Successful Management of Cleft Lip and Palate Malformation without Pre-Surgical Infant Orthopedics

Objective: To investigate the effect of lip closure on reduction of cleft palates when no pre-surgical infant orthopedics (PSIO) are used. Study design: Retrospective patient chart-review in our department for Cranio-Maxillofacial Surgery at the University Medical Centre Freiburg, Germany. 19 patients at the age of 5.9 ± 2.1 months with surgical treatment of uni- (UCLP), or bilateral cleft lip and palate (BCLP) without any use of PSIO were included. Results: Early soft tissue correction of the lip leads to an effective reduction of the maxillary arch without any use of PSIO. The presented conventional and digital measurements appeared to be reliable. A successful reduction of the cleft width (UCLP = 3.88 ± 2.42mm, BCLP = 7.33 ± 5.00mm), the width of the alveolar arch (1.91 ± 1.36mm) and the sagittal depth of the alveolar arch (3.07 ± 2.71 mm) could be achieved with the presented workflow. Conclusions: Cleft reduction was obtainable without PSIO when lip closure after Tennison-Randall was performed.

Does Infant Orthopedics and Neonate Lip Surgery Influence the Occlusal Relationship in Patients With Unilateral Cleft Lip and Palate (UCLP)?

Objective: To compare occlusal relationship in patients undergoing neonate versus conventional lip surgery (LS) with and without infant orthopedics (IO) by assessment of dental arch relationship in individuals with complete unilateral cleft lip and palate. Material and Methods: Three groups treated by different protocols; Group I: neonate LS (1-15 days) + IO and palatoplasty (13-31 months); Group II: LS (3-12 months) + IO and palatoplasty (15-35 months); and Group III: LS (3-6 months) without IO and palatoplasty (12-18 months). The 112 intraoral photographs of individuals of all groups, obtained between 6 and 12 years of age, were assessed by the occlusal index for intraoral photograph rating. The groups were compared by the χ2 test. The correlation between surgical timing and the scores was tested by the Spearman test ( P < .05). Results: Group I presented the highest percentage of score 5, group II exhibited highest percentage of score 1, and group III presented the lowest percentage of score 5 according to the χ2 test ( P = .029). The Spearman correlation test revealed statistically significant difference between timing of LS and the occlusal index. The earlier the surgical timing, the higher the occlusal index ( P = .019). Conclusions: Infant orthopedics has demonstrated the possibility of postponing primary plastic surgeries. Patients submitted to late lip and palate repair had the best prognosis, while patients undergoing lip repair from 1 to 15 days of life, even operating the palate later, had the worst prognosis. Neonate LS negatively influenced the occlusal relationships.

Comparative Study of Presurgical Infant Orthopedics by Modified Grayson Method and Dynacleft With Nasal Elevators in Patients With Unilateral Cleft Lip and Palate—A Clinical Prospective Study

Objective: To compare the effects of presurgical infant orthopedics using 2 different methods, that is, the Dynacleft with Nasal elevator system versus the modified Grayson’s technique in patients with complete unilateral cleft lip and palate. Design: Prospective comparative cohort study. Materials and Methods: Twenty-eight patients were divided into 2 groups, that is, Group A consisting of 14 patients who underwent correction with DynaCleft with Nasal elevator system and Group B consisting of 14 patients undergoing correction using the modified Grayson technique. Maxillary cast measurements were taken at 2-time intervals (pre- and posttreatment) to assess various parameters using a laser scanning machine (C500 Solutionix) and 3D software (GOM Inspect). Similarly, standardized anterior–posterior and worm’s-eye view photographs using a custom box were taken and imported to Adobe Photoshop CS6 for measurements. Paired t test and independent t test were used to compare intra- and intergroup changes, respectively. Results: The analysis of cast (primary outcome) and photographic (secondary outcome) measurements showed improved nasal asymmetry and alveolar correction in both groups which showed no significant intergroup difference when assessed using the independent t test ( P > .05). Group A showed higher chances (42.8%) of causing a T-shaped defect (due to excessive mesial-inward rotation of the minor segment) when compared to the Group B possibly due to a more controlled molding vector ( P < .05). Conclusion: Both methods proved effective in improving the nasal asymmetry, reducing the alveolar cleft gap, and approximating the lips together; but care must be taken when applying the alveolar molding vector in the Dynacleft system.

OrthoAligner “NAM”: A Case Series of Presurgical Infant Orthopedics (PSIO) Using Clear Aligners

Presurgical infant orthopedics (PSIO) is done to reduce the size of the cleft defect along with improving the arch alignment and nasolabial aesthetics in patients with cleft lip and palate, leading to an improvement of nasolabial aesthetics allowing for a tidier and more aesthetic reparative procedure and postsurgical scar. Since the 2000s, clear aligners have slowly and steadily treaded their way as an acceptable orthodontic modality, with their usage and acceptability increasing considerably over the past decade. Thus, from the knowledge gathered in its 10 years working with 3-dimensional (3-D) diagnosis, treatment planning, and 3-D Printing services, Compass 3D (Belo Horizonte, Brazil) developed the OrthoAligner NAM system. This case series highlights one of the world’s first documented cases of PSIO treated with a series of clear aligners.

Clinical Outcomes Utilizing a “Modified Latham” Appliance for Presurgical Infant Orthopedics in Patients With Unilateral Complete Cleft Lip and Palate

Presurgical infant orthopedic manipulation is utilized prior to cleft lip/nasal repair to facilitate a gingivoperiosteoplasty (GPP) and primary nasolabial repairs. The Latham dentomaxillary advancement appliance uses a screw that must be tightened daily to approximate the cleft segments in unilateral complete clefts. Our cleft center has been utilizing a “modified Latham” appliance since 1987, including an orthodontic elastic power chain to close the gap in a shorter amount of time. We performed a retrospective chart review of all patients undergoing treatment at Johns Hopkins All Children's Hospital (JHACH) with a unilateral complete cleft lip and palate between 1987 and 2017. Patients were identified by the International Classification of Diseases, Ninth Revision code (749.21). The majority of the patients represent the experience of the senior authors (E.R. and R.F.). Two hundred and eighty-one patients with unilateral complete cleft lip/palate were identified. Seventy-five patients were treated with a “modified Latham” appliance prior to their lip repair. The “modified Latham” appliance remained in place on average 20.6 days (range: 4-82), and average hospital stay after placement was 1.18 days. Nearly 96% of patients underwent a successful GPP at the time of nasolabial repair. Modification of the Latham appliance by utilizing an elastic power chain and eliminating the screw allows rapid closure of the alveolar cleft with limited need for adjustments and outpatient visits. Direct approximation of the palatal segments allows successful completion of a GPP in 95.9% of patients with limited dissection.

The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis

Background: Presurgical infant orthopedics (PSIO) techniques were introduced to improve the outcomes achieved when treating children with complete cleft lip and palate. The effect of PSIO on the incidence of postoperative fistulae has never been reliably demonstrated. We conducted a meta-analysis to assess the effectiveness of PSIO in reducing postoperative fistulas in patients with complete cleft lip and palate. Methods: A search of the PubMed and Embase databases was performed to identify relevant articles that included primary palate repairs of patients with unilateral or bilateral complete clefts, reported the incidence of postoperative fistulae, and explicitly stated if PSIO was used. Details including author, number of subjects, use of PSIO, and fistula rate were cataloged. Results: A review of the PubMed database yielded 1135 unique citations, and Embase yielded 507 articles. Review of these yielded 15 studies, comprising 1241 children, which met inclusion criteria. The overall rate of oronasal fistula development was 7.09%. The average fistula rate for studies using PSIO was 5.93% versus 9.71% in the non-PSIO group. This difference was not statistically significant ( P = .34). Conclusions: The use of PSIO prior to cleft lip and palate repair provides multiple benefits related to facial and nasal form and is supported by a body of literature. The effect of PSIO on the incidence of postoperative fistulae has received less attention in the literature. Our meta-analysis of the available literature does not provide evidence to support the premise that the use of PSIO affects the incidence of fistulae after cleft palate repair.