Dens Invaginatus in Patients With Cleft Lip and Palate: A Case Series.

Dens invaginatus is a rare developmental anomaly characterized by an infolding of the enamel organ within the crown or root of a tooth, and it is an example of a dental anomaly that has a higher incidence in patients with CL/P. If undiagnosed, dens invaginatus can lead to severe, acute pain and pulpal necrosis since it can permit direct entry of bacteria into the dental pulp. Treatment of dens invaginatus includes prophylactic sealant or composite restoration, endodontic therapy if pulpal involvement has already occurred, or extraction if aberrant tooth morphology precludes endodontic therapy. Few studies report on the incidence of dens invaginatus in patients with CL/P. The purpose of this article is to describe 4 cases of dens invaginatus in patients with CL/P which were encountered in a cleft-craniofacial orthodontic clinic. Each case describes dens invaginatus in a maxillary lateral incisor, and treatments ranged from sealant application to endodontic therapy to extraction. These cases highlight the importance of awareness of this dental anomaly among cleft team providers to facilitate early diagnosis in patients with CL/P.

Cone-Beam Computed Tomography Incidental Findings in Individuals With Cleft Lip and Palate.

OBJECTIVES: The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment. METHODS: This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed. RESULTS: Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas. DISCUSSION: In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental-alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.

Airway Obstruction Risk in Unique Infant Cleft Phenotype: PSIO Protocol Modification Recommendations.

Patients presenting with a unique unilateral cleft phenotype may be at risk of nasal airway obstruction which can be exacerbated by presurgical infant orthopedic (PSIO) appliance therapy and lip taping. Four patients presented to the UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center with a cleft phenotype characterized by: An anteriorly projected greater alveolar segment and medial collapse of the lesser segment posteriorly, leading to cleft alar base displacement posteromedial to the anteriorly projected greater segment. Resultant bilateral nasal airway obstruction: cleft ala drape over the leading edge of the greater segment's alveolus (cleft side obstruction) and caudal septum displacement secondary to attachments to the orbicularis oris from the noncleft side (noncleft side obstruction). The patient described presented at 3 months old from an outside institution, where PSIO therapy was undertaken. A second opinion was sought due to concern of significant difficulty in breathing and feeding with the PSIO oral plate. Lip-nose adhesion (LNA) was elected and airway obstruction was immediately relieved after this intervention. Lip-nose adhesion releases the tethered cleft side alar base from the pyriform rim of the posteromedially collapsed lesser segment and unites the superior lip and nostril sill-relieving the cleft side nostril obstruction. During the LNA, the caudal septum is surgically released from the anterior nasal spine and is uprighted, relieving the obstructed noncleft nostril. In this cleft anatomy, the treatment alternatives of modification to the PSIO appliance or LNA should be carefully considered in consultation with the surgeon, PSIO provider, and the infant's caretakers.

Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth.

OBJECTIVE: Cranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth. METHODS: This is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05. RESULTS: The early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group. CONCLUSIONS: Though our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

Management of the alveolar cleft.

Orthopedic and orthodontic management of patients born with clefts of the lip, alveolus and palate is based on the application of basic biomechanical principles adapted to the individualized cleft anatomy. This article focuses on orthopedic and orthodontic preparation for 2 stages of interdisciplinary orthodontic/surgical cleft care: presurgical infant orthopedics (nasoalveolar molding) for lip/alveolus/nasal surgical repair and maxillary arch preparation for secondary alveolar bone grafting. These preparatory stages of orthopedic/orthodontic therapy are undertaken with the goal of restoring normal anatomic relationships to assist the surgeon in providing the best possible surgical care.