What is the impact of miniscrew-assisted rapid palatal expansion on the midfacial soft tissues? A prospective three-dimensional stereophotogrammetry study.

OBJECTIVES: To evaluate the midfacial soft tissue changes of the face in patients treated with miniscrew-assisted rapid palatal expansion (MARPE). MATERIALS AND METHODS: 3D facial images and intra-oral scans (IOS) were obtained before expansion (T0), immediately after completion of expansion (T1), and 1 year after expansion (T2). The 3D images were superimposed and two 3D distance maps were generated to measure the midfacial soft tissue changes: immediate effects between timepoints T0 and T1 and overall effects between T0 and T2. Changes of the alar width were also measured and dental expansion was measured as the interpremolar width (IPW) on IOS. RESULTS: Twenty-nine patients (22 women, 7 men, mean age 25.9 years) were enrolled. The soft tissue in the regions of the nose, left of philtrum, right of philtrum, and upper lip tubercle demonstrated a statistically significant anterior movement of 0.30 mm, 0.93 mm, 0.74 mm, and 0.81 mm, respectively (p < 0.01) immediately after expansion (T0-T1). These changes persisted as an overall effect (T0-T2). The alar width initially increased by 1.59 mm, and then decreased by 0.08 mm after 1 year, but this effect was not significant. The IPW increased by 4.58 mm and remained stable 1 year later. There was no significant correlation between the increase in IPW and alar width (r = 0.35, p = 0.06). CONCLUSIONS: Our findings indicate that MARPE results in significant but small changes of the soft tissue in the peri-oral and nasal regions. However, the clinical importance of these findings is limited. CLINICAL RELEVANCE: MARPE is an effective treatment modality to expand the maxilla, incurring only minimal and clinically insignificant changes to the midfacial soft tissues.

The role of muscular traction in the occurrence of skeletal relapse after advancement bilateral sagittal split osteotomy (BSSO): A systematic review.

The aim of this systematic review was (i) to determine the role of muscular traction in the occurrence of skeletal relapse after advancement BSSO and (ii) to investigate the effect of advancement BSSO on the perimandibular muscles. This systematic review reports in accordance with the recommendations proposed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic database searches were performed in the databases MEDLINE, Embase and Cochrane Library. Inclusion criteria were as follows: assessment of relapse after advancement BSSO; assessment of morphological and functional change of the muscles after advancement BSSO; and clinical studies on human subjects. Exclusion criteria were as follows: surgery other than advancement BSSO; studies in which muscle activity/traction was not investigated; and case reports with a sample of five cases or fewer, review articles, meta-analyses, letters, congress abstracts or commentaries. Of the initial 1006 unique articles, 11 studies were finally included. In four studies, an intervention involving the musculature was performed with subsequent assessment of skeletal relapse. The changes in the morphological and functional properties of the muscles after BSSO were studied in seven studies. The findings of this review demonstrate that the perimandibular musculature plays a role in skeletal relapse after advancement BSSO and may serve as a target for preventive strategies to reduce this complication. However, further research is necessary to (i) develop a better understanding of the role of each muscle group, (ii) to develop new therapeutic strategies and (iii) to define criteria that allow identification of patients at risk.

Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults with the Dutch Maxillary Expansion Device: a prospective clinical cohort study.

OBJECTIVES: To provide a higher degree of evidence on the efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults, thereby applying the Dutch Maxillary Expansion Device (D-MED). MATERIALS AND METHODS: D-MED was developed as an individualized, 3D-designed, and fabricated MARPE appliance supported by 4 palatal miniscrews. Patients from the age of 16 onwards with transverse maxillary deficiency were enrolled consecutively. Pre-expansion and immediate post-expansion CBCTs and intra-oral scans were acquired and measurements of skeletal, alveolar, and dental expansion as well as dental and periodontal side-effects were performed. RESULTS: Thirty-four patients were enrolled (8 men, 26 women) with mean age 27.0 ± 9.4 years. A success rate of 94.1% was achieved (32/34 patients). The mean expansion duration, or mean observation time, was 31.7 ± 8.0 days. The mean expansion at the maxillary first molars (M1) and first premolars (P1) was 6.56 ± 1.70 mm and 4.19 ± 1.29 mm, respectively. The expansion was 60.4 ± 20.1% skeletal, 8.1 ± 27.6% alveolar, and 31.6 ± 20.1% dental at M1 and 92.2 ± 14.5% skeletal, 0.0 ± 18.6% alveolar, and 7.8 ± 17.7% dental at P1, which was both statistically (p < 0.001) and clinically significant. Buccal dental tipping (3.88 ± 3.92° M1; 2.29 ± 3.89° P1), clinical crown height increase (0.12 ± 0.31 mm M1; 0.04 ± 0.22 mm P1), and buccal bone thinning (- 0.31 ± 0.49 mm M1; - 0.01 ± 0.45 mm P1) were observed, while root resorption could not be evaluated. CONCLUSIONS: MARPE by application of D-MED manifested its efficacy in a prospective clinical setting, delivering a high amount of skeletal expansion with limited side-effects in late adolescents and adults. CLINICAL RELEVANCE: Higher quality evidence is supportive of MARPE as a safe and successful non-surgical treatment option for transverse maxillary deficiency.

What is the Oral Health-related Quality of Life following Miniscrew-Assisted Rapid Palatal Expansion (MARPE)? A prospective clinical cohort study.

BACKGROUND: Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is a non-surgical orthodontic treatment for transverse maxillary deficiency. This study aimed to investigate the Oral Health-related Quality of Life (OHRQoL) and pain perception of patients undergoing MARPE treatment. METHODS: 42 consecutive patients (9 men, 33 women) from the age of 16 onwards (mean: 27.4 ± 9.3 years; range 17.1-55.7 years) who received a MARPE treatment were included. OHRQoL was assessed with the short form of the Oral Health Impact Profile (OHIP-14) questionnaire. Patients filled out the questionnaire at baseline (T0) and weekly during the expansion phase (P1) and in the post-expansion phase (P2). Pain intensity was assessed with a Visual Analogue Scale (VAS) questionnaire and filled out daily during expansion, along with a question on the intake of analgesics. The mean weekly and total OHIP-score and OHIP-score per domain were calculated at T0, P1 and P2, as well as mean weekly and total VAS-scores for average pain, maximum pain and analgesics intake during P1. Kruskal-Wallis tests were used to test for differences in OHIP between T0, P1 and P2. The level of significance was set at 0.05. RESULTS: The mean OHIP-score was 10.86 ± 9.71 at T0 and increased to 17.18 ± 10.43 during P1 (p < 0.001), after which it returned to pre-expansion levels, 9.27 ± 7.92 (p = 0.907) during P2. At the domain level, there was a statistically significant increase in OHIP-score at P1 for functional limitation, physical pain, psychological discomfort and social disability. The mean VAS-score for average pain during expansion was 16.00 ± 19.73 mm. Both OHIP-score (25.00 ± 10.25), average pain (33.72 ± 16.88 mm), maximum pain (44.47 ± 17.99 mm) and analgesics intake (59%) were highest at initiation of the expansion and decreased by the end of expansion. CONCLUSIONS: MARPE is a generally well-tolerated expansion treatment. A temporary decline in OHRQoL and moderate pain are present at the start of expansion, followed by a recovery of OHRQoL and very mild pain during the rest of treatment. Clinicians should be aware of the effects of MARPE on patients' quality of life and manage the expected discomfort and impediments with adequate communication and patient education.

Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults: a systematic review and meta-analysis.

BACKGROUND: Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is a non-surgical treatment for transverse maxillary deficiency. However, there is limited evidence concerning its efficacy. OBJECTIVES: This systematic review aims to evaluate the efficacy of MARPE in late adolescents and adults by assessing success rate and skeletal and dental transverse maxillary expansion, as well as treatment duration, dental and periodontal side effects and soft tissue effects. SEARCH METHODS: Seven electronic databases were searched (MEDLINE, Embase, Cochrane Library, Web of Science, Scopus, ProQuest and ClinicalTrials.gov) without limitations in November 2020. SELECTION CRITERIA: Randomized and non-randomized clinical trials and observational studies on patients from the age of 16 onwards with transverse maxillary deficiency who were treated with MARPE and which included any of the predefined outcomes. DATA COLLECTION AND ANALYSIS: Inclusion eligibility screening, data extraction and risk of bias assessment were performed independently in duplicate. When possible, exploratory meta-analyses of mean differences (MDs) with their 95% confidence intervals (CIs) were conducted, followed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis of the evidence quality. RESULTS: Eight articles were included: two prospective and six retrospective observational studies. One study had a moderate risk of bias, whereas seven studies had a serious risk of bias. GRADE quality of evidence was very low. MARPE showed a high success rate (mean: 92.5%; 95%CI: 88.7%-96.3%), resulting in a significant skeletal width increase (MD: 2.33 mm; 95%CI: 1.63 mm-3.03 mm) and dental intermolar width increase (MD: 6.55 mm; 95%CI: 5.50 mm-7.59 mm). A significant increase in dental tipping, a decrease in mean buccal bone thickness and buccal alveolar height, as well as nasal soft tissue change was present (P < 0.05). The mean duration of expansion ranged from 20 to 126 days. LIMITATIONS: One of the main drawbacks was the lack of high-quality prospective studies in the literature. CONCLUSIONS AND IMPLICATIONS: MARPE is a treatment modality that is associated with a high success rate in skeletal and dental maxillary expansion. MARPE can induce dental and periodontal side effects and affect peri-oral soft tissues. Given the serious risk of bias of the included studies, careful data interpretation is necessary and future research of higher quality is strongly recommended. REGISTRATION: PROSPERO (CRD42020176618). FUNDING: No grants or any other support funding were received.

Influence of involuntary facial expressions on reproducibility of 3D stereophotogrammetry in children with and without complete unilateral cleft lip and palate from 3 to 18 months of age.

OBJECTIVES: To assess the influence of involuntary facial expressions on 3D facial stereophotogrammetry reproducibility in children with and without unilateral cleft lip, alveolus and palate (UCLP) aged 3-18 months. MATERIALS AND METHODS: Three to eight 3D facial images per time point were acquired within 10 min of 31 children with UCLP and 50 controls at 3, 12 and 18 months of age. 3D mapping of two 3D facial images per subject per age was performed. Distance kits of the full face and nasolabial area were calculated. RESULTS: In the total subject pool, mean variation between two 3D facial images ranged from 0.38-0.88 mm. There were no significant differences within groups for the various ages. Variation between controls and UCLP subjects did not differ significantly. Variation was higher in the nasolabial area than in the full face. CONCLUSIONS: The influence of involuntary facial expressions on the estimation of facial growth should not be underestimated, especially in the nasolabial region of UCLP subjects aged 3 months. To improve 3D facial imaging reliability, image capturing should be performed by a trained photographer following a meticulous image capturing protocol, including thorough review after capture. CLINICAL RELEVANCE: Facial 3D stereophotogrammetry is a useful tool for monitoring facial growth longitudinally in young children with facial deformities, as no radiation is involved and image capture is easy and fast. It can be performed reliably in children with and without UCLP aged 3-18 months by an experienced photographer utilising a meticulous image capturing protocol.

Integration of digital dental casts in cone beam computed tomography scans-a clinical validation study.

OBJECTIVES: Images derived from cone beam computed tomography (CBCT) scans lack detailed information on the dentition and interocclusal relationships needed for proper surgical planning and production of surgical splints. To get a proper representation of the dentition, integration of a digital dental model into the CBCT scan is necessary. The aim of this study was to validate a simplified protocol to integrate digital dental models into CBCT scans using only one scan. MATERIALS AND METHODS: Conventional protocol A used one combined upper and lower impression and two CBCT scans. The new protocol B included placement of ten markers on the gingiva, one CBCT scan, and two separate impressions of the upper and lower dentition. Twenty consecutive patients, scheduled for mandibular advancement surgery, were included. To validate protocol B, 3-dimensional reconstructions were made, which were compared by calculating the mean intersurface distances obtained with both protocols. RESULTS: The mean distance for all patients for the upper jaw is 0.39 mm and for the lower jaw is 0.30 mm. For ten out of 20 patients, all distances were less than 1 mm. For the other ten patients, all distances were less than 2 mm. CONCLUSIONS: Mean distances of 0.39 and 0.30 mm are clinically acceptable and comparable to other studies; therefore, this new protocol is clinically accurate. CLINICAL RELEVANCE: This new protocol seems to be clinically accurate. It is less time consuming, gives less radiation exposure for the patient, and has a lower risk for positional errors of the impressions compared to other integration protocols.

Validation of 3D documentation of palatal soft tissue shape, color, and irregularity with intraoral scanning.

OBJECTIVES: The purpose of this study was to assess the feasibility of 3D intraoral scanning for documentation of palatal soft tissue by evaluating the accuracy of shape, color, and curvature. MATERIALS AND METHODS: Intraoral scans of ten participants' upper dentition and palate were acquired with the TRIOS® 3D intraoral scanner by two observers. Conventional impressions were taken and digitized as a gold standard. The resulting surface models were aligned using an Iterative Closest Point approach. The absolute distance measurements between the intraoral models and the digitized impression were used to quantify the trueness and precision of intraoral scanning. The mean color of the palatal soft tissue was extracted in HSV (hue, saturation, value) format to establish the color precision. Finally, the mean curvature of the surface models was calculated and used for surface irregularity. RESULTS: Mean average distance error between the conventional impression models and the intraoral models was 0.02 ± 0.07 mm (p = 0.30). Mean interobserver color difference was - 0.08 ± 1.49° (p = 0.864), 0.28 ± 0.78% (p = 0.286), and 0.30 ± 1.14% (p = 0.426) for respectively hue, saturation, and value. The interobserver differences for overall and maximum surface irregularity were 0.01 ± 0.03 and 0.00 ± 0.05 mm. CONCLUSIONS: This study supports the hypothesis that the intraoral scan can perform a 3D documentation of palatal soft tissue in terms of shape, color, and curvature. CLINICAL RELEVANCE: An intraoral scanner can be an objective tool, adjunctive to the clinical examination of the palatal tissue.

Placement of an antibiotic oral pack on the hard palate after primary cleft palatoplasty: a randomized controlled trial into the effect on fistula rates.

OBJECTIVE: The objective of this study is to determine whether placement of an antibiotic oral pack on the hard palate reduces fistula rates after primary cleft palatoplasty. SUBJECTS AND METHODS: This study was a parallel blocked randomized controlled trial. The study consisted of two groups of 100 patients each with non-syndromic unilateral complete cleft lip, alveolus, and hard and soft palate that underwent primary palatoplasty. Group A had an oral pack placed on the hard palate for 5 days postoperatively while group B did not. Occurrence of fistulae between both groups was tested using odds ratios (OR). RESULTS: In 2% of the patients in group A, a fistula was found 6 months after palatal surgery. In contrast, in 21% of the patients in group B, a palatal fistula could be confirmed. The fistula occurrence in group A was statistically significantly lower than that in group B (OR = 0.0768, CI = [0.02 … 0.34], p < 0.001). CONCLUSION: The findings of this study provide evidence that the rate of fistula formation after primary palatoplasty is significantly reduced if a pack soaked with antibiotic cream is placed on the palate postoperatively for 5 days. CLINICAL RELEVANCE: The use of an antibiotic pack after cleft palate repair can be recommended to prevent occurrence of oronasal fistulae.

AGORA, a data- and biobank for birth defects and childhood cancer.

BACKGROUND: Research regarding the etiology of birth defects and childhood cancer is essential to develop preventive measures, but often requires large study populations. Therefore, we established the AGORA data- and biobank in the Netherlands. In this study, we describe its rationale, design, and ongoing data collection. METHODS: Children diagnosed with and/or treated for a structural birth defect or childhood cancer and their parents are invited to participate in the AGORA data- and biobank. Controls are recruited through random sampling from municipal registries. The parents receive questionnaires about demographics, family and pregnancy history, health status, prescribed medication, lifestyle, and occupational exposures before and during the index pregnancy. In addition, blood or saliva is collected from children and parents, while medical records are reviewed for diagnostic information. RESULTS: So far, we have collected data from over 6,860 families (3,747 birth defects, 905 childhood cancers, and 2,208 controls). The types of birth defects vary widely and comprise malformations of the digestive, respiratory, and urogenital tracts as well as facial, cardiovascular, kidney, skeletal, and central nervous system anomalies. The most frequently occurring childhood cancer types are acute lymphatic leukemia, Hodgkin and non-Hodgkin lymphoma, Wilms' tumor, and brain and spinal cord tumors. Our genetic and/or epidemiologic studies have been focused on hypospadias, anorectal malformations, congenital anomalies of the kidney and urinary tract (CAKUT), and orofacial clefts. CONCLUSION: The large AGORA data- and biobank offers great opportunities for investigating genetic and nongenetic risk factors for disorders in children and is open to collaborative initiatives. Birth Defects Research (Part A) 106:675-684, 2016. © 2016 Wiley Periodicals, Inc.

Does powdering of the dentition increase the accuracy of fusing 3D stereophotographs and digital dental casts.

OBJECTIVES: The shiny vestibular surfaces of teeth make it difficult to match digital dental casts to 3D stereophotogrammetric images of patient teeth. This study tested whether reducing this shininess by coating the teeth with titanium-oxide powder might improve the accuracy of the matching procedure. METHODS: Twenty patients participated in the study. For each patient, 3D stereophotogrammetric images were taken without and with a powder coating. Separately, digital dental casts were created. Next, the digital dental casts were fused with the 3D stereophotogrammetric images of either non-powdered or powdered dentition. Distance maps were created to evaluate the inter-surface distance between the digital dental cast and the 3D images. The matching accuracy was compared for dentition with and without powdering. RESULTS: Of all recorded distances between corresponding points, 95% was smaller than 0.84mm for the powdered dentition and smaller than 0.90mm for the non-powdered dentition. Although powdered dentition showed significantly better matching than non-powdered dentition, the difference was less than 0.1mm. Intra-observer statistics showed that five out of 24 repetitions gave significantly different results, but only for dentition that was not powdered. LIMITATIONS: The patients did not have any major malocclusions. Severe malocclusions might cause greater difficulty in matching the dentition without powder. Only one type of powder was used, but it effectively reduced shininess. CONCLUSION: Powdering the dentition had a small, but significant, positive effect on matching. However, this effect was of minor clinical importance. Therefore, we do not recommend powdering the dentition for 3D stereophotogrammetric images used for matching procedures.

Three-dimensional facial simulation in bilateral sagittal split osteotomy: a validation study of 100 patients.

PURPOSE: Three-dimensional (3D) virtual planning of orthognathic surgery in combination with 3D soft tissue simulation allows the surgeon and the patient to assess the 3D soft tissue simulation. This study was conducted to validate the predictability of the mass tensor model soft tissue simulation algorithm combined with cone-beam computed tomographic (CBCT) imaging for patients who underwent mandibular advancement using a bilateral sagittal split osteotomy (BSSO). MATERIALS AND METHODS: One hundred patients were treated with a BSSO according to the Hunsuck modification. The pre- and postoperative CBCT scans were matched and the mandible was segmented and aligned. The 3D distance maps and 3D cephalometric analyses were used to calculate the differences between the soft tissue simulation and the actual postoperative results. Other study variables were age, gender, and amount of mandibular advancement or rotation. RESULTS: For the entire face, the mean absolute error was 0.9 ± 0.3 mm, the mean absolute 90th percentile was 1.9 mm, and for all 100 patients the absolute mean error was less than or equal to 2 mm. The subarea with the least accuracy was the lower lip area, with a mean absolute error of 1.2 ± 0.5 mm. No correlation could be found between the error of prediction and the amount of advancement or rotation of the mandible or age or gender of the patient. CONCLUSION: Overall, the soft tissue prediction algorithm combined with CBCT imaging is an accurate model for predicting soft tissue changes after mandibular advancement. Future studies will focus on validating the mass tensor model soft tissue algorithm for bimaxillary surgery.

Regional facial asymmetries in unilateral orofacial clefts.

OBJECTIVES: Assess facial asymmetry in subjects with unilateral cleft lip (UCL), unilateral cleft lip and alveolus (UCLA), and unilateral cleft lip, alveolus, and palate (UCLP), and to evaluate which area of the face is most asymmetrical. METHODS: Standardized three-dimensional facial images of 58 patients (9 UCL, 21 UCLA, and 28 UCLP; age range: 8.6-12.3 years) and 121 controls (age range 9-12 years) were mirrored and distance maps were created. Absolute mean asymmetry values were calculated for the whole face, cheek, nose, lips, and chin. One-way analysis of variance, Kruskal-Wallis, and t-test were used to assess the differences between clefts and controls for the whole face and separate areas. RESULTS: Clefts and controls differ significantly for the whole face as well as in all areas. Asymmetry is distributed differently over the face for all groups. In UCLA, the nose was significantly more asymmetric compared with chin and cheek (P = 0.038 and 0.024, respectively). For UCL, significant differences in asymmetry between nose and chin and chin and cheek were present (P = 0.038 and 0.046, respectively). In the control group, the chin was the most asymmetric area compared to lip and nose (P = 0.002 and P = 0.001, respectively) followed by the nose (P = 0.004). In UCLP, the nose, followed by the lips, was the most asymmetric area compared to chin, cheek (P < 0.001 and P = 0.016, respectively). LIMITATIONS: Despite division into regional areas, the method may still exclude or underrate smaller local areas in the face, which are better visualized in a facial colour coded distance map than quantified by distance numbers. The UCL subsample is small. CONCLUSION: Each type of cleft has its own distinct asymmetry pattern. Children with unilateral clefts show more facial asymmetry than children without clefts.

Secondary closure of small- to medium-size palatal defects after ablative surgery: reappraisal of reconstructive techniques.

PURPOSE: Postoncologic reconstruction of the palate represents a major surgical challenge with respect to the thin intraoral and intranasal lining. Current reconstructive methods have ranged from obturative closure of the defect to microsurgical free tissue transfer. The final choice of treatment will be influenced by the size and location of the defect and surgeon experience. The goals of palate repair include optimizing palatal function for speech and eating, and avoiding dehiscence or postoperative fistulas. This study assessed the reliability of locoregional flaps for reconstructing maxillary defects. PATIENTS AND METHODS: The present study described the surgical outcome of locoregional reconstruction of the hard and soft palate of 5 patients who had previously undergone tumor ablative surgery. They ranged in age from 19 to 64 years. None had received postoperative radiotherapy. The resultant surgical defects ranged in size from 2.5 to 12 cm(2). One patient experienced velopharyngeal insufficiency. RESULTS: In all cases, the palate was closed at the first attempt without complications. All flaps survived, and complete closure was obtained in these 4 patients. The patient with the velopharyngeal insufficiency experienced a significant improvement in articulation and swallowing function. CONCLUSIONS: The results of these 5 cases indicate that secondary locoregional flaps are a suitable alternative for palatal defect management. They have a high success rate and functional outcome. These secondary techniques can be reliably used to reconstruct small- to moderate-size palatal defects and represent a reliable reconstructive option with minimal morbidity.

Three-dimensional stereophotogrammetry: a novel method in volumetric measurement of infantile hemangioma.

Accurate and objective measurement of volume changes in infantile hemangiomas (IHs) is essential in routine clinical practice and clinical studies, particularly in the changing therapeutic landscape after the discovery of propranolol. Several bedside techniques for volume measurement have been described in the literature, but an objective method of measurement of this variable, dynamic vascular tumor is lacking. Three-dimensional (3D) phototechnology with data analysis is an up-and-coming technique in the objective measurement of facial volume changes. In this pilot study, the usability and clinical relevance of two methods of 3D stereophotogrammetry in the volume measurement of IH were explored.

Incidental findings on cone beam computed tomography scans in cleft lip and palate patients.

OBJECTIVES: Cone beam computed tomography (CBCT) is frequently used in treatment planning for alveolar bone grafting (ABG) and orthognathic surgery in patients with cleft lip and palate (CLP). CBCT images may depict coincident findings. The aim of this study was to assess the prevalence of incidental findings on CBCT scans in CLP patients. SUBJECTS AND METHODS: Initial CBCTs taken from consecutive patients (n = 187; mean age 11.7 years, range 6.9-45) with a non-syndromic orofacial cleft from January 2006 until June 2012 were systematically evaluated. Twenty-eight patients (mean age 19.3 years, range 13.2-30.9) had been subjected to ABG before their first CBCT was taken; 61 patients had a CBCT before and after ABG. Sinuses, nasopharynx, oropharynx, throat, skull, vertebrae, temporomandibular joint (TMJ), maxilla and mandible were checked for incidental findings. RESULTS: On 95.1 % of the CBCTs, incidental findings were found. The most prevalent were airway/sinus findings (56.1 %), followed by dental problems, e.g. missing teeth (52 %), nasal septum deviation (34 %), middle ear and mastoid opacification, suggestive for otitis media (10 %) and (chronic) mastoiditis (9 %), abnormal TMJ anatomy (4.9 %) and abnormal vertebral anatomy (1.6 %). In the 28 patients whose first CBCT was taken at least 2 years after ABG, bone was still present in the reconstructed cleft area except in 2 out of 12 patients with a bilateral CLP. The ABG donor site (all bone grafts were taken from the chin area) was still recognizable in over 50 % of the patients. Based on the CBCT findings, 10 % of the patients were referred for further diagnosis and 9 % for further treatment related to dental problems. CONCLUSION: Incidental findings are common on CBCTs. Compared with the literature, CLP patients have more dental, nasal and ear problems. Thus, whenever a CBCT is available, this scan should be reviewed by all specialists in the CLP team focusing on their specific background knowledge concerning symptoms and treatment of these patients. CLINICAL RELEVANCE: The high number of findings indicates that CBCT imaging is a helpful tool in the treatment of CLP patients not only related to alveolar bone grafting and orthognathic surgery but it also provides diagnostic information for almost all specialties involved in CLP treatment.

A clinically relevant validation method for implant placement after virtual planning.

PURPOSE: To design a relevant method to compare the virtual planned implant position to the ultimately achieved implant position and to evaluate, in case of discrepancy, the cause for this. MATERIALS AND METHODS: Five consecutive edentulous patients with retention problems of the upper denture received four implants in the maxilla. Preoperatively, first a cone-beam CT (CBCT) scan was acquired, followed by virtual implant planning. Then, a surgical template was designed and endosseous implants were flapless installed using the template as a guide. To inventory any differences in position, the postoperative CBCT scan was matched to the preoperative scan. The accuracy of implant placement was validated three-dimensionally (3D) and the Implant Position Orthogonal Projection (IPOP) validation method was applied to project the results to a bucco-lingual and mesio-distal plane. Subsequently, errors introduced by virtual planning, surgical instruments, and validation process were evaluated. RESULTS: The bucco-lingual deviations were less obvious than mesio-distal deviations. A maximum linear tip deviation of 2.84 mm, shoulder deviation of 2.42 mm, and angular deviation of 3.41° were calculated in mesio-distal direction. Deviations included errors in planning software (maximum 0.15 mm), for surgical procedure (maximum 2.94°), and validation process (maximum 0.10 mm). CONCLUSIONS: This study provides the IPOP validation method as an accurate method to evaluate implant positions and to elucidate inaccuracies in virtual implant planning systems.

Validation of cephalic index measurements in scaphocephaly.

INTRODUCTION: The cephalic index (CI) of the head can be measured manually using a caliper, the original technique, but it is also possible to determine it using skull X-ray, 2DCT and 3DCT images, 3D photo and with help of plagiocephalometry (PCM). PATIENTS AND METHODS: In this study, the manual caliper determination is statistically compared with other measuring methods for scaphocephaly patients (n = 39). RESULTS: The CI mean differences for the most representative data are sequentially 3.74, 2.16, 1.09 and 0.97 for the 2DCT, PCM, 3D photo and 3DCT techniques. The CI 2DCT values show a significant difference (p < 0.01) in reference to CI manually, while the other techniques show a p > 0.05. CONCLUSION: The conclusions are that significantly different results are achieved when using 2DCT relative to the manual caliper determination. No significant difference is observed between the 3D techniques and the manual method.

Oromandibular reconstruction using 3D planned triple template method.

PURPOSE: Reconstruction of an oromandibular defect remains one of the most formidable surgical challenges faced by the reconstructive head and neck surgeon. The purpose of this study was to illustrate the added value of 3D imaging and planning in oromandibular reconstruction. MATERIALS AND METHODS: A 41-year-old dentate male patient with T2N0M0 osteosarcoma of the mandible required segmental resection of the lateral mandible. In a virtual environment, the bony resection and reconstruction were planned preoperatively based on computed tomographic data of the head and neck and lower leg. Three custom-made templates designed in a computer-assisted design and manufacturing software package and materialized by a selective laser sintering process (DuraForm PA, 3D Worknet, Ede, Netherlands) were used to transfer this planning to the operating theater. RESULTS: During the operative procedure, the 3 templates allowed for a rapid and accurate execution of the different surgical steps, ie, establishing the bony surgical margins and resection of the mandible (first template), cutting of the fibula while being pedicled to the leg (second template), and placement of the fibula to the donor site (third template). CONCLUSION: Computer-aided surgery and planning using the 3-template method lead to an accurate and oncologically safe reconstruction of the mandibular geometry by eliminating intraoperative decision making, shortening ischemic time of the fibular graft, and shortening overall operative time.

Three-dimensional evaluation of soft tissue changes in the orofacial region after tooth-borne and bone-borne surgically assisted rapid maxillary expansion.

OBJECTIVES: This study seeks to three-dimensionally assess soft tissue changes in the orofacial region following tooth-borne and bone-borne surgically assisted rapid maxillary expansion (SARME). MATERIALS AND METHODS: This prospective cohort study included 40 skeletally mature patients with transverse maxillary hypoplasia. A tooth-borne distractor (Hyrax) was used for expansion in 25 patients. In the remaining 15, a bone-borne distractor (transpalatal distractor, TPD) was used. Cone beam computed tomography (CBCT) scans were acquired before treatment (T0) and 22 months later (T1). 3D models were constructed from CBCT data and superimposed using voxel-based matching. Distance maps between the superimposed 3D models were computed to evaluate the degree of skeletal and soft tissue changes in the maxillary region. RESULTS: Distance maps showed negative distances (mean -1.25 (±1.5) mm) in the middle of the upper lip, indicating posterior repositioning of this area. The cheek region showed positive changes (mean 1.66 (±1.1) mm), reflecting the underlying increase in maxillary width. There was no significant difference between the two groups in all measured distances (p > 0.05). Retro-positioning of the upper lip accompanied skeletal remodeling in the anterior alveolar region at a mean ratio of 88 %, while the cheek region followed 32 % of the alveolar expansion. CONCLUSION: Soft tissue changes following SARME include posterior repositioning of the upper lip and increased projection of the cheek area. These changes were comparable between bone-borne and tooth-borne appliances. CLINICAL RELEVANCE: This study provides clinicians with more information over the expected orofacial soft tissue changes following SARME.