Faculty Bibliography

OBJECTIVE:To determine the effects of nasoalveolar molding (NAM) on nasal airway architecture. DESIGN/METHODS:Retrospective case-control study of patients with unilateral cleft lip treated with NAM vs without NAM. SETTING/METHODS:Tertiary referral center specializing in cleft and craniofacial care. Patients, Participants, and Interventions: Thirty-six patients with complete unilateral cleft lip and alveolus: 19 with NAM therapy and 17 without NAM therapy. MAIN OUTCOME MEASURES/METHODS:Cone beam computed tomography (CBCT) scans were compared in multiple coronal sections and were evaluated for linear and angular septal deviation, inferior turbinate hypertrophy, and linear and 2-dimensional airway area. RESULTS:There were no significant differences in linear or angular septal deviation, inferior turbinate area, linear stenosis, or airway area between NAM- and non-NAM-treated patients. CONCLUSIONS:NAM effectively molds the external nasal cartilage and structures but may have limited effects on internal nasal structures.

Background/Purpose:Management of patientswith cleft lip and palate is complex and requires a multidisciplinary team with several treatment interventions. Proper sequencing and timing of orthodontic and surgical treatment is important for successful long-term outcome and reducing the burden of care on the families. This presentation will focus on orthodontic management of patients born with cleft lip and palate from infancy to skeletal maturity. Methods/Description: The management of patients with cleft lip and cleft palate requires extended orthodontic treatment and an interdisciplinary approach in providing these patients with optimal aesthetics, function, and stability. Orthodontic or orthopedic management in infancy, primary, mixed, and permanent dentition and after the completion of facial growth will be discussed with a proper interdisciplinary approach to treatment planning and treatment sequencing during each phase of orthodontic and surgical treatment. This presentation will discuss the presurgical infant orthopedic, pre and post bone graft orthodontics, phase II comprehensive orthodontic treatment, and LeFort I distraction and orthognathic surgery at skeletal maturity. Long-term outcome of treatment will be presented of patients treated from birth to adulthood

Background/Purpose: The aim of this study was to investigate the effect of infant orthopedics on transversal, sagittal and vertical dimensions of maxillary and mandibular dentoalveolar measurements in patients with unilateral cleft lip and palate (UCLP) and to compare them to patients without cleft at the age of 5. Methods/Description: Forty-five dental casts of nonsyndromic patients with completeUCLP were assessed for this retrospective study (age range: 4.5-6.5 years). These patientswere divided into 2 groups based onwhether infant orthopedics were applied (IO) or not (NIO). Maxillary andmandibular dental casts were available for 25 patients in the IOgroup and 20 in the NIO group 20. These 2 cleft groups were compared to a control group of age-matched patients with class I occlusion and without a cleft (n = 48). Maxillary and mandibular anterior and posterior arch widths, arch lengths, and palatal depths were measured with a ruler and digital caliper. Lesser segment canine position and the amount of cleft gap were evaluated as well. For statistical analysis, ANOVA was used for comparisons between groups.
Result(s): Maxillary anterior (III-III) and posterior arch widths (V-V) were similar in the subgroups of patientswith clefts, whereas they were narrower than the noncleft control group (P < .01). There was no significant difference in mandibular arch dimensions between samples from patients with and without a cleft (P >= .05). Lesser segment arch perimeter did not differ between groups (P <= .336), while greater segment arch perimeter was found to be higher in the control group when compared to the groups with a cleft (P <= .01). Posterior palatal depth, measured from the occlusal surfaces of the second primary molars, was found to be higher in noncleft samples (P <= .001) and the difference between patients in the IO and NIO groups were not significant. However, measurement of anterior palatal depth revealed no significant difference between patients with a cleft and the control group (P >= .05). The maxillary deciduous canine at the lesser segmentwas located more palatinally in theNIO group than in the IOgroup (P < .05). Regarding the amount of cleft gap, the NIO group exhibited a bigger cleft width (3.98 +/- 2.65 mm) and depth (2.12 +/- 2.63 mm) than those of the IO group (2.36 +/- 2.48 mm, 0.78 +/- 1.14 mm, respectively) significantly (P <= .05).
Conclusion(s): Maxillary transverse measurements were decreased in groups of patients with a cleft both with/without IO when compared to a noncleft control group. The IO and NIO groups exhibited similar arch widths. Cleft depth and width were found to be higher in the NIO group

Background/Purpose: Skeletal Class III malocclusion with maxillary hypoplasia results in anterior-posterior discrepancy of the upper and lower incisors position and lip incompetence. This affects the ability to achieve appropriate placement of tongue and management of the intraoral air pressure for sound production, resulting in perceived nasal emission and abnormal articulatory gestures. The aim of this study is to investigate the relationship between occlusal disharmony, velopharyngeal competence, and speech outcomes in patients with skeletal Class III malocclusion undergoing orthognathic surgery. Methods/Description: Seventy-five consecutive patients between 2015 and 2017 who underwent orthognathic surgery secondary to maxillary hypoplasia were evaluated on type of orthognathic procedure (LeFort I only; LeFort I and III; LeFort I and BSSO); amount of anterior and vertical advancement achieved, severity of skeletal Class III malocclusion, and lip incompetence. Patients were divided into 3 groups: cleft lip and palate, syndromic, and those with noncleft/nonsyndromic skeletal deformity. Each group received speech assessments preoperatively and 3 months postoperatively (velopharyngeal competence, resonance and articulatory integrity, and the Pittsburgh Weighted Speech Score [PWSS]).
Result(s): Following exclusionary analysis, 58 patients were included in the study; cleft lip and palate (n = 28), syndromic (n = 15), and noncleft/nonsyndromic skeletal (n =15). Preoperatively, the cleft palate and syndromic groups with increased mean skeletal discrepancy and lip incompetence values presented with higher total mean PWSS scores, and mean nasal emission values than the noncleft/nonsyndromic group (P <= .001). Postoperatively, the cleft group that underwent LFI only presented with insignificantly improved total PWSS (P <= .99) and nasality (P <= .28) scores. The syndromic patients who had the most severe skeletal discrepancy preoperatively and who underwent an LFI and LFIII combined procedure continued to present with significantly higher mean nasal emission values postoperatively than cleft and noncleft/ nonsyndromic patients undergoing LFI only or LFI and BSSO (P < .001). There was no significant difference in the amount of anterior advancement achieved and degree of velopharyngeal competence.
Conclusion(s): Our results show that orthognathic surgery to correct skeletal disharmony does not provide increased compromise to the velopharynx. However, the severity of the skeletal Class III malocclusion and lip position, especially those with a syndromic diagnosis, increases presence of nasal emission pre- and postoperatively. This study suggests that severity of skeletal Class III malocclusion can contribute to the perception of nasality post orthognathic surgery. Severity of skeletal discrepancy should be considered as an additional iatrogenic factor related to perceived velopharyngeal competence in orthognathic surgery

Background/Purpose: In October 2012, a freely available, Internetbased cleft simulator was created in partnership among academic, nonprofit, and industry sectors. The purpose of this educational resource was to address disparities in surgical education resulting from resident work-hour restraints in developed countries and limited resources in developing nations. This report assesses demographics, utilization, and global impact of our simulator, in its fifth year since inception. Methods/Description: Simulator modules demonstrate surgical anatomy, markings, detailed procedures, and intraoperative footage to supplement digital animation. Available data regarding number of users, sessions, countries reached, and content access was collected. Surveys evaluating the demographic characteristics of registered users and simulator utility were collected by direct e-mail.
Result(s): The total number of simulator new and active users reached 2865 and 4086 in June 2017, respectively. A steady increase in number of new users (217-327), active users (407-555), and sessions (1956-2304) was noted from January 2016 to June 2017. From March 2015 to June 2017, our simulator was accessed in an increasing number of countries (85-136). In the same time frame, the number of sessions was 11 176, with a monthly average of 399.0 +/- 190.0. Developing countries accounted for 35% of sessions. New users generated the majority of sessions (59.8% +/- 8.5%), and the average session duration was 9.0 +/- 7.3 minutes. This yields a total simulator screen time of 100 584 minutes (1676 hours) and an average of 3725 minutes (62 hours) per month. A total of 151 users responded to our survey, the majority of whom were surgeons or trainees (87%) specializing in plastic, maxillofacial or general surgery (89%). Most users found the simulator to be useful (88%), at least equivalent or more useful than other resources (83%), and used it for teaching (58%).
Conclusion(s): Internet-based distribution of a freely available cleft surgery simulator can deliver an interactive teaching platform that reaches the intended target audience, is not restricted by socioeconomic barriers to access, and is judged to be useful by surgeons. Our simulator has reached more than 4000 active users since inception. The great majority of users are surgeons or surgical trainees. The total screen time over approximately 2 years exceeded 1600 hours. This suggests that future educational simulators of this kind may be sustainable by stakeholders interested in reaching this target audience

Vascular malformations (VMs) of the head and neck can lead to aesthetic problems as well as cranial nerve damage, airway compromise, and vision loss. Large VMs are typically managed surgically, with sclerotherapy or embolization performed in the perioperative period to decrease the risk of excessive blood loss and minimize the size of the VM. However, this initial treatment is frequently insufficient leading to excessive blood loss intraoperatively, poorer margin visualization for the surgeon, and decreased likelihood of complete resection. As a result, resections of large VMs are often performed in a multistage approach. This article introduces a new hybrid approach for the management of head and neck VMs entailing the use of an endovascular operating room where a neuroendovascular surgeon performs embolization or sclerotherapy intraoperatively as needed in conjunction with surgical excision. Three patients with large VMs in the facial region underwent successful use of the hybrid approach. The hybrid approach improved visualization, leading to complete resection in 1 patient and nearly complete resections (70% and 90%) in the other patients. The technique also helped minimize blood loss because only the youngest patient (23 months old) required a blood transfusion. Implications of these findings include the transition from a multistaged approach for large VMs to a single-stage approach. In addition, decreases in blood loss may allow for the development and use of minimal access techniques, leading to a decrease in visible scarring for patients. We suggest the consideration of the hybrid approach for large head and neck VMs.

Background/Purpose: 3D-printed bioactive ceramic (3DPBC) scaffolds composed of beta-tricalcium phosphate (b-TCP) and coated in the osteogenic agent dipyridamole have been previously shown to heal critically sized calvarial defects in an adult animal model. This bone tissue engineering construct has yet to be applied in a pediatric craniofacial model and there has been evidence that other osteogenic agents such as BMP-2 can prematurely fuse growing sutures. The purpose of this study is to apply the described bone tissue engineering construct in a pediatric growing animal model and 1) quantify osteogenic potential in a growing calvarium; 2) maximize the scaffold design and dipyridamole (DIPY) concentration for the growing calvarium; and 3) characterize the effects of this bone tissue engineering construct on the growing suture. Methods/Description: Bilateral calvarial defects (10 mm) were created in 5-week-old New Zealand White rabbits (n = 14) 2 mm posterior and lateral to the coronal suture and sagittal sutures, respectively. 3DPBC scaffolds were constructed in quadrant form composed by varying pore dimensions (220, 330, and 500 mum). Each scaffold was collagen coated and soaked in varying concentrations of DIPY (100, 1000, and 10 000 muM). Controls comprised empty defects and collagen-coated scaffolds. Scaffolds were then placed into the calvarial defects to fill the bone space. Animals were euthanized 8 weeks postoperatively. Calvaria were analyzed using micro-computed tomography and 3D reconstruction.Mixed model analyses were conducted considering pore size and dosage effects on bone growth (a = 0.05).
Result(s): Scaffold group healing presented bone formation throughout the scaffold structure (defect marginal and central regions) while bone healing in empty sites was restricted to the defect margins, confirming its critical size dimension at 8 weeks in vivo. No significant difference in bone formation was detected when experimental groups were collapsed over pore size (P > .40). When pore size was collapsed over DIPY concentration, higher mean values were observed for the DIPYimmersed groups, and significance was shown between the 1000-muM and collagen groups (P < .05). Pore size and DIPY interaction was more pronounced for the 330-mum pore size where both the 100-and 1000-mum dosages presented significantly higher bone formation compared to collagen (P < .05). Across all concentrations of DIPY, including 10 000 mM (10 times greater than the experimental concentration, yielding the highest bone formation), sutures remained patent.
Conclusion(s):We present an effective bone tissue engineering scaffold design and dipyridamole concentration that significantly improve bone growth in a pediatric growing calvarial model and preserves cranial suture patency

Increased lifespans and population growth have resulted in an older U.S. society that must reckon with the complex oral health needs that arise as adults age. Understanding accessibility to screening and treatment facilities for older adults is necessary in order to provide them with preventive and restorative services. This study uses an agent-based model to examine the accessibility of screening and treatment facilities via transportation networks for older adults living in the neighborhoods of northern Manhattan, New York City. Older adults are simulated as socioeconomically distinct agents who move along a GIS-based transportation network using transportation modes that mediate their access to screening and treatment facilities. This simulation model includes four types of mobile agents as a simplifying assumption: walk, by car, by bus, or by van (i.e., a form of transportation assistance for older adults). These mobile agents follow particular routes: older adults who travel by car, bus, and van follow street roads, whereas pedestrians follow walkways. The model enables the user to focus on one neighborhood at a time for analysis. The spatial dimension of an older adult's accessibility to screening and treatment facilities is simulated through the travel costs (indicated by travel time or distance) incurred in the GIS-based model environment, where lower travel costs to screening and treatment facilities imply better access. This model provides a framework for representing health-seeking behavior that is contextualized by a transportation network in a GIS environment.

Background/Purpose: Surgical education is increasingly relying on digital and online resources. However, the educational benefit of learning through digital media has not been rigorously tested in the field of cleft care. We present a prospective, randomized, blinded trial comparing the educational efficacy of a textbook vs digital simulation in teaching cleft lip repair. Methods/Description: Medical student volunteers (N = 35) were asked to draw a cleft lip repair on a standardized patient photograph of a complete unilateral cleft lip deformity (Pretest). They were then randomized to 1 of 2 study groups that demonstrated unilateral cleft lip repair markings: textbook (n = 17) or digital simulation (n = 18). After 20 minutes of study, volunteers were asked to draw a cleft lip repair a second time on the same standardized photograph (Posttest). Volunteers were then shown the educational material provided to the other study group and given a validated survey to compare the educational value of both resources. Cleft lip marking was graded in a blinded manner on 2 separate occasions using a 0-to 10-point scale created by 2 senior cleft surgeons. Paired and independent t tests were used to compare differences between groups. Intrarater reliability was evaluated using intraclass correlation coefficients (ICCs).
Result(s): Intrarater reliability was excellent for both pretest (ICC = 0.94; P < .001) and posttest (ICC = 0.95; P < .001) grading. Pretest performances between the textbook and simulator groups were comparable (0.82 +/-1.17 vs 0.64+/-0.95; P = .31). There was significant improvement in posttest performance compared to pretest in both the textbook (3.50 +/- 1.62 vs 0.82 +/- 1.17; P < .001) and simulator (6.44 +/- 2.03 vs 0.64 +/- 0.95; P < .001) groups. However, significantly greater improvement was demonstrated by the simulator group when compared to the textbook group (5.81 +/- 2.01 vs 2.68 +/- 1.49; P < .001). Participants thought the simulator increased interest (3.91 +/- 1.01 vs 2.31+/-1.21; P < .001); allowed learning (3.83+/-0.95 vs 2.17 +/-1.20; P < .001); was stimulating (3.74+/-0.98 vs 1.69+/-0.87; P < .001), clearer (3.66+/-1.08 vs 2.17+/-1.22; P < .001), and effective in teaching (4.14 +/- 0.94 vs 2.31 +/- 1.21; P < .001); and that they were likely to be recommended to others (4.00+/-1.11 vs 2.14+/-1.19; P < .001) more than the textbook.
Conclusion(s): A prospective, randomized, blinded study demonstrates superior cleft lip repair learning through digital simulation compared to textbook. Learners subjectively found digital simulation to be the superior educational medium. The cleft and craniofacial society should strongly consider investment into digital media platforms to teach future cleft surgeons

Background/Purpose: Early LeFort III (LFIII) surgery or LFIII distraction involve osteotomies and disjunction in the region of the maxillary tuberosity in proximity to the maxillary posterior tooth buds. The purpose of this study was to determine the effect of early LFIII advancement and/or distraction on survival of the maxillary posterior permanent dentition. Methods/Description: A retrospective review of patients with syndromic craniosynostosis treated by early LFIII surgery and distraction was conducted. Of 225 syndromic craniosynostosis patients enrolled between 1973 and 2006, a total of 50 patients satisfied the inclusion criteria: 1) surgical intervention prior to age 8 years; 2) two panoramic radiographs, one prior to surgery and one in adolescence; 3) no apparent abnormalities in the position of permanent tooth buds. Of the 50 patients, 25 underwent LFIII surgery and 25 underwent midface distraction (M = 21, F = 29, average age at time of surgery = 5 +/- 1.1 years with diagnoses of Crouzon (20), Apert (17) and Pfeiffer (13), syndromes). Panoramic radiographs presurgically (T1) and postsurgically (T2) were inspected by a trained observer. The tooth buds were classified as being present (P), displaced (D), impacted (I), ankylosed (ANK), extracted (E), or absent (A). SPSS software was used to carry out chi-squared analysis and Fisher exact test.
Result(s): In the LFIII surgery group, 94% of maxillary second molars (D = 16%, I = 8%, E = 6%, A = 64%) and 28% of maxillary first molars (D = 18%, I = 4%, ANK = 2%, E = 2%, A = 2%) experienced a disturbance in eruption. Of the displaced second molars, 75% were located in the maxillary sinus and 25% in the maxillary tuberosity. Of the displaced first molars, 78% were located in the maxillary sinus and 22% in the maxillary tuberosity. In the distraction group, 80% of maxillary second molars (D = 38%, ANK = 4%, E = 14%, A = 24%) and 18% of maxillary first molars (D = 10%, I = 2%, E = 2%, A = 4%) experienced a disturbance in eruption. Of the displaced second molars, 37% were located in the maxillary sinus and 63% in the maxillary tuberosity. Of the displaced first molars, 100% were located in the maxillary tuberosity. Traditional LFIII osteotomy was significantly more likely to result in an adverse event for maxillary second molars compared to distraction (chi² = 4.33, P = .037).
Conclusion(s): The eruption of maxillary second molars had a high incidence of disruption following early LFIII intervention, with traditional LFIII surgery having greater negative consequences for the maxillary second molars compared to distraction. The maxillary first molars show significantly less disruption during early LFIII intervention with no significant differences noted between surgical procedures. Furthermore, a common disruption seen postsurgically is the displacement of the maxillary second molar tooth buds into the maxillary sinus, leading to the question if presurgical planning should include extraction/enucleation of the second molar tooth buds to avoid this sequela