standard deviation [SD] 3.10 mm). For the distal resection templates, the mean shift was 3.06 mm (SD 1.57 mm) with no significant interobserver difference (ICC = 0.99). An absolute mean deviation of 8.5° (SD 5.3°) was found for the proximal resection angle and 10.4° (SD 5.0°) for the distal resection angle. Again, no significant interobserver differences were found (ICC = 0.98). CONCLUSION: The resection templates used in this study proved reasonably accurate. Although the concept of virtual surgical planning aids significantly in mandibular reconstruction with microvascular free flaps, further improvement of resection accuracy is necessary for further improvement of reconstruction accuracy.

AGORA, a data- and biobank for birth defects and childhood cancer.

BACKGROUND: Research regarding the etiology of birth defects and childhood cancer is essential to develop preventive measures, but often requires large study populations. Therefore, we established the AGORA data- and biobank in the Netherlands. In this study, we describe its rationale, design, and ongoing data collection. METHODS: Children diagnosed with and/or treated for a structural birth defect or childhood cancer and their parents are invited to participate in the AGORA data- and biobank. Controls are recruited through random sampling from municipal registries. The parents receive questionnaires about demographics, family and pregnancy history, health status, prescribed medication, lifestyle, and occupational exposures before and during the index pregnancy. In addition, blood or saliva is collected from children and parents, while medical records are reviewed for diagnostic information. RESULTS: So far, we have collected data from over 6,860 families (3,747 birth defects, 905 childhood cancers, and 2,208 controls). The types of birth defects vary widely and comprise malformations of the digestive, respiratory, and urogenital tracts as well as facial, cardiovascular, kidney, skeletal, and central nervous system anomalies. The most frequently occurring childhood cancer types are acute lymphatic leukemia, Hodgkin and non-Hodgkin lymphoma, Wilms' tumor, and brain and spinal cord tumors. Our genetic and/or epidemiologic studies have been focused on hypospadias, anorectal malformations, congenital anomalies of the kidney and urinary tract (CAKUT), and orofacial clefts. CONCLUSION: The large AGORA data- and biobank offers great opportunities for investigating genetic and nongenetic risk factors for disorders in children and is open to collaborative initiatives. Birth Defects Research (Part A) 106:675-684, 2016. © 2016 Wiley Periodicals, Inc.

Does powdering of the dentition increase the accuracy of fusing 3D stereophotographs and digital dental casts.

OBJECTIVES: The shiny vestibular surfaces of teeth make it difficult to match digital dental casts to 3D stereophotogrammetric images of patient teeth. This study tested whether reducing this shininess by coating the teeth with titanium-oxide powder might improve the accuracy of the matching procedure. METHODS: Twenty patients participated in the study. For each patient, 3D stereophotogrammetric images were taken without and with a powder coating. Separately, digital dental casts were created. Next, the digital dental casts were fused with the 3D stereophotogrammetric images of either non-powdered or powdered dentition. Distance maps were created to evaluate the inter-surface distance between the digital dental cast and the 3D images. The matching accuracy was compared for dentition with and without powdering. RESULTS: Of all recorded distances between corresponding points, 95% was smaller than 0.84mm for the powdered dentition and smaller than 0.90mm for the non-powdered dentition. Although powdered dentition showed significantly better matching than non-powdered dentition, the difference was less than 0.1mm. Intra-observer statistics showed that five out of 24 repetitions gave significantly different results, but only for dentition that was not powdered. LIMITATIONS: The patients did not have any major malocclusions. Severe malocclusions might cause greater difficulty in matching the dentition without powder. Only one type of powder was used, but it effectively reduced shininess. CONCLUSION: Powdering the dentition had a small, but significant, positive effect on matching. However, this effect was of minor clinical importance. Therefore, we do not recommend powdering the dentition for 3D stereophotogrammetric images used for matching procedures.