Early hard palate closure using a vomer flap in unilateral cleft lip and palate: effects on cleft width

Objectives

Although no universal consensus exists on treatment of cleft palates, early hard palate closure is commonly performed. The aim of the present study was to determine the influence of a vomer flap for early hard palate closure on residual palatal cleft width in patients with a unilateral complete cleft lip and palate (UCLP).

Materials and methods

Forty-seven UCLP patients were retrospectively divided into two groups. Group A consisted of 25 patients who underwent early lip closure and simultaneous hard palate closure using a vomer flap. Group B included 22 patients who had lip closure only at first surgery. Palatal cleft widths of both groups were measured at two time points and were compared using the Mann–Whitney U test to examine the influence of vomerplasty in this very early stage.

Results

No significant difference of baseline characteristics between the groups was found, and comparison of age at the time of surgeries was not significantly different. Mean age at the time of vomerplasty was 4.0 months. After the first surgery, a significantly greater total cleft width reduction of 5.0 mm average was found in group A compared to only 1.5 mm reduction in group B. This reduction took place after an average of 7.1 and 7.0 months, respectively.

Conclusions

Lip closure accompanied by early hard palate closure using a vomer flap is associated with a significant postoperative reduction of the residual cleft when compared to lip closure only.

Clinical relevance

This study shows another great advantage of performing early hard palate closure using a vomer flap.     

Mid Versus Late Secondary Alveolar Cleft Grafting Using Iliac Crest Corticocancellous Bone Graft

Background

Mid-secondary alveolar cleft repair performed at ages 9–12, in the mixed dentition stage, prior to eruption of the permanent canine, is generally accepted as the ideal time for residual alveolar cleft closure in cleft lip and palate cases with a cleft alveolus.

Methods

In our study, four cases of mid-secondary and five cases of late–secondary alveolar cleft grafting were carried out using iliac crest corticocancellous bone graft. Clinical defect closure and radiographic bone fill were compared.

Results

All the nine cases performed in the two different age groups showed excellent results, clinically, with complete closure of the cleft defect and achievement of continuity of the dental arches. One case was planned for a two-stage procedure owing to the large bilateral maxillary defects. Good bone fill was visualized radiographically in all nine cases.

Conclusion

Precise timing for undertaking alveolar cleft repair may not be all that crucial for a successful alveolar cleft grafting procedure.     

Vomer flap for hard palate repair is related to favorable maxillary growth in unilateral cleft lip and palate

Objective

Vomer flap repair is assumed to improve maxillary growth because of reduced scarring in growth-sensitive areas of the palate. Our aim was to evaluate whether facial growth in patients with unilateral cleft lip and palate was significantly affected by the technique of hard palate repair (vomer flap versus two-flap).

Materials and methods

For this retrospective longitudinal study, we analyzed 334 cephalometric radiographs from 95 patients with nonsyndromic complete unilateral cleft lip and palate who underwent hard palate repair by two different techniques (vomer flap versus two-flap). Clinical notes were reviewed to record treatment histories. Cephalometry was used to determine facial morphology and growth rate. The associations among facial morphology at age 20, facial growth rate, and technique of hard palate repair were assessed using generalized estimating equation analysis.

Results

The hard palate repair technique significantly influenced protrusion of the maxilla (SNA: β?=??3.5°, 95 % CI?=??5.2-1.7; p?=?0.001) and the anteroposterior jaw relation (ANB: β?=??4.2°, 95 % CI?=??6.4-1.9; p?=?0.001; Wits: β?=??5.7 mm, 95 % CI?=??9.6-1.2; p?=?0.01) at age 20, and their growth rates (SNA p?=?0.001, ANB p?<?0.01, and Wits p?=?0.02).

Conclusions

The results suggest that in patients with unilateral cleft lip and palate, vomer flap repair has a smaller adverse effect than two-flap on growth of the maxilla. This effect on maxillary growth is on the anteroposterior development of the alveolar maxilla and is progressive with age. We now perform hard palate closure with vomer flap followed by soft palate closure using Furlow palatoplasty.

Clinical relevance

These findings may improve treatment outcome by modifying the treatment protocol for patients with unilateral cleft lip and palate.     

Genitopatellar syndrome, sensorineural hearing loss, and cleft palate

Introduction

Genitopatellar syndrome is characterized by absent/hypoplastic patellae, genital and renal abnormalities, dysmorphic facial features, and mental retardation. Cardiac anomalies, ectodermal dysplasia, and radio-ulnar synostosis have been suggested as additional features.

Discussion

We report on additional female patient with sensorineural hearing loss, cleft palate, and hypothyroidism in addition to known anomalies. Findings are discussed based on a literature review of the known patients with the genitopatellar syndrome.     

The prevalence of specific dental anomalies in a group of Saudi cleft lip and palate patients

Objective

The aims of this study were to investigate the prevalence and distribution of dental anomalies in a group of Saudi subjects with cleft lip and palate (CLP), to examine potential sex-based associations of these anomalies, and to compare dental anomalies in Saudi subjects with CLP with published data from other population groups.

Design

This retrospective study involved the examination of pre-treatment records obtained from three CLP centers in Riyadh, Saudi Arabia, in February and March 2010. The pre-treatment records of 184 subjects with cleft lip and palate were identified and included in this study. Pre-treatment maxillary occlusal radiographs of the cleft region, panoramic radiographs, and orthodontic study models of subjects with CLP were analyzed for dental anomalies.

Results

Orthopantomographs and occlusal radiographs may not be reliable for the accurate evaluation of root malformation anomalies. A total of 265 dental anomalies were observed in the 184 study subjects. Hypodontia was observed most commonly (66.8%), followed by microdontia (45.6%), intra-oral ectopic eruption (12.5%), supernumerary teeth (12.5%), intra-nasal ectopic eruption (3.2), and macrodontia (3.2%). No gender difference in the prevalence of these anomalies was observed.

Conclusions

Dental anomalies were common in Saudi subjects with CLP type. This will complicate the health care required for the CL/P subjects. This study was conducted to epidemiologically explore the prevalence of dental anomalies among Saudi Arabian subjects with CLP.     

Relationship of children’s salivary microbiota with their caries status: a pyrosequencing study

Purpose

Different dental caries status could be related with alterations in oral microbiota. Previous studies have collected saliva as a representative medium of the oral ecosystem. The purpose of this study was to assess the composition of oral microbiota and its relation to the presence of dental caries at different degrees of severity.

Materials and methods

One hundred ten saliva samples from 12-year-old children were taken and divided into six groups defined in strict accordance with their dental caries prevalence according to the International Caries Detection and Assessment System II criteria. These samples were studied by pyrosequencing PCR products of the 16S ribosomal RNA gene.

Results

The results showed statistically significant intergroup differences at the class and genus taxonomic levels. Streptococcus is the most frequent genus in all groups; although it did not show intergroup statistical differences. In patients with cavities, Porphyromonas and Prevotella showed an increasing percentage compared to healthy individuals. Bacterial diversity diminished as the severity of the disease increased, so those patients with more advanced stages of caries presented less bacterial diversity than healthy subjects.

Conclusion

Although microbial composition tended to be different, the intragroup variation is large, as evidenced by the lack of clear intragroup clustering in principal component analyses. Thus, no clear differences were found, indicating that using bacterial composition as the sole source of biomarkers for dental caries may not be reliable in the unstimulated saliva samples used in the current study.     

La frequenza delle anomalie dentarie nei pazienti affetti da cheilognatopalatoschisi

Objectives

The purpose of this study was to investigate dental abnormalities in children with cleft lip and palate (CLP) in order to identify the most prevalent anomalies and the teeth most frequently affected.

Materials and methods

We analyzed orthopanoramics X-rays (OPT), computed tomography Dental Scans, clinical records, and dental casts from 18 consecutive patients (10 boys, 8 girls; mean age 11.2 years, range: 6 to 18), with CLP (complete or incomplete, mono- or bilateral) and recorded the presence of the following anomalies: supernumerary teeth, agenesis, shape and size anomalies, ectopic and dystopic eruptions, rotations and retained teeth.

Results

The most frequent abnormalities were: agenesis (prevalence: 22.5%), ectopic and dystopic eruption (19.3%), rotations (17.7%), shape and size anomalies (16.1%), and retained teeth (14.5%). The most frequently affected teeth were the lateral (45.1%) and central incisors (32.2%), the cuspids (14.5%), and the second bicuspid (6.4%). Lateral incisors were usually missing (39.2%) or retained (21.4%), while central incisors were more often rotated (50%) or deformed (25%). The cuspids were ectopic (66.6%) or retained (23%), while the bicuspids were missing (25%), retained (25%), or presented alterations in number (25%) or shape/size (25%).

Conclusions

Each subject presented at least one dental anomaly. This high frequency indicates that identification of these anomalies is fundamental for appropriate management of cleft lip and palate.     

Nasenfisteln und -zysten bei Patienten mit Lippen-Kiefer-Gaumen-Spalten

Background

Nasal dermoid sinus cysts are uncommon congenital lesions. They are usually isolated occurrences and are not associated with syndromes or additional malformations. The coincidence of both, cleft malformations and nasal dermoid sinus cysts, has seldom been reported.

Case reports

Within the last 2?years two patients with reconstructed cleft lip and palate and additional nasal dermoid sinus cysts underwent surgical removal. One patient with bilateral complete cleft lip exhibited a fistula from the medial third of the nasal dorsum up to the glabella. Another patient with unilateral cleft lip and Peters' plus syndrome had undergone removal of a nasal dermoid sinus cyst 12? years ago and was referred for management of recurrent disease.

Discussion

Concerning the common cleft-dependent nose malformations with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no frequent occurrence of nasal dermoids has thus far been documented. However, the proximity and temporal closeness of an embryological pathway of the frontonasal region and lip development could also argue for a unique formation of both lesions. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended.     

The role of the tensor veli palatini muscle in the development of cleft palate-associated middle ear problems

Objective

Otitis media with effusion is common in infants with an unrepaired cleft palate. Although its prevalence is reduced after cleft surgery, many children continue to suffer from middle ear problems during childhood. While the tensor veli palatini muscle is thought to be involved in middle ear ventilation, evidence about its exact anatomy, function, and role in cleft palate surgery is limited.This study aimed to perform a thorough review of the literature on (1) the role of the tensor veli palatini muscle in the Eustachian tube opening and middle ear ventilation, (2) anatomical anomalies in cleft palate infants related to middle ear disease, and (3) their implications for surgical techniques used in cleft palate repair.

Materials and methods

A literature search on the MEDLINE database was performed using a combination of the keywords “tensor veli palatini muscle,” “Eustachian tube,” “otitis media with effusion,” and “cleft palate.”

Results

Several studies confirm the important role of the tensor veli palatini muscle in the Eustachian tube opening mechanism. Maintaining the integrity of the tensor veli palatini muscle during cleft palate surgery seems to improve long-term otological outcome. However, anatomical variations in cleft palate children may alter the effect of the tensor veli palatini muscle on the Eustachian tube’s dilatation mechanism.

Conclusion

More research is warranted to clarify the role of the tensor veli palatini muscle in cleft palate-associated Eustachian tube dysfunction and development of middle ear problems.

Clinical relevance

Optimized surgical management of cleft palate could potentially reduce associated middle ear problems.

     

Craniofacial cephalometric morphologies in different cleft types: a retrospective cross-sectional study of 212 patients

Objective

The aim of this study was to evaluate and compare the craniofacial cephalometric morphologies among different cleft types in a Spanish population.

Methods

A retrospective cross-sectional study was carried out on 212 patients. The patients were subdivided into four groups according to their cleft types: unilateral cleft lip and palate; bilateral cleft lip and palate; cleft lip; and cleft palate. Angular and linear cephalometric measurements were taken on lateral radiographs.

Results

Unilateral cleft lip and palate was associated with a dolichofacial growth pattern, skeletal Class III with correct maxillary position, and lingual incisor inclination. Bilateral cleft lip and palate was associated with a mesofacial growth pattern, skeletal Class I with protruded maxillary position, and lingual incisor inclination. Cleft palate was associated with a mesofacial growth pattern, skeletal Class III with correct maxillary position, and lingual incisor inclination. Cleft lip was associated with a brachyfacial growth pattern, skeletal Class I with protruded maxillary position, lingual upper incisor inclination, and corrects lower incisor inclination. Significant correlations were observed between cleft types and their craniofacial cephalometric measurements.

Conclusions

The present information can be used for the determination of orthodontic treatment and even future orthognathic surgery planning, a requirement in most cleft patients.

     

Herpes simplex virus reactivation and dental procedures

Objectives

Dental extraction is reported to trigger recurrent herpes labialis (RHL).

Aim

This aims to prospectively study the clinical occurrence of RHL and the oral herpes simplex virus type 1 (HSV-1) viral shedding before and 3 days after different dental procedures.

Materials and methods

Oral HSV-1 DNA was measured by real-time PCR before and 3 days after dental procedures of the inferior dentition in 57 immunocompetent patients (mean age 32.4 years) who were selected and divided into four distinct subgroups (dental inspection without anesthesia, n?=?19; dental filling under local anesthesia, n?=?14; molar extraction under local anesthesia, n?=?15; and molar extraction under general anesthesia, n?=?9) and compared to 32 healthy controls (mean age 33 years).

Results

None of the patients suffered from RHL at day 3. Oral HSV-1 DNA was detected before and after procedure in 1.7 % (1/57) and 5.3 % (3/57), respectively [dental inspection without anesthesia, 5.3 % (1/19); molar extraction under local anesthesia, 6.7 % (1/15); and molar extraction under general anesthesia, 11 % (1/9)]. None of the controls presented RHL or detectable oral HSV-1 DNA. There was no statistically significant difference between the study groups and controls.

Conclusion

Molar extraction increases the risk of oral HSV-1 shedding but not of RHL. Procedure-related nerve damage probably accounts for HSV reactivation.

Clinical relevance

Antiviral prophylaxis for RHL is not routinely recommended for dental procedures, regardless of a prior history of RHL.     

Lippen-Kiefer-Gaumen-Spalten

Investigation

In most cases it is not sufficient to use photographs and plaster casts to document and analyze the three-dimensional morphology of lip, jaw, and palate clefts. The aim of this study was to evaluate the applicability of surface scanning with a 3-D laser topography scanner in patients with unilateral cleft lip.

Patients and methods

Three-dimensional surface scans of the face were performed pre- and postoperatively in 20?patients (3–35?years of age) with a 3-D laser topography scanner. All patients were suffering from nonoperated, one-sided cleft lip, cleft lip-jaw, or cleft lip-jaw and palate. The digital data sets were metrically analyzed and expressed on the basis of quotients, independent of size factors.

Results

Using this 3-D laser scanner it was possible to acquire good quality three-dimensional data sets. Measurements were in the dimension of millimeters. Based on the data sets it was possible to provide the three-dimensional cleft morphology with reproducible landmarks and analyze the data. The postoperative symmetry of the face was controlled and objectively quantified. It is disadvantageous however that numerous views need to be taken to get the full image of the face and that the scanning process takes about 2?s.

Conclusion

The presented 3-D laser scanner renders a precise 3-D surface analysis of the lip and nose region in cleft patients. For lively infants or uncooperative adults, the system is suitable only to a limited extent due to the time-consuming scanning process.     

Osteopathology induced by bisphosphonates and dental implants: clinical observations

Objectives

Although there are many reports about risk factors for the development of BP-associated osteonecrosis of the jaws, the role of dental implants as a local risk factor is still discussed, especially in patients with oral BP treatment. Until now, a few case reports and surveys display a possible minor risk in patients with oral BP therapy, whereas the avoidance of implant placement is generally accepted in patients with intravenous BP therapy.

Patient and methods

In this study, the cases of 14 patients with osteonecrosis of the jaws in association with BP therapy and dental implant placement were analyzed carefully with a detailed literature review.

Results

Of 14 patients, nine had underlying malignant disease and five patients had osteoporosis. In ten patients, implants were placed either in the posterior mandible or maxilla; the mean interval between implant insertion and disease onset was 20.9 months. Pain (n12) and signs of infection (n10) were the most common symptoms. Histologically, signs of infection were found in nine of 11 analyzed patients with presence of Actinomyces in six patients. Two patients turned out to have infiltration of underlying malignant disease.

Conclusions

Posteriorly placed implants seem to be of higher risk of development of osteonecrosis of the jaws. Not only the implant placement but also the inserted implant itself seems to be a continuous risk factor.

Clinical relevance

The herein elaborated risk factors help dentists plan dental rehabilitation with implants in this high-risk group of patients and indicate careful and regular dental recall.     

Oral malignant melanoma diagnosed in an Iranian population over an 11-year period

Objective

The aim of this study was to determine the prevalence of oral malignant melanoma along with age range and site of presentation over an 11-year period in Iran.

Materials and methods

The files of Tehran Cancer Institute served as a source of material for this study. Files were systematically searched for all malignant melanomas and oral malignant melanomas during an 11-year period. Prepared slides and demographic data from the biopsy files were reviewed. Statistical analysis was performed with the use of SPSS.

Results

Of the 38,993 cases accessed during the 11-year period, 569 were identified as malignant melanomas, while 41 cases among this group had malignant oral melanomas comprising 0.1% of the total cases and 7.2% of all the malignant melanoma lesions.

Conclusion

The palate was the most common location for oral malignant melanoma. Thus, all melanocytic lesions in the palate should be viewed with caution, and biopsy is recommended to rule out melanoma.     

Nasoalveolar Moulding for Children with Unilateral Cleft Lip and Palate

Introduction

Cleft lip and palate represents the most frequently occurring congenital deformity second only to club foot deformity in our country. Wide alveolar clefts if not preceded by pre surgical orthodontic adjuncts like nasoalveolar moulding, may affect the final outcome of the primary surgery. Presurgical nasoalveolar moulding is to align and approximate the alveolar cleft segments while at the same time achieving correction of the nasal cartilage and soft tissue deformity.

Materials and methods

The device we used is designed by Barry Grayson. It is simple to fabricate, causes less discomfort to the patient and optimum results are achieved in three months of time, compared to other complicated appliances like Latham’s which are more invasive. A child of 3 months presented with a complaint of unilateral cleft deformity on one side of the face.

Conclusion

After three months of nasoalveolar moulding considerable changes were observed. The widths of the cleft alveolus were reduced and the nasal contours of columella on the cleft side showed considerable improvement.     

Mesiodistal tooth size in non-syndromic unilateral cleft lip and palate patients: a meta-analysis

Objectives

To evaluate, using meta-analysis methodology, mesiodistal tooth dimensions in non-syndromic unilateral cleft lip and palate (CLP) patients.

Materials and methods

A literature search was conducted using PubMed, Medline, Google Scholar Beta, EMBASE Excerpta Medica, CINAHL, Web of Science, and the Cochrane Collaboration, identifying English and non-English articles reporting on mesiodistal tooth dimensions on the cleft and non-cleft side of non-syndromic unilateral CLP patients. Additional studies were identified by searching reference lists of articles consulted. Only studies with a suitable control group were included. Two examiners independently performed the literature search and data extraction. Using meta-analysis software, data extracted from each selected study were statistically combined using the fixed-effects model. Weighted mean differences, 95 % confidence intervals, and heterogeneity were calculated for each measurement.

Results

Four articles fulfilling the inclusion criteria were located and included in the meta-analysis. Maxillary incisors and first molars were found to be significantly larger on the non-cleft side while mandibular incisors and premolars were larger on the cleft side, in non-syndromic unilateral CLP patients. On the cleft side, maxillary premolars and second molars were larger in cleft than control patients while incisors were smaller, whereas all mandibular teeth were larger in cleft patients. On the non-cleft side, all maxillary teeth except for the central incisors were larger in the cleft than control patients, while all mandibular teeth were larger in the cleft patients except for lateral incisors.

Conclusions

Non-syndromic unilateral CLP patients tend to have larger posterior but smaller anterior teeth compared with the general population. Comparing sides, unilateral CLP patients tend to have smaller maxillary but larger mandibular teeth on the cleft than on the non-cleft side.

Clinical relevance

Given that obtaining a stable, functional, and esthetic occlusion requires a thorough evaluation of tooth size, knowledge about trends in tooth size variations in CLP patients can help with dental and orthodontic treatment planning.     

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.     

Dental risk factors for osteonecrosis of the jaws: a CONDOR case–control study

Background

Reports of osteonecrosis of the jaw (ONJ) have associated this lesion to treatment with bisphosphonates (BPs) and dental procedures. In this study, we investigated the association of specific dental diagnoses and procedures with ONJ among patients with past BP use.

Methods

Dentists from three practice-based research networks provided ONJ cases and controls (1:3). Data gathered from patients and dental offices with two respective standard questionnaires included demographic, medical, pharmaceutical, and dental information. Diagnoses and procedures up to 3 years prior to ONJ (prior to interview for controls) were analyzed within risk strata, defined by BP use and cancer status, using interaction terms within conditional logistic regression models.

Results

We enrolled 191 ONJ cases and 573 controls from 119 dental offices. Among participants who had used only oral BP, extraction was the only dental risk factor for ONJ (odds ratio (OR)?=?12, p?=?0.01). Suppuration was also more prevalent in cases (18 %) than in controls (9 %), but not statistically significant (OR?=?9, p?=?0.06). Among participants who had not used either oral or IV BP (a majority of whom received radiation therapy to the head and neck), suppuration was the only dental risk factor for ONJ (prevalence?=?34 % for cases and 8 % for controls; OR?=?7, p?=?0.01). The prevalence of extractions in this group was also higher, but not statistically significant (44 vs 10 %; OR?=?3). Limited power precludes definitive findings among participants exposed to IV BP.

Conclusions

Among patients taking oral BP, extraction was the only dental procedure associated with subsequent ONJ development

Clinical relevance

Results of this study suggest that routine dental procedures are not associated with development of ONJ in patients exposed to BPs.