Evaluation of nasolabial esthetics in 8- to 12-year-old patients with cleft lip and palate by healthcare professionals in Northeast Thailand.

Objective: To assess the aesthetics of the nasolabial appearance of patients with cleft lip and palate aged 8-12 years by experienced and inexperienced professionals. Methods: A cross-sectional study was conducted on 32 patients with cleft lip and palate, who underwent surgery and follow-up treatment at the Cleft Center. The research tools included a parent-completed survey providing GO graphic data and two-dimensional frontal view photographs of patients from both left and right sides. The aesthetic of the lip, nose, and nasolabial region was evaluated by an experienced and inexperienced medical professional team in groups of four individuals. In addition, data analysis was performed using descriptive statistics, mean values, standard deviations, Cronbach's alpha reliability coefficient, and the Wilcoxon signed-rank test. Results: The average age of patients was 10.32 years, mainly male (65.63%), had unilateral cleft lip and palate (62.50%), and underwent bone grafting (96.88%). Regarding the assessment in three aspects, the aesthetic score assessed by experienced evaluators is fair level (2.64 ± 1.09) with an acceptable value of 0.73. In contrast, the inexperienced evaluator showed a high level (2.43 ± 0.83) with a high inter-rater reliability acceptable value of 0.60. Inexperienced evaluators showed higher scores for the lip and nasolabial region than experienced evaluators, which was statistically significant (p-values < 0.01). Conclusions: The inexperienced evaluators showed significantly higher scores for appearance than experienced evaluators. This result can improve surgical techniques in future procedures to meet the needs of patients seeking lip and nasolabial appearance corrections across different age groups.

Individualized Digital Nasoalveolar Molding: A Proof of Concept.

Nasoalveolar molding (NAM) is a recognized adjunctive therapy to primary cheiloplasty in patients with complete cleft lip and palate (CLP). The conventional technique can be time-consuming, costly, and requires experienced clinicians. Over the past decade, CAD/CAM technology has been employed to facilitate NAM therapy, showing promising results. This study introduces an individualized Digital NAM (iDNAM), a digital approach revolutionizing NAM treatment using CAD/CAM technology, and evaluates treatment outcomes. A 57-day-old infant with complete UCLP underwent intraoral and nasolabial scans, along with 3D photogrammetry. Open-source software was utilized for virtual alveolar segmentation and NAM plate design. iDNAM incorporates a nasal molding extension, introducing an innovative nasal stent activation protocol. Changes in alveolar and nasal morphology were compared between the initial and presurgery stages. After treatment with iDNAM, the alveolar cleft gap was reduced to 4.22 mm. Nostril height on the cleft side, columellar length, and nose projection increased by 0.98, 2.40, and 1.90 mm, respectively. The nasal base-columellar angle improved by 29.50 degrees. The results demonstrate a significant reduction in the alveolar cleft gap and improved nasal morphology, making iDNAM as an alternative to NAM therapy.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty.

OBJECTIVE: Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty. METHODS: A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups. RESULTS: Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P=0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold (P=0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P=0.003). CONCLUSION: Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Cleft Size and Success of Secondary Alveolar Bone Grafting-A Systematic Review.

OBJECTIVE: This study aimed to review all research evidence of presurgical cleft size and related factors to success of secondary alveolar bone grafting (SABG). DESIGN AND SETTING: The systematic review searched the OVID-Medline®, PubMed®, Embase®, and Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2020. Two reviewers independently selected potential abstracts for full review. Disagreeements were resolved by consensus. The first author extracted data and assessed the risk of bias using Risk of Bias in Non-randomized studies-of Interventions tool. PATIENTS AND INTERVENTIONS: Patients with non-syndromic clefts who received SABG were selected. Presurgical cleft size/volume and treatment results must be available. MAIN OUTCOME MEASURES: Level of the grafted bone, achievement of orthodontic tooth movement into the grafted area, need for re-operation. RESULTS: From 962 abstracts, 23 publications were included. Mean cleft width was 6.80 ± 1.98 mm, cleft area 20-240 mm2, and mean volume 0.89 ± 0.33 cm3. No definite conclusion was achieved on whether a narrow or wide cleft showed better treatment outcomes, but other potentially related factors were good oral hygiene and eruptive force of the maxillary canines. Lack of a standard definition of cleft size, a small sample size, varying outcome parameters, and moderate-to-high risk of bias contributed to the summary. A meta-analysis could not be performed because of the heterogeneity. CONCLUSION: Due to insufficient evidence, cleft width/volume could not be specified leading to more successful SABG. Care of patients could be improved in both research by following rigorous methodology, and practice by clear communication.

Effectiveness of the Nasal Creator Device after Cheiloplasty in Patients with Cleft Lip and Palate as Measured by 3D Stereophotogrammetry.

OBJECTIVE: To evaluate nostril morphology post-cheiloplasty after patients with unilateral cleft lip and palate (UCLP) use of the nasal creator device. STUDY DESIGN: This is a prospective study. Sixteen patients with nonsyndromic UCLP treated at Khon Kaen University underwent cheiloplasty and then wear the nasal creator device for 6 months. Three-dimensional images were taken, from which 5 lines and 8 landmark points were evaluated prior to (T0) and 1 day (T1), 1 month (T2), 3 months (T3), and 6 months (T4) after cheiloplasty. A Repeated Measure ANOVA was used to evaluate nostril changes between time periods and a paired t-test was used to compare values between the affected and non-affected side at T4 (P < .05). RESULTS: On the affected side, the nostril height significantly increased from T0 (2.46±0.89 mm) to T4 (4.22±1.03 mm), and the nostril width significantly decreased from T0 (9.46±2.57 mm) to T4 (7.34±1.41 mm). On the non-affected side, the nostril height significantly increased from T0 (3.39±0.78 mm) to T4 (4.65±1.07 mm), and the nostril width was not significantly different from T0 (6.00±1.25 mm) to T4 (6.59±0.95 mm). The alar base width was not significantly different between T0 (30.18±2.72 mm) and T4 (29.82±1.69 mm). Nostril height and width were not significantly different by T4 when comparing the affected and non-affected sides. CONCLUSION: Using nasal creator device for 6 months significantly increased the nostril height and decreased nostril width and alar base width after cheiloplasty.

Mandibular premolar transplantation to replace missing maxillary anterior teeth: A multidisciplinary approach.

One of the most challenging problems for orthodontists is that of multiple missing maxillary teeth in a growing patient. In many patients, a good treatment option is autotransplantation. This case report describes the multidisciplinary treatment of an 11-year-old girl with regional odontodysplasia affecting the maxillary right and left central incisors, and congenitally missing maxillary left lateral incisor and canine. Autotransplantation of the mandibular second premolars to the affected area was combined with orthodontic space closure, and the transplanted premolars were reshaped and restored with a resin composite to be in line with the left central and lateral incisors. After completion of the orthodontic treatment, gingivectomy was performed to obtain an even gingival contour and symmetrical gingival tissue. Space closure of the maxillary anterior teeth was achieved. Autotransplantation enabled the patient to retain her natural teeth rather than having a prosthesis or dental implant. The autotransplanted tooth allows for alveolar bone growth in synchrony with neighboring teeth and the formation of normal interdental papilla while adapting to functional stimuli and confers a high survival rate in the long term.

In vitro resorbability and granular characteristics of 3D-printed hydroxyapatite granules versus allograft, xenograft, and alloplast for alveolar cleft surgery applications.

Three-dimensionally printed hydroxyapatite (3DP HA) was investigated in regards to its functional properties supporting bone regeneration and tooth movement in alveolar cleft applications. Commercially available bovine xenograft (BXG), biphasic calcium phosphate alloplast (BCP), and two types of freeze-dried bone allograft granules (FDBA and FDBA-CMC) were employed as control samples. Degradability was studied by submerging the samples in pH 7.4 buffered solution at 37°C for 28 days and determining subsequent weight loss percentage. The wicking property and granular agglomeration were evaluated by putting the granules in contact with deionized water, blood, and phosphate-buffered saline (PBS). Both of FDBA and FDBA-CMC showed the greatest weight loss at 28 days followed by 3DP HA. In contrast, 3DP HA showed significantly greater wicking ability than other samples for all liquid types. FDBA-CMC exhibited the greatest granular agglomeration for all liquid types followed by 3DP HA. 3DP HA was found to be a favorable candidate for bone grafting in alveolar cleft treatment.

Function of Nasoalveolar Molding Devices in Bilateral Complete Cleft Lip and Palate: A 3-Dimensional Maxillary Arch Analysis.

OBJECTIVE: This study aimed to observe and analyze the effects of nasoalveolar molding (NAM) on maxillary arch dimensions in patients with bilateral complete cleft lip and palate (BCLP) using 3-dimensional analyses. DESIGN: Retrospective case series. MATERIALS AND METHODS: Seventeen infants were treated using modified Khon Kaen University presurgical nasoalveolar molding devices (KKU-NAM). Dental casts were evaluated 3 dimensionally at 3 time points: pretreatment (T1), after using modified KKU-NAM for 2 weeks (T2), and before cheiloplasty (T3). Repeated-measures analysis of variance and Friedman test were used to compare the maxillary arch dimensions between time points. RESULTS: Both sides of the cleft width, premaxilla deviation, and premaxilla protrusion had significantly reduced with the use of KKU-NAM. Premaxillary rotation had significantly improved, whereas the arch depth did not change significantly. Premaxilla width, posterior arch width, alveolar length, and height had significantly increased. The anterior arch width, intercanine width, and lateral sulcus width showed no significant changes. The intraclass correlation coefficient used to test the measurements indicated substantial reliability. CONCLUSION: The modified KKU-NAM is an effective device for reducing the severity of bilateral cleft deformities, especially in the premaxilla area.

Evaluation of Postorthodontic Changes in the Treatment of Cleft Lip and Palate Patients Using the PAR Index.

OBJECTIVE: To evaluate dental changes in cleft patients after undergoing orthodontic treatment for at least 2 years. HYPOTHESIS: The dental change would decline significantly after 2 years of completing orthodontic treatment. DESIGN: This is a retrospective study. PATIENT: Eighteen repaired cleft lip and palate patients from the Faculty of Dentistry, KhonKaen University, Thailand, participated in this study. MEAN OUTCOME MEASURES: A dental model with before treatment (T0), completed treatment (T1), and retention period (T2) data was analyzed using the peer assessment rating (PAR) index. RESULT: The results showed that the PAR score improved enormously after treatment; from T0 to T1, it was 34.00 ± 10.01 to 4.67 ± 2.47, and there was a reversion in the retention period. There was statistical significance between T0, T1, and T2, with P values <.001, .005, and <.001 when comparing T0 with T1, T1 with T2, and T0 with T2, respectively. CONCLUSION: Occlusion in cleft lip and palate patients changed from the time of completing treatment to the final results after the retention period. To sustain satisfactory results, orthodontists should plan carefully for the retention period before performing the treatment.

Treatment of a severe Class II Division 1 malocclusion combined with surgical miniscrew anchorage.

This article reports the camouflage treatment of a female patient, aged 15 years 2 months, who had a Class II Division 1 malocclusion with severe anterior protrusion and deep incisor overbite. The camouflage treatment plan included bilateral extraction of the maxillary first premolars combined with the use of temporary anchorage devices (TADs) and tension coil springs to retract canines into the extraction spaces and then the 4 incisors. The treatment included use of a mandibular fixed labial arch with minimal use of Class II elastics to correct mild mandibular spacing and level the curve of Spee. Ideal overjet and overbite relationships were established, and the final result was well balanced and esthetically pleasing. The molars were finished in a Class II relationship. Total treatment time was 2 years 6 months. Cephalometric superimpositions revealed that mandibular molars were not disturbed by the limited use of Class II elastics. Surgical miniscrews in canine and incisor retraction in Class II Division 1 malocclusion are an alternate type of temporary anchorage that reduce or remove reliance on conventional intermaxillary anchorage.

Evaluation of the Effects of Cheiloplasty on Maxillary Arch in UCLP Infants Using Three-Dimensional Digital Models.

OBJECTIVE: To analyze and identify changes in the maxillary dental arch before and after cheiloplasty in a group of unilateral complete cleft lip and palate (UCLP) infants. DESIGN: This is a cohort study. MATERIAL AND METHOD: Study models from 16 infants with nonsyndromic UCLP, who were treated at Khon Kaen University, were taken before (T1) and after cheiloplasty (T2). The dental models underwent a process of scanning through a 3D scanner, from which 9 linear and 2 angular landmarks were evaluated. Paired t test was used to compare the measurement statistically between T1 and T2. RESULTS: Alveolar cleft gap (G-L), anterior basal angle (∠GC-CC'), and anterior arch curvature angle on greater segment (∠GIC) were significantly decreased (P < .05). Contrarily, anterior ridge length of greater segment (C-I), anterior ridge length of lesser segment (L-C'), and posterior arch width (T-T') were significantly increased (P < .05) after cheiloplasty. While, anterior portion of greater segment (I-G), anterior arch width (C-C'), anterior arch depth (I⊥CC'), arch length (G⊥TT'), and arch circumference (T-C-I-G-L-C'-T') showed no significant difference. The measurements were tested using the Intraclass correlation coefficient. The coefficients indicated high reliability. CONCLUSION: Cleft gap significantly decreased after lip repair, and the anterior part of maxillary dental arch was also bent palatally after cheiloplasty without any other intervention except cheiloplasty. More studies are needed to assess the amount of lip pressure. If any convincing force is presented, an appliance to prevent undesirable pressure is indicated.

Evaluation of Facial Appearance among Patients With Repaired Unilateral Cleft Lip and Palate: Comparison of Patient- and Clinician-Ratings of Satisfaction.

The objective of this study was to determine the levels of patient-satisfaction on facial and dental appearance compared with clinician ratings. Participants included 61 patients with repaired unilateral cleft lip and palate (UCLP), aged 14-25 years. Raters comprised three cleft team clinicians. A Likert scale was used to assess the levels of satisfaction of the patients themselves and the clinicians. The results revealed that the patients were moderately satisfied with their appearance. Nose was the least satisfactory feature, followed by lip appearance. When compared to the clinician ratings, the patients were less satisfied with their own nose and lip, but more satisfied with teeth. Concerning age, self-assessment did not differ between adolescents and young adults. Females were less likely to be satisfied compared to males, but the difference was not statistically significant. In conclusion, patients with repaired UCLP were moderately satisfied with their facial and dental appearance. Clinician- and patient-opinions were different in some aspects. This study highlights the importance of patient satisfaction as a meaningful treatment outcome assessment, which could lead to an improvement in cleft care to meet the patient expectations.

Agreement of Tracing and Direct Viewing Techniques for Cervical Vertebral Maturation Assessment.

OBJECTIVE: This study aimed to evaluate agreement among three methods for cervical vertebral maturation (CVM) assessment, comprising direct viewing, tracing only, and tracing with digitized points. MATERIAL AND METHOD: Two examiners received training and tests of reliability with each CVM method before evaluation of agreement among methods. The subjects were 96 female-cleft lateral cephalometric radiographs (films of eight subjects for each age ranged from seven to 18 years). The examiners interpreted CVM stages of the subjects with four-week interval between uses of each method. RESULTS: The range of weighted kappa values for paired comparisons among the three methods were: 0.96-0.98 for direct viewing and tracing only comparison; 0.93-0.94 for direct viewing and tracing with digitized points comparison; and 0.96-0.97 for tracing only and tracing with digitized points comparison. The intraclass correlation coefficient (ICC) value among the three methods was 0.95. These results indicated very good agreement among methods. CONCLUSION: Use of direct viewing is suitable for CVM assessment without spending more time for tracing. However, the three methods might be used interchangeably.

Oral Health-Related Quality of Life in Children and Young Adolescent Orthodontic Cleft Patients.

OBJECTIVE: To evaluate and compare the oral health-related quality of life (OHRQoL) in Thai patients with cleft lip and palate and to evaluate parents' and their children perceptions. MATERIAL AND METHOD: Child Oral Health Impact Profile (COHIP) questionnaire was used to evaluate OHRQoL of the patients and parents' perceptions of patients' OHRQoL. The subjects consisted of 140 cleft patients (aged 8-15 years) and their parents who visited the Department of Orthodontics, Khon Kaen University. RESULTS: COHIP scores in cleft patients were relatively high. No statistically significant differences were found for overall and subscales COHIP scores between gender and age groups (aged 8-11 and 12-15 years) of patients. Comparison among cleft types, overall COHIP and functional well-being subscales scores showed statistically significant differences (p = 0.01 and p = 0.002, respectively). Cleft lip with or without alveolus (CL/A) had higher overall and functional well-being subscale scores than unilateral and bilateral cleft lip and palate patients (CLP). Only self-image subscale scores were statistically significant differences between patients and parents at p<0.001. CONCLUSION: Young and adolescent patients with cleft lip and palate had generally positive oral health-related quality of life. Impacts of gender and age of patients on OHRQoL were similar CL/A patients had more positive in overall oral health-related quality of life and functional well-being domains than CLP patients did. Parents had higher perceptions of self-image shown by their children than the children themselves.

Correlations between Cervical Vertebral Maturation (CVM) and Dental Development in Thai Cleft Patients.

OBJECTIVE: To examine correlations between cervical vertebral maturation stages (CVMs) and dental development stages, and cervical vertebral maturation (CVM) stage 6 and completion of root formation of mandibular third molar in Thai cleft patients. MATERIAL AND METHOD: Lateral cephalograms of 366 cleft subjects aged 7-9 years were assessed for CVMs using Baccetti method. Calcication stages of all left mandibular teeth within each CVMs were assessed from panoramic films using Demirjian method. RESULTS: Spearman rank correlation coefficients comparing CVMs and teeth were 0.51-0.79 (p<0.001). Second molar had the highest and central incisor had the lowest correlations. In CVMs 6, 2.9% of third molars had completed root formation. However, only CVMs 6 could be predicted from third molar stage G that had a high likelihood ratio (30.94). CONCLUSION: Dental development was highly correlated with CVM in clefts. Third molar stage G could predict completed growth of mandible in individual patients, but it should be combined with other maturation indicators.

Orthodontic Treatment Combined with Orthognathic Surgery and Simultaneous Alveolar Bone Graft of a Unilateral Complete Cleft Lip and Palate Patient: A Case Report.

This article aimed to present a case of 22 year-old Thai female with cleft lip and palate who had malocclusion developed from dental problems, skeletal disharmony and unrepaired alveolar cleft. The treatment was orthodontic combined with one-stage surgical correction which corrected skeletal discrepancy and alveolar cleft in single operation. After treatment, the patient had improved in facial esthetics, attaining good occlusal function and continuous maxillary dental arch. This procedure can reduce morbidity, preclude a second hospitalization and the cost of two-stage surgical correction. However this is only an alternative treatment for adult cleft patients who need late alveolar bone graft and orthognathic surgery.

Presurgical Nasoalveolar Molding Techniques for a Complete Unilateral Cleft Lip and Palate Infant: A Case Report.

The purpose of this article was to present a modified protocol and devices of presurgical nasoalveolar molding techniques to improve deformity of lip, nose and alveolus at Department of Orthodontic, Khon Kaen University (KKU). This new protocol was developed in order to address nasal problems as early as possible with a new extra-oral type of nasal molding device, "forehead type of nasoalveolar molding device". Extra-oral strapping was applied to approximate lip segments and also help to reduce alveolar cleft rapidly. The remaining alveolar cleft was reduced till completely, using alveolar molding plate with traction screw. The forehead type of nasal molding device could be used continuously after cheiloplasty to maintain nasal configuration until the secondary palate repaired. A case of complete unilateral cleft lip and palate girl was presented to clearly demonstrate treatment steps and results of lips, nose and alveolus after being treated with this new presurgical nasoalveolar molding protocol and devices for a period of four months.

Pre-surgical nasoalveolar molding technique: a literature review.

Cleft lip and palate patients have many defects particularly nasal deformities. The nasoalveolar molding (NAM) technique is an adjunctive treatment, which not only corrects deviated alveolar segments but also addresses nasal deformity before cheiloplasty. NAM technique is claimed to facilitate primary surgical correction and to provide favorable esthetic outcomes. However, there is limited evidence to confirm the special benefits ofNAM technique since so far there have been no truly long term controlled clinical trials to evaluate outcomes of treatment based on pre-surgical NAM technique. NAM technique can aid surgeons in their primary repairs ofnasal deformities but there should be concern about cost-risk benefits and ability ofparents to manage home care. Further studies based on properly designed and managed long-term clinical trials are still neededfor reaching consensus on special benefits ofNAM technique compared with other treatment protocols.

A comparison of cervical vertebral maturation assessment of skeletal growth stages with chronological age in Thai between cleft lip and palate and non-cleft patients.

OBJECTIVE: (1) To search for any difference in chronological age related to stages of the cervical vertebral maturation index stages (CVMIs) comparing groups of cleft lip and palate (CLP) and non-cleft (non-CLP) subjects; (2) To investigate the relationship between chronological age and CVMIs in both groups of subjects. MATERIAL AND METHOD: Cervical vertebrae C2, C3, C4 were assessed on 1,549 cephalometric films (503 CLP films, 1,046 non-CLP films of subjects aged 5 to 18 years) using Hassel and Farman's method. RESULTS: T-tests showed mean chronological ages of CVMIs 2, 3 and 6 were different at p = 0.001, 0.024 and 0.016, respectively. CVMIs 1, 4 and 5 showed no significant differences. The CLP group achieved each CVMI score one year ahead of the non-CLP group, except for CVMI 4. Spearman's rank order correlations were r = 0.80 (95% CI: 0.76-0.83) for CLP, and 0.77 (95% CI: 0.74-0.79) for non-CLP. CONCLUSION: CLP subjects tended to have a slightly advanced growth compared with non-CLP subjects. A high correlation coefficient was found between chronological age and cervical vertebral skeletal maturation.