Fabrication of Nasoalveolar Molding Devices for the Treatment of Cleft Lip and Palate, Using Stereolithography Additive Manufacturing Processes and Computer-Aided Design Manipulation Software.

INTRODUCTION: Nasoalveolar molding (NAM) is a presurgical orthopedic treatment modality that attempts to reorient misaligned bony and soft tissue structures in patients with clefting of the lip and palate. The NAM devices are implemented prior to surgical intervention in order to minimize the gap across the cleft and thereby reduce tension across the eventual repair. Currently, NAM devices are fabricated in a laboratory and then refined chairside by the provider. The present article describes the potential of three-dimensional (3D) printing and computer-aided design (CAD) software for the fabrication of NAM devices. MATERIAL AND METHODS: A workflow was developed to demonstrate the use of 3D printing and CAD software to design NAM devices. This workflow encompasses scanning an impression into CAD software, performing a series of manipulations, and then printing the digital model. RESULTS: To test the workflow, a cleft palate plaster model was scanned into CAD software. Through a series of linear and angular freeform manipulations of the body, the model was modified to display a cleft with a reduced alveolar gap. Sequential molding devices were produced which would gradually apply pressure to targeted areas of hard and soft tissue until the cleft is minimized. The resulting devices are printed using a stereolithography printer. CONCLUSIONS: The use of 3D printing and CAD software shows promise in improving the accuracy, speed, and cost-effectiveness of designing NAM devices. The accuracy and flexibility from digitally visualizing the manipulations made to an appliance before its creation can result in a more personalized device for the patient.

Quantitative Evaluation of Nasolabial Alterations following Nasoalveolar Molding (NAM) Therapy in Patients with Unilateral Cleft Lip.

The clinical benefit of nasoalveolar molding (NAM) is actively debated between cleft centers without clear consensus. Nasolabial measurements were performed on pediatric patients with unilateral clefts of the lip, with or without cleft palate, at an academic cleft/craniofacial center prior to and following NAM therapy between June 2015 and August 2016. The parameters of interest were: columella height and width, cleft nostril height and width, and lip width. Measurements were performed using photographs taken alongside a reference object. The image output was then scaled to the size of the reference object and the capture angle. Intraclass correlation coefficient was calculated to assess reliability of the photographic measurements. Descriptive statistics (mean, standard deviation [SD]) were calculated to characterize the pre- and post-NAM measurements. Student's t-tests were performed to compare the pre-NAM versus post-NAM measurements. The primary objective was to measure the effect of NAM on the nasal aesthetic units that are known to be anatomically aberrant in the cleft lip patient. Nine patients were included in this study. Average pre-NAM age was 2.5 weeks, and average post-NAM age was 13 weeks. Average columellar height increased from 3.70 mm (SD = 0.14) pre-NAM to 5.85 mm (SD = 1.96) post-NAM (p < 0.01); average columellar width increased from 4.71 mm (SD = 0.49) to 5.93 mm (SD = 0.71) (p < 0.01); average cleft nostril height increased from 3.54 mm (SD = 2.97) to 6.81 mm (SD = 2.98) (p = 0.01); and average cleft nostril width decreased from 15.46 mm (SD = 2.91) to 11.05 mm (SD = 1.01) (p = 0.01). Average lip width decreased from 34.61 mm (SD = 1.73) to 33.87 mm (SD = 3.67); however, this change was not statistically significant (p = 0.16). This study objectively quantifies positive changes in nasal aesthetics associated with NAM therapy, providing further evidence for its utility as a presurgical treatment modality for optimal aesthetic nasal results in the unilateral cleft lip patient. The major limitation of this study was a lack of control group, as our center universally treats complete unilateral cleft lip patients with NAM therapy. However, the authors strongly believe that the positive aesthetic nasal findings would persist if compared with a non-NAM control group.

Maternal Tobacco Exposure and Development of Orofacial Clefts in the Child: A Case-Control Study Conducted in Pakistan.

INTRODUCTION: The purpose of this study was to evaluate the association between maternal tobacco exposure and development of orofacial clefts (OFCs) in the child in a Pakistani population. METHODS: A case-control study was conducted at the Cleft Hospital and Bashir Hospital in Gujrat, Pakistan, from December 2015 to December 2016. All new cases of OFC at the Cleft Hospital were included. Patients at Bashir Hospital younger than 3 years and without congenital malformations were selected as control subjects. Risk factors associated with OFC were identified through bivariate analyses. Multiple logistic regression was then performed to calculate adjusted odds ratios (ORs) of developing OFC according to various risk factors. RESULTS: The study included 297 patients with OFC and 131 control subjects. Upon univariable analysis, the following were associated with OFC: maternal tobacco exposure (P < 0.001), complications during pregnancy (P < 0.001), maternal hypertension (P = 0.01), mother not on physician-recommended medications (P < 0.001), mother not receiving vaccinations (P < 0.001), consanguineous marriage (P < 0.001), and lower socioeconomic status (P < 0.001). Upon multivariable analysis, having a smoking parent (OR, 1.89; 95% confidence interval [CI], 1.10-3.26), complications during pregnancy (OR, 2.36; 95% CI, 1.43-3.88), and consanguineous marriage (OR, 1.79; 95% CI, 1.13-2.85) were associated with increased odds of development of OFC; receiving vaccinations (OR, 0.31; 95% CI, 0.16-0.63) and higher socioeconomic status (OR, 0.20; 95% CI, 0.05-0.74) were protective. CONCLUSIONS: Patients with OFC were nearly twice as likely to have a parent who smokes as those without. Efforts to reduce tobacco consumption among prospective parents, such as perinatal tobacco cessation counseling programs, should be evaluated in this population.

Association Between Cleft Lip and/or Cleft Palate and Family History of Cancer: A Case-Control Study.

BACKGROUND: Cleft lip and/or cleft palate (CL ± P) are among the most common congenital anomalies. Nevertheless, their etiologies remain poorly understood. Several studies have demonstrated increased rates of cancer among patients with CL ± P and their relatives, as well as increased risk of CL ± P among family members of cancer survivors. In addition, a number of possible genetic associations between cancer and CL ± P have been identified. However, these studies are limited by confounding factors that may be prevalent in these patients, such as tobacco exposure and perinatal complications.The purpose of this study was to quantitatively evaluate the association between family history of cancer and development of CL ± P in the child. METHODS: A case-control study was conducted at the Cleft Hospital and the Bashir Hospital in Gujrat, Pakistan from December 2015 to December 2016. All new cases of CL ± P at the Cleft Hospital were included. Sociodemographically similar patients without congenital malformations at the Bashir Hospital served as controls. Risk factors associated with CL ± P were identified through bivariate analyses. Multiple logistic regressions were performed to calculate adjusted odds ratios of developing CL ± P. RESULTS: There were 137 patients with CL ± P and 147 controls in the study. The following factors were statistically significantly associated with development of cleft: history of cancer in the family (P < 0.001), complications during pregnancy (P = 0.02), maternal hypertension during pregnancy (P = 0.01), mother not on any medications (P < 0.001), consanguineous marriage (parents are first or second cousins) (P = 0.03), lower socioeconomic status (P < 0.001), having a parent who smokes (P = 0.001), and history of miscarriage (P = 0.01). After adjustment for these variables, having a history of cancer in the family was independently associated with a 5.19 times increased odds of the child being born with CL ± P (95% confidence interval [CI], 1.57-17.03). Middle-class socioeconomic status (compared with lower) (odds ratio [OR], 0.36; 95% CI, 0.16-0.83), having a smoking parent (OR, 2.12; 95% CI, 1.05-4.28), and history of miscarriage (OR, 4.60; 95% CI, 1.21-17.54) were also statistically significantly associated with CL ± P within this model. CONCLUSIONS: This study provides evidence for a relationship between CL ± P and cancer that has been adjusted for confounders traditionally associated with patients with CL ± P, thereby supporting the evidence of shared environmental and/or genetic etiologies.

Location-Specific Oral Microbiome Possesses Features Associated With CKD.

INTRODUCTION: Chronic kidney disease (CKD), a progressive loss of renal function, can lead to serious complications if underdiagnosed. Many studies suggest that the oral microbiota plays important role in the health of the host; however, little is known about the association between the oral microbiota and CKD pathogenesis. METHODS: In this study, we surveyed the oral microbiota in saliva, the left and right molars, and the anterior mandibular lingual area from 77 participants (18 with and 59 without CKD), and tested their association with CKD to identify microbial features that may be predictive of CKD status. RESULTS: The overall oral microbiota composition significantly differed by oral locations and was associated with CKD status in saliva and anterior mandibular lingual samples. In CKD patients, we observed a significant enrichment of Neisseria and depletion of Veillonella in both sample types and a lower prevalence of Streptococcus in saliva after adjustment for other comorbidities. Furthermore, we detected a negative association of Neisseria and Streptococcus genera with the kidney function as measured by estimated glomerular filtration rate. Neisseria abundance also correlated with plasma interleukin-18 levels. CONCLUSION: We demonstrate the association of the oral microbiome with CKD and inflammatory kidney biomarkers, highlighting a potential role of the commensal bacteria in CKD pathogenesis. A better understanding of the interplay between the oral microbiota and CKD may help in the development of new strategies to identify at-risk individuals or to serve as a novel target for therapeutic intervention.

Correlation between Nasoalveolar Molding and Surgical, Aesthetic, Functional and Socioeconomic Outcomes Following Primary Repair Surgery: a Systematic Review.

OBJECTIVES: The authors performed a systematic review to evaluate the potential beneficial effects of the nasoalveolar molding appliance on nonsyndromic unilateral clefts of the lip and/or palate prior to primary lip repair. MATERIAL AND METHODS: A literature search was performed using three electronic databases (PubMed, Embase, Web of Science) and three journals ("Cleft Palate-Craniofacial Journal", "Plastic and Reconstructive Surgery Journal" and "American Journal of Orthodontics and Dentofacial Orthopaedic") from January 1980 to April 2017. Data extraction was performed with tables treating different subjects: surgical, aesthetical, functional, socio-economical effects of nasoalveolar molding (NAM) appliances and the evolution of NAM appliances, especially three-dimensional technology. RESULTS: Of the 145 articles retrieved in the literature surveys, 28 were qualified for the final analysis and 20 studies were excluded because of their small sample size (less than 10 patients) and/or too long follow-up (exceeded 18 months). Four randomized controlled trials were available. Although literature allowed discussing the short-term benefits of NAM appliance and the three-dimensional technology, scientific evidence is lacking. CONCLUSIONS: Based on the results, nasoalveolar molding appliances have positive surgical, aesthetical, functional and socio-economical effects on unilateral clefts of the lip and/or palate treatment before the primary repair surgeries. Three-dimensional technology results in a more efficient and predictable nasoalveolar molding appliance treatment. However, nasoalveolar molding appliance effect in a short term remains unclear with the available literature. Further studies that integrate three-dimensional technology in a large scale are still needed.

Review of the Genetic Basis of Jaw Malformations.

Genetic etiologies for congenital anomalies of the facial skeleton, namely, the maxilla and mandible, are important to understand and recognize. Malocclusions occur when there exist any significant deviation from what is considered a normal relationship between the upper jaw (maxilla) and the lower jaw (mandible). They may be the result of anomalies of the teeth alone, the bones alone, or both. A number of genes play a role in the facial skeletal development and are regulated by a host of additional regulatory molecules. As such, numerous craniofacial syndromes specifically affect the development of the jaws. The following review discusses several genetic anomalies that specifically affect the bones of the craniofacial skeleton and lead to malocclusion.

Alveolar Bone Grafting and Cleft Lip and Palate: A Review.

Alveolar bone grafting in the mixed dentition stage is an accepted step in the management of cleft alveoli, providing maxillary arch support for dentition and mastication. Points of contention regarding best practices remain, including specific timing, perioperative orthodontic management, bone harvest and substitutes, pain management, and outcomes evaluations. SCOPUS and MEDLINE were searched for articles about alveolar bone grafting, which were read independently by two authors and selected for inclusion on the basis of relevance and merit. Articles on which recommendations were based were rated using the methodological index for non-randomized studies criteria. Three hundred thirty-three distinct articles were found, of which 64 were found to be suitable and relevant for inclusion. The average methodological index for non-randomized studies score was 10.39, with an interrater weighted kappa of 0.7301. Prospective comparative studies about alveolar bone grafting are rare, but available evidence suggests grafting before canine eruption with targeted preoperative orthopedic interventions, the continued use of iliac crest corticocancellous autologous graft, and adjunctive pain control methods. Greater consensus must be reached about valuable outcome measures for research, including use of imaging and indications for regrafting following graft failure.

The Correlation between Maternal Exposure to Air Pollution and the Risk of Orofacial Clefts in Infants: a Systematic Review and Meta-Analysis.

OBJECTIVES: The authors performed a systematic review and meta-analysis to investigate the possible correlation between ambient air pollution and orofacial cleft anomalies in newborns. MATERIAL AND METHODS: A literature search was performed using the PubMed and Google Scholar, using the keywords "air pollution", "cleft lip", "cleft palate", "carbon monoxide", "ozone", "sulfur dioxide", "nitrogen oxide", "nitrogen dioxide", and "aerodynamic diameter". Eight epidemiologic articles met the criteria of correlating either carbon monoxide (CO), ozone (O3), nitrogen oxides (NOx), airborne particulate matter of less than 10 µm in diameter (PM10), or sulfur dioxide (SO2) exposures with clefting of the palate alone, clefting of the lip alone, or clefting of the lip and palate. Odds ratios were extracted from the eight studies and tabulated in this meta-analysis. Quality analysis showed six high quality, one medium quality, and one low quality study. RESULTS: Meta-analysis of the combined data confirmed the association of O3 exposure and risk of orofacial cleft anomalies (OR = 1.08; P = 0.02). NOx was consistently associated with decreased risk of cleft lip with or without palate and cleft palate. CONCLUSIONS: Ozone showed the strongest correlation with cleft lip and cleft palate anomalies. However, the studies overall showed an inconsistent correlation between orofacial clefts and air pollutants.

Novel mutations in EVC cause aberrant splicing in Ellis-van Creveld syndrome.

Ellis-van Creveld syndrome (EvC) is a rare autosomal recessive disorder characterized by disproportionate chondrodysplasia, postaxial polydactyly, nail dystrophy, dental abnormalities and in a proportion of patients, congenital cardiac malformations. Weyers acrofacial dysostosis (Weyers) is another dominantly inherited disorder allelic to EvC syndrome but with milder phenotypes. Both disorders can result from loss-of-function mutations in either EVC or EVC2 gene, and phenotypes associated with the two gene mutations are clinically indistinguishable. We present here a clinical and molecular analysis of a Chinese family manifested specific features of EvC syndrome. Sequencing of both EVC and EVC2 identified two novel heterozygous splice site mutations c.384+5G>C in intron 3 and c.1465-1G>A in intron 10 in EVC, which were inherited from mother and father, respectively. In vitro minigene expression assay, RT-PCR and sequencing analysis demonstrated that c.384+5G>C mutation abolished normal splice site and created a new cryptic acceptor site within exon 4, whereas c.1465-1G>A mutation affected consensus splice junction site and resulted in full exon 11 skipping. These two aberrant pre-mRNA splicing processes both produced in-frame abnormal transcripts that possibly led to abolishment of important functional domains. To our knowledge, this is the first report of EVC mutations that cause EvC syndrome in Chinese population. Our data revealed that EVC splice site mutations altered splicing pattern and helped elucidate the pathogenesis of EvC syndrome.

Risk of persistent palatal fistula in patients with cleft palate.

IMPORTANCE: Many individuals with a cleft palate also have an associated craniofacial syndrome or anomaly. OBJECTIVE: To investigate the predictive associations of persistent palatal fistulas in patients with previously repaired cleft palate. DESIGN, SETTING, AND PARTICIPANTS: We performed a case-control study of patients with cleft palate repairs from January 1, 1986, through December 31, 2000, at a major tertiary care hospital center in the Bronx, New York. The study population consisted of patients who had their primary surgery before the age of 3 years and had all their cleft-related treatment completed at the same hospital center. Palatal fistula was defined as a breakdown of the primary surgical repair of the palate, resulting in persistent patency between the oral and nasal cavities. Data collection was conducted by using the hospital centers' electronic medical records and patient tracking systems and confirmed by review of hard copies of patient records. MAIN OUTCOMES AND MEASURES: The Veau classification system was used to classify the preoperative cleft severity. RESULTS: A total of 130 patients were identified-23 patients with palatal fistula and 107 controls. A total of 12 girls and 11 boys were identified in the palatal fistula group and 56 girls and 51 boys in the control group. The mean patient age at the time of palatoplasty was 12.6 and 14.5 months in the palatal fistula and control groups, respectively. A statistically significant association was found between the outcome of fistula and severity of cleft, as defined by the Veau classification system (P = .01). Furthermore, for each Veau class increase, the odds of a palatal fistula increased by 2.64 (95% CI, 1.35-5.13; P = .004). No statistically significant associations were found between the outcome of fistula and the following independent variables: patient sex (P = .98), patient age at palatoplasty (P = .82), type of palatoplasty (P = .57), surgeon (P = .15), orthodontic treatment (P = .59), ear infection (P = .30), or clefts associated with syndromes (P = .96). CONCLUSIONS AND RELEVANCE: Palatal fistulas are reliably associated with severity of cleft, as defined by the Veau classification system. This knowledge gives the health care professional a more reliable method of preoperatively assessing the risk of postoperative palatal fistula in the cleft palate population. LEVEL OF EVIDENCE: 3.

Forces of various nickel titanium closed coil springs.

OBJECTIVE: To compare the forces generated by 14 different 9 mm springs supplied by five different companies. MATERIALS AND METHODS: Five replicates of 14 different 9 mm springs were evaluated, resulting in 70 total specimens. Each was extended once from its resting length to 12 mm and then was deactivated. All tests were performed in a 37 degrees C water bath. Forces were recorded at the 12 mm extension and deactivation distances of 9 mm, 6 mm, 3 mm, and 1 mm using an MTS force gauge. Data were collected with Testworks software, version 4.0, and were analyzed by analysis of variance (ANOVA) with one factor alternated. RESULTS: Mean peak load forces at 12 mm were significantly different between springs, and these forces varied from 147 to 474 grams. Mean unload forces measured at 9 mm, 6 mm, and 3 mm of deactivation values were highly variable, and only 6 of the 14 springs exhibited a "physiologic" mean unload force of 50 grams or less over the total deactivation range. CONCLUSIONS: Few springs tested exhibited physiologic peak load forces and constant deactivation forces. This study suggests that labeling of nickel titanium closed coil springs is confusing and misleading.

Amalgam matrix for class II and class V preparations connected at the proximal box.

BACKGROUND: The authors present a technique for placing and reinforcing an amalgam matrix around combined Class II and Class V preparations that connect at the proximal box. OVERVIEW: First, the dentist fills the Class V aspect of the preparation, using a temporary resin-based composite wall at the line angle to support amalgam condensation. The dentist then removes the wall and places a matrix band around the tooth, internally reinforcing the band with smaller pieces of matrix band and resin-saturated cotton balls that are light-polymerized and externally reinforcing the band with fast-polymerizing vinyl polysiloxane. Finally, the dentist condenses the line angle amalgam through the proximal box and condenses the proximal box and occlusal aspects. CONCLUSION: For connected Class II and Class V preparations, this matrix technique permits controlled amalgam condensation, even at the line angle aspect, where it is difficult to condense amalgam without voids or microleakage. CLINICAL IMPLICATIONS: This technique allows dentists to provide a stable, inexpensive direct restoration for teeth with connected Class II and Class V preparations, providing an alternative for patients who do not wish to have crowns placed.

Preventing sharps, splash, and needlestick injuries in dentistry: a comprehensive overview.

This article presents a comprehensive collection of precautions and suggestions for preventing sharps, splash, and needlestick injuries in dentistry. The authors looked at studies of sharps and splash injuries in dentistry to determine which of these injuries are most common. They then assembled a set of precautions to prevent these injuries based on published literature, tips learned from other dentists, and their own clinical observations. Dentists must remember and apply many precautions to prevent the broad spectrum of sharps and splash injuries that could occur during the delivery of dental care.