Surgical Management of Submucous Cleft Palate by Radical Muscle Dissection Veloplasty: Speech Outcomes in Patients with 22q11.2 Deletion Syndrome.

OBJECTIVE: To evaluate the benefit of anatomical muscle dissection repair for velopharyngeal insufficiency (VPI) in patients with submucous cleft palate (SMCP) with 22q11.2 deletion syndrome. DESIGN: Retrospective blinded randomised analysis of a surgeon's management over 10 years. SETTING: The study was performed at a specialised Paediatric hospital in the United Kingdom. PATIENTS: Children with SMCP and 22q11.2 deletion syndrome. INTERVENTIONS: All participants underwent radical muscle dissection veloplasty. OUTCOMES MEASURED: Pre- and post- operative measurements included severity of anatomical defect, speech samples and lateral images which were digitised, randomised then externally and blindly analysed using validated techniques. Stata software was used to perform statistical analysis. RESULTS: 57 children with 22q11.2 deletion syndrome were included in this analysis. Intra-operatively, the majority of cases were identified as SMCP Grade I anomalies. Post-operatively, a statistically significant improvement in hypernasality, resting palate length, palate length at maximum closure, palate excursion and gap size at maximum closure was observed. Secondary surgery was performed for 59% of patients by ten years. CONCLUSION: Muscle dissection repair improves hypernasality, palate closure function and the closure gap in patients with 22q11.2 deletion syndrome. Although over 50% of patients may require further surgery, muscle dissection repair should be a first step due to its utility at a younger age, when invasive investigations are impossible, its lower morbidity, speech and language benefits or altering the plans for less obstructive secondary surgery when it lead to reduced velo-pharyngeal gap and improved palate mobility even when adequate velo-pharyngeal closure was not achieved.

The CLEFT Student Section: Engaging the future of cleft through fundraising; Structure of the section and results from inaugural year.

BACKGROUND: There is a disparity in access, quality, and sustainability of cleft care in low and middle income countries, where burden of disease is greatest. CLEFT-Bridging the Gap (registered charity number: 1194581) is a UK-based charity that aims is to solve this through teaching, empowerment and development of sustainable cleft services. A Student Section, composed of medical, dental and speech and language therapy students, was established to support these endeavours through fundraising. AIMS: 1) examine effectiveness of the Student Section, 2) explore students' perception of cleft care, 3) provide a framework for similar groups. METHODS: Cross-sectional survey study design. Likert-Scale responses to questions regarding organisation and experience of the section were collected. Data was analysed using Chi statistical test, ordinal data assessed using Wilcoxon-Signed Rank test. RESULTS: 40/64 ambassadors responded to the survey. 90% had a positive perception on the organisation of the section, this correlated with group size (p = 0.012) and number of fundraising events organised (p = 0.032). 85% had an overall positive experience, scores for consideration of a career in cleft significantly improved from 2.25 (95%CI: 1.95-2.55) to 3.30 (95%CI: 3.03-3.57) (p < 0.001). CONCLUSION: This study presents the first example of a nationwide student group involved with a charitable cleft organisation.

Submucous Cleft Palate (SMCP): Indications and Outcomes of Radical Muscle Dissection Palatoplasty in Children Under 4 Years of Age.

To delineate the indications, referral sources and outcomes of radical muscle dissection palate repair in the first 4 years of life for patients with submucous cleft palate (SMCP).This study presents a retrospective analysis of a single surgeon's management.All children were treated at Great Ormond Street Hospital, United Kingdom.Twenty-three children with nonsyndromic SMCP were included in this study.All participants underwent radical muscle dissection repair before their fourth birthday.Parameters analyzed included: referral sources, indications for referral, extent of anatomical abnormality, and postoperative outcomes.Paediatricians provided the largest proportion of referrals to the cleft lip and palate clinic (39%) due to the presence of cleft lip/palate on prenatal scans or during neonatal examination. Over half (n = 12, 52%) of patients had severe anatomical anomalies being in grade IV (score 8-9), with the classical triad present to some extent in all but 2 of the patients. The main indication for surgery was nasal regurgitation of food and liquid (n = 9, 35%) followed by hypernasality (n = 6, 21%), difficulty feeding (n = 3, 8%), and severe anatomical defect (n = 2; 4%). Postoperatively, the presenting complaint improved in the majority of cases.Nonsyndromic SMCP is often missed, though may present with nasal regurgitation, feeding problems, and/or hypernasality, though may be missed in nonsyndromic children. Early radical muscle dissection repair in the first 4 years of life is safe and effective, facilitating normal speech development.

The First Hybrid International Educational Comprehensive Cleft Care Workshop.

OBJECTIVE: Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance. DESIGN: Cross-sectional survey-based evaluation. SETTING: International comprehensive cleft care workshop. PARTICIPANTS: Total of 489 participants. INTERVENTIONS: Three-day simulation-based hybrid comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance. RESULTS: The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01). CONCLUSION: Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Simulation Training Approach for Cleft Lip and Palate Repair in Low-Income Countries.

BACKGROUND: During periods of civil strife, the need for trauma care and lack of sufficient cleft surgeons causes an increase in children left untreated with cleft lip and palate deformities. During the Syrian war, some cleft care was provided through visiting charities, with surgeries performed both in Syria and neighboring countries. There is a need to increase the number of adequately trained cleft surgeons available in such regions so that care can be achieved beyond mission trips. METHODOLOGY: Cleft lip and palate repair workshops were delivered to 50 doctors in Syria. Pre-workshop, trainees received supplementary learning material. During the workshop, attendees received didactic teaching followed by 2 simulation sessions. Pre- and post-workshop, attendees completed questionnaires regarding their confidence and ability to perform cleft lip and palate repair. RESULTS: Pre-workshop, 96% of workshop attendees had never independently performed cleft lip repair while 100% of attendees had not previously performed cleft palate repair. The mean pre-workshop confidence score was 2.452. Post-workshop, the mean confidence score was 3.503. Confidence rating scores significantly improved (P < .001). CONCLUSION: The workshop delivered in Syria, together with this cleft lip and palate simulator provides an effective training tool that may support surgical training globally, particularly those in low-income countries. Further support is needed by charity organizations to ensure the continued delivery of such training.

Simulation-Based Comprehensive Cleft Care Workshops: A Reproducible Model for Sustainable Education.

OBJECTIVE: Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact. DESIGN: Cross-sectional survey-based evaluation. SETTING: Simulation-based comprehensive cleft care workshop. PARTICIPANTS: Total of 180 participants. INTERVENTIONS: Three-day simulation-based comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice. RESULTS: The workshop included 180 participants from 5 continents. The response rate was 54.5%, with participants reporting high satisfaction with all aspects of the workshop and with simulation-based workshops as educational tools. Participants reported a significant improvement in cleft lip (33.3 ± 5.7 vs 25.7 ± 7.6; P < .001) and palate (32.4 ± 7.1 vs 23.7 ± 6.6; P < .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices. CONCLUSION: Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

Familial Absent Uvula With Velopharyngeal Incompetence-A New Syndrome?

We present a family with a previously undescribed abnormality of the palate and oropharynx which involved the absence of the uvula and the anterior pillar of the fauces, rudimentary posterior pillar of the fauces, and hypernasality. Eight family members over 4 generations are affected in a pattern consistent with autosomal dominant inheritance. A causal role for the FOXF2 gene has been identified and previously reported. We describe the management of the proband, which involved attempting to lengthen the palate and to retroposition the abnormally anteriorly directed velar musculature, along with speech therapy.

Maxillary Growth in Cleft Lip and Palate Patients, With and Without Vomerine Flap Closure of the Hard Palate at the Time of Lip Repair: A Retrospective Analysis of Prospectively Collected Nonrandomized Data, With 10-Year Cephalometric Outcomes.

OBJECTIVE: To assess the midterm effect on maxillary growth of vomerine flap (VF) closure of the hard palate, at the time of lip repair. DESIGN: A retrospective analysis of prospectively collected nonrandomized data. INTERVENTIONS: Consecutive participants with a unilateral cleft lip and palate (UCLP) were operated on, at 3 months of age, by the same surgeon. They were divided into 2 groups, those who had a VF and those who did not (non-VF). SETTING: Participants were treated at 2 hospitals in the United Kingdom. PARTICIPANTS: Twenty-eight participants in the VF group and 24 participants in the non-VF group attended follow-up at 10 years of age. MAIN OUTCOME MEASURES: Standardized lateral cephalometric radiographs were taken at 10 years. Following tracing and digitization, parameters to assess the maxillary growth were analyzed. RESULTS: No statistically significant differences were found in the anterior-posterior or vertical skeletal cephalometric parameters. CONCLUSIONS: The results of this study support the statement that VF repair does not significantly affect maxillary growth in patients with a UCLP, when assessed cephalometrically at 10 years of age. It should be noted that at this age, growth is not yet complete.

A Reliable Method to Measure Lip Height Using Photogrammetry in Unilateral Cleft Lip Patients.

There is still no reliable tool to determine the outcome of the repaired unilateral cleft lip (UCL). The aim of this study was therefore to develop an accurate, reliable tool to measure vertical lip height from photographs. The authors measured the vertical height of the cutaneous and vermilion parts of the lip in 72 anterior-posterior view photographs of 17 patients with repairs to a UCL. Points on the lip's white roll and vermillion were marked on both the cleft and the noncleft sides on each image. Two new concepts were tested. First, photographs were standardized using the horizontal (medial to lateral) eye fissure width (EFW) for calibration. Second, the authors tested the interpupillary line (IPL) and the alar base line (ABL) for their reliability as horizontal lines of reference. Measurements were taken by 2 independent researchers, at 2 different time points each. Overall 2304 data points were obtained and analyzed. Results showed that the method was very effective in measuring the height of the lip on the cleft side with the noncleft side. When using the IPL, inter- and intra-rater reliability was 0.99 to 1.0, with the ABL it varied from 0.91 to 0.99 with one exception at 0.84. The IPL was easier to define because in some subjects the overhanging nasal tip obscured the alar base and gave more consistent measurements possibly because the reconstructed alar base was sometimes indistinct. However, measurements from the IPL can only give the percentage difference between the left and right sides of the lip, whereas those from the ABL can also give exact measurements. Patient examples were given that show how the measurements correlate with clinical assessment. The authors propose this method of photogrammetry with the innovative use of the IPL as a reliable horizontal plane and use of the EFW for calibration as a useful and reliable tool to assess the outcome of UCL repair.

A case-control study of maternal periconceptual and pregnancy recreational drug use and fetal malformation using hair analysis.

OBJECTIVE: Maternal recreational drug use may be associated with the development of fetal malformations such as gastroschisis, brain and limb defects, the aetiology due to vascular disruption during organogenesis. Using forensic hair analysis we reported evidence of recreational drug use in 18% of women with a fetal gastroschisis. Here we investigate this association in a variety of fetal malformations using the same method. METHODS: In a multi-centre study, women with normal pregnancies (controls) and those with fetal abnormalities (cases) gave informed consent for hair analysis for recreational drug metabolites using mass spectrometry. Hair samples cut at the root were tested in sections corresponding to 3 month time periods (pre and periconceptual period). RESULTS: Women whose fetus had gastroschisis, compared to women with a normal control fetus, were younger (mean age 23.78 ± SD4.79 years, 18-37 vs 29.79 ± SD6 years, 18-42, p = 0.00001), were more likely to have evidence of recreational drug use (15, 25.4% vs 21, 13%, OR2.27, 95thCI 1.08-4.78, p = 0.028), and were less likely to report periconceptual folic acid use (31, 53.4% vs 124, 77.5%, OR0.33, 95thCI 0.18-0.63, p = 0.001). Age-matched normal control women were no less likely to test positive for recreational drugs than women whose fetus had gastroschisis. After accounting for all significant factors, only young maternal age remained significantly associated with gastroschisis. Women with a fetus affected by a non-neural tube central nervous system (CNS) anomaly were more likely to test positive for recreational drugs when compared to women whose fetus was normal (7, 35% vs 21, 13%, OR3.59, 95th CI1.20-10.02, p = 0.01). CONCLUSIONS: We demonstrate a significant association between non neural tube CNS anomalies and recreational drug use in the periconceptual period, first or second trimesters, but we cannot confirm this association with gastroschisis. We confirm the association of gastroschisis with young maternal age.

Submucous cleft palate: a systematic review of surgical management based on perceptual and instrumental analysis.

Objective : Submucous cleft palate (SMCP) is a congenital condition associated with abnormal development of the soft palate musculature. In a proportion of cases, this results in velopharyngeal insufficiency (VPI), the treatment for which includes pharyngeal flap surgery, pharyngoplasty, and palate reconstruction. The aim of this paper is to determine whether there is superiority of one or more types of surgical procedure over the others in improving speech in patients with VPI secondary to SMCP. Methodology : Nine databases, including MEDLINE and EMBASE, were searched between inception and January 2013 to identify articles published relating to the surgical management of SMCP. Only studies that reported outcome measures for postoperative speech were included in the systematic review. Results : Twenty-six studies analyzing the outcomes of surgery for VPI in patients with SMCP met the inclusion criteria. In these studies, speech outcomes were measured either in a binary fashion (i.e., normal speech or evidence of VPI) or using scales of VPI severity. Of the 26 studies, only two utilized blinded speech assessment, and 12 included both preoperative and postoperative speech assessment. Conclusions : The review found little evidence to support any specific surgical intervention. This is in large part due to the inclusion of mixed etiologies within study populations and the lack of unbiased validated preoperative and postoperative speech assessment. Further methodologically rigorous studies need to be conducted to provide a secure evidence base for the surgical management of SMCP.

International confederation for cleft lip and palate and related craniofacial anomalies task force report: palatoplasty in the speaking individual with unrepaired cleft palate.

Introduction : The benefits or otherwise of late palate repair in older children or adults are uncertain. The outcomes, particularly without appropriate speech therapy, are often disappointing. The issue is of special importance in the poorer countries where these patients are most commonly seen and where limited capacity and facilities may have to be rationed. Method : A task force was set up to report back to the International Congress in Orlando in May 2013. The chairman and some members were nominated by the organizers and further members were added during the discussion process. Some of the members had considerable experience of late palate repair. The task force compiled a report after 9 months of e-mail correspondence. The report includes reports of some previously unpublished studies. A summary of the report was presented at Cleft 2013 in Orlando. Conclusions : There was a general consensus that late palate repair is of benefit for many patients and that, even if normal speech is not attained, outcomes are positive. Outcomes depend on the age of the patient (the younger the better), on the skill of the surgeon and, ideally, on the availability of appropriate speech therapy. A protocol for a prospective international multi-center study is proposed.

Early effect of vomerine flap closure of the hard palate at the time of lip repair on the alveolar gap and other maxillary dimensions.

OBJECTIVE: Comparison of the effects of vomerine flap (VF) closure of the hard palate at the time of lip repair with non-closure of the hard palate in subjects with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective, single-blinded, cohort study. SETTING: Study model sets of 40 consecutive, non-syndromic, infants with complete UCLP operated on between 1988 and 1998. PATIENTS: All subjects were operated on by a single consultant plastic surgeon immediately before and after the unit's change of protocol (1993), when VF closure of the hard palate was incorporated at the time of lip repair. Subjects were divided into two groups: VF ( n = 18) and non-VF (n = 22), which acted as a control group. Each subject had maxillary impressions taken before lip repair at 3 months (VF mean age = 11.7 weeks; non-VF mean age = 13.4 weeks) and before palate repair at 6 months (VF mean age = 22.8 weeks; non-VF mean age = 24.0 weeks). MAIN OUTCOME MEASURES: Seven predetermined landmarks and four maxillary dimensions were computed following single-blinded analysis using a reflex microscope. RESULTS: Repeatability tests showed good measurement precision. The operator measurement errors were 0.00018 mm in a horizontal plane (X and Y) and 0.00028 in the vertical plane (Z). The VF group showed significant changes in the alveolar cleft width. There were no statistically significant changes in any arch-form variable between the VF and non-VF groups. CONCLUSION: The decrease of alveolar arch gap width at palate repair (6 months) in the VF group was significantly more than the decrease observed in the non-VF group, and there was no significant decrease in the, anterior and posterior arch width or anteroposterior length of the hard palate in the VF group compared with the non-VF group.

Submucous Cleft Palate: A Systematic Review of Surgical Management Based on Perceptual and Instrumental Analysis.

Objective: Submucous cleft palate (SMCP) is a congenital condition associated with abnormal development of the soft palate musculature. In a proportion of cases, this results in velopharyngeal insufficiency (VPI), the treatment for which includes pharyngeal flap surgery, pharyngoplasty, and palate reconstruction. The aim of this paper is to determine whether there is superiority of one or more types of surgical procedure over the others in improving speech in patients with VPI secondary to SMCP. Methodology: Nine databases, including MEDLINE and EMBASE, were searched between inception and January 2013 to identify articles published relating to the surgical management of SMCP. Only studies that reported outcome measures for postoperative speech were included in the systematic review. Results: Twenty-six studies analyzing the outcomes of surgery for VPI in patients with SMCP met the inclusion criteria. In these studies, speech outcomes were measured either in a binary fashion (i.e., normal speech or evidence of VPI) or using scales of VPI severity. Of the 26 studies, only two utilized blinded speech assessment, and 12 included both preoperative and postoperative speech assessment. Conclusions: The review found little evidence to support any specific surgical intervention. This is in large part due to the inclusion of mixed etiologies within study populations and the lack of unbiased validated preoperative and postoperative speech assessment. Further methodologically rigorous studies need to be conducted to provide a secure evidence base for the surgical management of SMCP.

Does nasogastric feeding reduce distress after cleft palate repair in infants?

AIMS: To determine the effect of nasogastric (NG) feeding compared with oral feeding on morphine requirements after primary cleft palate repair, and secondarily on enteral intake. METHODS: This was a pilot study involving 50 infants, aged five to ten months, who were randomised to receive NG or oral feeding after palate repair. All infants received the same anaesthetic and analgesic management. Post-operatively, paracetamol and ibuprofen were administered regularly and intravenous (IV) morphine was given on demand using a nurse-controlled analgesia device. The primary outcome measure was the total morphine consumption in the first 24 hours. Secondary outcome measures included the numbers of painful episodes and the volumes of IV fluid and enteral feed administered. RESULTS: Of the 50 infants enrolled, 18 and 23 received either NG or oral feeding, respectively, and completed the study. Numbers of painful episodes and morphine consumption in the first 24 hours were similar in each group. Volumes of feed administered in the first 24 hours were significantly different: the NG group received approximately three times more than the oral group. Nine of the oral group required IV fluids in the 24 hours compared with none in the NG group. CONCLUSION: NG feeding was more effective than oral feeding in the first 24 hours after surgery, but numbers of painful episodes recorded were similar. Further research is required.

Effect of palate re-repairs and hynes pharyngoplasties on pediatric airways: an analysis of preoperative and postoperative cardiorespiratory sleep studies.

OBJECTIVES : To determine whether Sommerlad palate re-repairs and Hynes pharyngoplasties cause obstructive sleep apnea/hypopnea or increased upper airway resistance. DESIGN : Prospective before-and-after study. SETTING : Tertiary cleft unit. PATIENTS : A total of 44 patients undergoing a Sommerlad palate re-repair or a Hynes pharyngoplasty. Interventions : Preoperative and postoperative multichannel cardiorespiratory sleep studies. MAIN OUTCOME MEASURES : The main outcome measures were mean arterial oxygen saturation, desaturation index, percentage of time spent with arterial oxygen saturation <90%, mean pulse rate, number of pulse rate rises (arousals) per hour, inspiratory effort derived from pulse transit time, pulse transit time arousals, and snoring. RESULTS : No patient in either group required intervention for airway obstruction or obstructive sleep apnea/hypopnea. Re-repairs caused no significant change in any parameter. Hynes caused an increase in inspiratory effort (P = .04) and obstructive sleep apnea/hypopnea grading (P = .002). All other parameters showed no significant deterioration. No patient developed more than mild/moderate obstructive sleep apnea/hypopnea. Snoring and arterial oxygen saturation levels were not reliable indicators of increased inspiratory effort. CONCLUSIONS : A palate re-repair had no significant adverse effect on the airway. A Hynes, in patients with optimized velar function, caused a significant increase in inspiratory effort and obstructive sleep apnea/hypopnea grade. However, compared with studies on midline flaps and on sphincter pharyngoplasties, a Hynes appears to be less obstructive. Failure to study changes in inspiratory effort in patients undergoing velopharyngeal incompetence surgery may underestimate the obstructive effect of pharyngoplasties.

Nasendoscopy: an analysis of measurement uncertainties.

Objective : The purpose of this study was to analyze the optical characteristics of two different nasendoscopes used to assess velopharyngeal insufficiency and to quantify the measurement uncertainties that will occur in a typical set of clinical data. Design : The magnification and barrel distortion associated with nasendoscopy was estimated by using computer software to analyze the apparent dimensions of a spatially calibrated test object at varying object-lens distances. In addition, a method of semiquantitative analysis of velopharyngeal closure using nasendoscopy and computer software is described. To calculate the reliability of this method, 10 nasendoscopy examinations were analyzed two times by three separate operators. The measure of intraoperator and interoperator agreement was evaluated using Pearson's r correlation coefficient. Results : Over an object lens distance of 9 mm, magnification caused the visualized dimensions of the test object to increase by 80%. In addition, dimensions of objects visualized in the far-peripheral field of the nasendoscopic examinations appeared approximately 40% smaller than those visualized in the central field. Using computer software to analyze velopharyngeal closure, the mean correlation coefficient for intrarater reliability was .94 and for interrater reliability was .90. Conclusion : Using a custom-designed apparatus, the effect object-lens distance has on the magnification of nasendoscopic images has been quantified. Barrel distortion has also been quantified and was found to be independent of object-lens distance. Using computer software to analyze clinical images, the intraoperator and interoperator correlation appears to show that ratio-metric measurements are reliable.

Presurgical orthopedics has no effect on archform in unilateral cleft lip and palate.

OBJECTIVE: Evaluation of the effect of presurgical orthopedics on maxillary archform up to 6 months of age. DeSIGN: Retrospective, single-blinded, case-control study. PARTICIPANTS: Study model sets of 75 infants with consecutive, nonsyndromic, complete unilateral cleft lip and palate (excluding Simonart bands) from 1995 to 2005. INTERVENTIONS: All patients (PSO group, n  =  14; non-PSO group, n  =  61) received lip repair/vomer flap at 3 months and soft palate repair at 6 months by the same consultant surgeon. The two groups were comparable at birth (p > .01) in all archform variables. MAIN OUTCOME MEASURES: Sixteen variables were computed, following single-blinded analysis using the Reflex Microscope to describe the archform in the transverse, anteroposterior, and vertical dimensions and the arch circumference. Data were analyzed using a repeated-measures hierarchical analysis of variance with a significance level of 1%. RESULTS: Repeatability studies showed good measurement precision. Presurgical orthopedics produced no statistically significant mean change in any archform variable when compared with the non-PSO group. The difference in the mean reduction in the alveolar cleft width between the groups was 0.69 mm (95% confidence interval, -0.89 to 2.28 mm, p  =  .52). Lip repair produced greater change in archform than did presurgical orthopedics, reducing the mean alveolar cleft width by 4.45 mm (95% confidence interval, 3.53 to 5.37 mm; p < .001). CONCLUSIONS: There was no evidence that presurgical orthopedics produced any significant effect on archform, raising questions for its continued use in this context. Lip repair had a greater impact on arch dimensions than did presurgical orthopedics.