Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study.

Objective: To qualitatively assess surgeons decision making for lip surgery in patients with cleft lip/palate (CL/P). Design: Prospective, non-randomized, clinical trial. Setting: Clinical data institutional laboratory setting. Patients Participants: The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the Standardized Assessment for Facial Surgery (SAFS) for systematic viewing by the surgeons. Interventions: The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either in person or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method. Results: Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. For diagnoses/treatments, surgeons agreed, and level of surgical experience was not a factor. Conclusions: The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

Body Dysmorphic Disorder in Adult Patients With an Orofacial Cleft: An Unseen Psychological Burden.

OBJECTIVES: Facial dysmorphic disorder (FDD), a variant of body dysmorphic disorder, occurs when individuals are preoccupied with perceived defects in their facial appearance. Cleft lip and/or palate (CL/P) requires many clinical interventions and has significant psychological impacts on a patient's perception of appearance. This study identified psychological burdens related to living as an adult with CL/P and characterizes the degree of FDD symptoms in an adult craniofacial population. METHODS: This was a prospective, single-center, cross-sectional case-control study using semi-structured interviews and symptom assessments at a university-based craniofacial center. Patients without CL/P undergoing non-cosmetic facial surgery were recruited as controls (n = 20). Patients with an orofacial cleft (n = 30) were recruited from medical and dental providers at the University of North Carolina. Body Dysmorphic Disorder-Yale Brown Obsessive Compulsive Scale (BBD-YBOCS) scores were collected from a control population and patients with CL/P to assess FDD severity. RESULTS: Demographic factors such age, biological sex, and ethnicity had no significant impact on FDD symptom scores. Patient with CL/P were more likely to have significant FDD symptoms (BDD-YBOCS greater than 16) than patients without CL/P (OR 10.5, CI95 2.7-41.1), and had a mean difference in FDD symptoms scores of 10.04 (p < 0.0001; CI95 5.5-14.6). Patients with CL/P seen by a mental health provider in the past 3 months had 3-fold lower overall FDD symptom scores (OR 0.081; CI95 0.0085-0.77). CONCLUSIONS: Adults with CL/P would benefit from treatment for cleft-specific needs and psychological support as they face unique stressors related to their appearance, including an increase in FDD-associated symptoms. This study emphasizes the importance of recognizing psychological symptoms and providing ongoing multidisciplinary care to adults with CL/P. LEVEL OF EVIDENCE: 3; Individual case-control study Laryngoscope, 133:818-821, 2023.

Decision Considerations and Strategies for Lip Surgery in Patients with Cleft lip/Palate: A Qualitative Study.

Objective: To qualitatively assess surgeons' decision making for lip surgery in patients with cleft lip/palate (CL/P). Design: Prospective, non-randomized, clinical trial. Setting: Clinical data institutional laboratory setting. Patients Participants: The study included both patient and surgeon participants recruited from four craniofacial centers. The patient participants were babies with a CL/P requiring primary lip repair surgery (n=16) and adolescents with repaired CL/P who may require secondary lip revision surgery (n=32). The surgeon participants (n=8) were experienced in cleft care. Facial imaging data that included 2D images, 3D images, videos, and objective 3D visual modelling of facial movements were collected from each patient, and compiled as a collage termed the 'Standardized Assessment for Facial Surgery (SAFS)' for systematic viewing by the surgeons. Interventions: The SAFS served as the intervention. Each surgeon viewed the SAFS for six distinct patients (two babies and four adolescents) and provided a list of surgical problems and goals. Then an in-depth-interview (IDI) was conducted with each surgeon to explore their decision-making processes. IDIs were conducted either 'in person' or virtually, recorded, and then transcribed for qualitative statistical analyses using the Grounded Theory Method. Results: Rich narratives/themes emerged that included timing of the surgery; risks/limitations and benefits of surgery; patient/family goals; planning for muscle repair and scarring; multiplicity of surgeries and their impact; and availability of resources. In general, there was surgeon agreement for the diagnoses/treatments. Conclusions: The themes provided important information to populate a checklist of considerations to serve as a guide for clinicians.

Decellularized pulp matrix as scaffold for mesenchymal stem cell mediated bone regeneration.

Scaffolds that are used for bone repair should provide an adequate environment for biomineralization by mesenchymal stem cells (MSCs). Recently, decellularized pulp matrices (DPM) have been utilized in endodontics for their high regenerative potential. Inspired by the dystrophic calcification on the pulp matrix known as pulp stone, we developed acellular pulp bioscaffolds and examined their potential in facilitating MSCs mineralization for bone defect repair. Pulp was decellularized, then retention of its structural integrity was confirmed by histological, mechanical, and biochemical evaluations. MSCs were seeded and proliferation, osteogenic gene expression, and biomineralization were assessed to verify DPM's osteogenic effects in vitro. MicroCT, energy-dispersive X-ray (EDX), and histological analyses were used to confirm that DPM seeded with MSCs result in greater mineralization on rat critical-sized defects than that without MSCs. Overall, our study proves DPM's potential to serve as a scaffolding material for MSC-mediated bone regeneration for future craniofacial bone tissue engineering.

Polydopamine-Laced Biomimetic Material Stimulation of Bone Marrow Derived Mesenchymal Stem Cells to Promote Osteogenic Effects.

A hydroxyapatite-collagen (HC) composite material can mimic composition and ultra-structures of natural bone and provide adequate bioactive material-tissue interactions. Incorporation of dopamine (DA) is one of keys in increasing the mechanical strength of the HC material to approaching that of cortical bone. In this study, the in vitro osteogenic effects of polydopamine-laced hydroxyapatite collagen calcium silicate (HCCS-PDA) were examined by culturing rat mesenchymal stem cells (rMSCs) on HCCS-PDA and HCCS coated plates. HCCS-PDA group demonstrated less cytotoxic from Live/Dead cytotoxic assay and displayed higher cell attachment, proliferation and mineralization than the HCCS group in vitro. For in vivo bone regeneration, HCCS-PDA or HCCS particulates with or without rMSC aggregates were implanted into rat critical-sized calvarial defects (CSD). After 12 weeks, calvarial bone regeneration was evaluated radiographically, histologically, and histomorphometrically. While the majority of new bone formation occurred around the HCCS-PDA particulates with rMSC aggregates, The HCCS-PDA particulates without rMSC aggregates showed limited osteoconductivity. HCCS with or without rMSC aggregates resulted in less bone formation, indicating a prominent role of DA in effective bone regeneration. Therefore, the HCCS-PDA biomaterial with the aid of rMSCs can be used to develop therapeutic strategies in bone tissue engineering with numerable clinical applications.

End-of-Life Issues for the Oral and Maxillofacial Surgeon.

The oral and maxillofacial surgeon (OMS) plays a critical role when it comes to listening and answering patients' questions regarding prognosis, course of treatment, and overall expectations of what lies ahead. The OMS should remain an advocate for the patient, always keeping in mind that it is the patient's wishes that must be respected. The surgeon should champion patients' autonomy and cooperate with their families and other clinicians to ensure that patients have a "good death," defined as one that is pain free, peaceful, and dignified, at a place of their choosing with the relatives present and without futile heroic interventions. Indeed, the relationship and open communication between patient and surgeon may be one of the best treatments that the patient can have.