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Highlights: • Complete unilateral cleft lip influences not only the aesthetics of the face but also the functionality of the lip, nose, and upper jaw (maxilla). • The surgery aims to establish a symmetrical, functional, and visually appealing contour of the lip, vermilion border, and nasal structure. • The modified rotation-advancement flap represents a valuable approach for complete unilateral cleft lip repair surgery. ABSTRACT Introduction: Unilateral cleft lip is a common congenital anomaly affecting the upper lip and nose, impacting both aesthetics and function. Advances in surgical techniques have enhanced cleft lip repair, with the rotation-advancement flap being a notable method. This study examines the outcomes of a modified Millard’s rotation-advancement flap technique, developed and refined over 14 years. Case Illustration: Between September 2023 and February 2024, four patients with complete unilateral cleft lip and associated nasal deformity were treated at RSPAL Dr. Ramelan Hospital. Each patient underwent cleft lip repair using the modified rotation-advancement flap technique. Case Illustration: Four patients presented with complete unilateral cleft lip with nose deformity came to RSPAL Dr. Ramelan Hospital between September 2023 and February 2024, We performed cleft lip surgery using the modified rotation-advancement flap for each patient. Discussion: Surgical outcomes showed excellent symmetry, proper vermilion border alignment, and minimal scarring. Complications were rare, with no instances of wound dehiscence or infection. The study discusses the aesthetic and functional improvements achieved with this technique, underscoring its effectiveness in treating complete unilateral cleft lip and enhancing patient quality of life. Conclusion: The Modified Rotation-Advancement Flap technique provides a valuable approach for unilateral cleft lip repair, yielding satisfactory aesthetic and functional results. Further research with long-term follow-up and larger sample sizes is needed to confirm its efficacy and refine the technique.

Cleft lip re-repair is a procedure frequently endorsed to enhance a compromised nasolabial appearance. However, the actual effect of such revision surgery on the nasolabial appearance has scarcely been studied. Therefore, the aim of this study was to critically review surgical outcomes of patients that underwent surgical re-do of their cleft lip, using well-validated objective and subjective methods and standardised outcome measures. 20 patients with at least 6 months follow-up after cleft lip re-repair were assessed. Standardised pre- and postoperative photographs were analysed. The objective assessment was carried out using the SymNose-software. Furthermore, a subjective evaluation of the nasolabial area was conducted by ten examiners who rated seven parameters using a Likert-scale ranging from 1to5. The objective evaluation showed substantial improvement regarding symmetry values. Significant postoperative decrease in labial asymmetry from 26.42% (±8.13) to 18.77% (±6.28) (p < 0.001) and upper lip asymmetry in relation to the facial midline (26.91% (±8.03) vs. 18.27% (±5.17) (p < 0.001)) was observed. Similar results were corroborated in the subjective analysis. Differences regarding the ratings were detected considering the examiners' professional background and level of expertise. Cleft re-repair was found to significantly improve upper lip symmetry and lead to a more harmonious nasolabial appearance. [ABSTRACT FROM AUTHOR]

Background: Alveolar bone grafting (ABG) using iliac crest bone graft (ICBG) is the best practice for children with complete cleft lip and palate. With the advent of recombinant human bone morphogenetic protein (rhBMP-2) and demineralized bone matrix (DBM), excellent results can be achieved while avoiding donor-site morbidity. This study aimed to determine critical-size defects by analyzing graft failure rates for ICBG and rhBMP-2/DBM to guide surgeons performing ABG., Methods: A retrospective review was conducted evaluating patients who underwent ABG from 2016 through 2022. Patients with preoperative and postoperative cone beam computed tomography (CBCT) imaging were included. Volumetric defect sizes were calculated using preoperative imaging. Graft success criteria were based on both clinical and radiographic outcomes. Logistic regressions analyzed graft failure rates to identify an optimal cutoff, which defined the critical-size defect., Results: A total of 93 patients were included. Bone graft cohorts included ICBG ( n = 30) and rhBMP-2/DBM ( n = 63). The critical-size defects were calculated to be 810 mm 3 and 885 mm 3 for ICBG and rhBMP-2/DBM, respectively. There were significantly higher graft failure rates beyond the critical size compared with below for both ICBG (71.4% versus 0.0%; P < 0.001) and rhBMP-2/DBM (65.0% versus 14.0%; P < 0.001)., Conclusions: This study identified critical-size defects based on alveolar cleft volume for ICBG or rhBMP-2/DBM with higher graft failure rates beyond the predicted thresholds. Distinct ranges in cleft volume were identified where patients might benefit from each select graft option., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Recreating the philtral ridge and restoring orbicularis oris muscle (OOM) continuity in patients with cleft is a challenging task. The muscle-to-subdermis technique introduces an effective method for achieving the desired philtral ridge reconstruction., Methods: From August of 2015 to July of 2023, a retrospective study was conducted with a follow-up period of at least 6 months. This procedure involved a suture technique using muscle-to-subdermis sutures. Measurements of philtral projection were taken at 2 distinct points: one above Cupid's bow and the other at the midphiltral level. In the comparative analysis of philtral ridges between the cleft and noncleft sides, the root mean square projection value was assessed. In addition, an analysis of the restoration of the OOM included the use of color mapping from the midsagittal plane and covered 7 different points across 3 distinct horizontal planes: below subnasale, at the midphiltral level, and above Cupid's bow., Results: A total of 134 patients were included, with a 37.8-month follow-up (SD 9.4). Philtral side projection was well maintained, measuring -0.36 (0.43) mm, -0.24 (0.49) mm in the classic group versus 0.23 (0.29) mm, 0.20 (0.21) mm in the muscle-to-subdermis group ( P = 0.001). The root mean square projection value was 0.57 (0.46) versus 0.14 (0.046), indicating greater symmetry in the muscle-to-subdermis group, with no difference in sagittal vector analysis of the OOM between normal and cleft sides., Conclusions: A suturing technique using muscle-to-subdermis sutures has shown promising results in philtral projection and dimple formation. This improvement can be attributed to the combined effect of subdermis and fewer muscle sutures., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Cleft type affects speech outcomes, but exact relationships remain unclear as outcome measures vary. The primary aim was to investigate the relationship between cleft type and speech outcome using different measures in 4-to-6-year-olds with non-syndromic clefts. Secondary aims were to explore the relationships between (i) speech measures used; and (ii) parent perception of speech intelligibility and listener familiarity. Twenty-two pre-schoolers with clefts, plus one parent for each child, were recruited through a hospital outpatient clinic. Children with cleft lip and palate (CLP; n  = 11) and those with cleft palate only (CP; n  = 11), matched on age and time of palate repair, were compared on Percentage Consonants Correct (PCC), clinician-reported speech intelligibility, and parent rating on the Intelligibility-in-Context Scale (ICS). Children with CLP had significantly lower PCC scores than children with CP ( p = .020), but had no significant differences in their clinician- or parent-reported speech intelligibility. Clinician-reported speech intelligibility correlated significantly with both PCC ( τ  = .594, p  < 0.01) and ICS ( τ = .424, p  = 0.009). No significant correlation was found between PCC and ICS ( τ =.197, p  = 0.113). Overall, parents rated their child's intelligibility higher for familiar compared to unfamiliar communication partners ( τ  = 2.325, p  = 0.001, r  = .76). Cleft type is crucial for intervention planning when objective measures are employed. Speech outcomes should be evaluated at impairment, activity, and participation levels, and by different communication partners, to comprehensively evaluate communicative effectiveness.

Pre- and postoperative photos to assess results are widely used in plastic and reconstructive surgery, for instance, in patients with cleft lip and palate (CL/P). Evaluations are often performed by assessment panels by viewing the photos. However, these are prone to be subjective. Measurements of soft tissues in photos could be an alternative method but have not been widely used so far. Some patients with CL/P develop a retrognathic maxilla in adolescence, with ensuing Class III malocclusion. In severe cases, distraction osteogenesis (DO) of the maxilla may be indicated. The effect of DO on the facial soft tissues is sparsely reported, perhaps due to the rare procedure. The primary aim of the present study is to provide a reliable and objective method of measuring soft tissue profiles in two-dimensional digital photos. Furthermore, the study aims at assessing changes in soft tissues following DO. Fourteen patients who had undergone DO at our unit were recruited. Preoperative and postoperative photos were identified, and long-term follow-up photos were taken. Three raters performed measurements of four angles and two distances. Inter- and intra-rater reliability and soft tissue changes were analyzed statistically. Inter- and intra-rater reliability was high overall for most variables. Two angles related to facial convexity changed significantly. So did the upper lip height. Soft tissues can be measured with a high degree of accuracy, but further evaluation of the method is necessary. DO causes a favorable increase in facial convexity, and an increased upper lip height.

Dynamic assessment (DA) is a new approach to evaluating speech and language disorders, focusing on the learning process over static abilities. It involves a test-teach-retest format and uses the mediated learning experience (MLE) to measure a child's modifiability through intervention efforts. This method is especially relevant for children with cleft lip and palate (CLP). A study on DA in CLP aims to demonstrate its effectiveness in creating personalised intervention plans. The study involved a child with a history of repaired CLP presenting with misarticulation and hypernasality. Over five 45-min sessions of MLE teletherapy with a speech-language pathologist, the child's modifiability across speech errors was observed. The results showed varying levels of modifiability, emphasising the importance of identifying and using a child's learning potential in speech sound production., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: To explore the surgical methods and treatment outcomes of nasal endoscopic surgery for nasal deformity secondary to unilateral cleft lip and palate, combined with nasal septal deviation, using nasal septal cartilage and bone. Methods: Eleven patients who underwent surgical treatment for unilateral cleft lip and palate secondary to nasal deformity in the Department of Otorhinolaryngology, Head and Neck Surgery, Linyi People's Hospital, Shandong Second Medical University, from March 2021 to March 2023, were retrospectively analyzed. The cohort included 8 males and 3 females, aged (22.0±8.4) years (range: 17 to 35 years). Preoperatively, all of them underwent CT scanning and three-dimensional reconstruction of the nasal bones and sinuses to evaluate the size of the nasal septal cartilage and the design of the material to be taken, and to assess the degree of nasal deformity. During the operation, an open "V"-shaped incision was made through the nasal columella, and part of the septal bone and cartilage were removed under direct nasal endoscopic visualization. The septal cartilage and bony structures were used to correct the nasal deformity, and a nasal brace was used as an intraoperative support for the reconstruction of the nasal cartilage, which was then worn for 1 month after the operation to maintain a stable nasal shape. A visual analog scale (VAS) was used before and after surgery to assess the patient's satisfaction with the nasal shape and the degree of nasal ventilation. Corresponding data on both sides of the external nose were measured, including nasal tip height, nostril height, nostril width, nasal base width, and nasal columella inclination, to assess the symmetry of the external nose objectively. SPSS 22.0 software was used for statistical analysis to evaluate the surgical results. Results: The surgical incisions of all 11 patients healed at stage Ⅰ. At 6-24 months of postoperative follow-up, nasal symmetry was restored, and the nostrils were equal in size. The difference in symmetry indexes before and after the surgery was statistically significant. The t value for nasal tip height, the nostril height, the nostril width, the nasal base width, and the nasal columellar inclination were 4.21, 2.26, 3.38, 3.65, and 2.36, respectively (all P <0.05). Postoperative incision scarring was not obvious, and patients were satisfied with the nasal appearance [VAS score (9.14±0.48) points vs (3.45±1.23) points, t =14.29, P <0.001], and nasal ventilation was significantly improved [VAS score (9.32±1.24) points vs (4.61±0.85) points, t =10.39, P <0.001]. Conclusion: Nasal endoscopic surgery using septal cartilage and bone to treat nasal deformity secondary to unilateral cleft lip and palate, combined with deviated septum, can simultaneously improve the patients' nasal shape and nasal ventilation, yielding good clinical outcomes.

Median craniofacial hypoplasia is characterized by tissue deficiency of the midline facial structures and/or brain. Patients can present with a wide variety of facial differences that may or may not require operative intervention. Common reconstructive procedures include cleft lip and/or palate repair, rhinoplasty, and orthognathic surgery, among others. Surgical needs can vary greatly among patients and an individualized management plan is critical. In this paper, the authors present a case series of 3 patients with different severities of median craniofacial hypoplasia, including a discussion of their surgical procedures and the reconstructive principles used to guide their management. The authors also present a general algorithm for the surgical management of median craniofacial hypoplasia, which considers each patient's unique medical and surgical circumstances., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Analyze contributing factors toward satisfaction after cleft lip and palate treatments in Senyum Bali Foundation. Qualitative case study, an interview with a semi-structured question from February to April 2023 by purposive sampling informants including parents, foundation staff, and plastic surgeon. Unsatisfying nose and teeth appearance due imperfect effects after surgery and requirement of more procedures. Mini model theory study that includes the appearance of the face and lips; speech and hearing; the functions of feeding, masticatory, breathing; psychosocial, quality of life, treatment cost-effectiveness, funding, health services, physician, implementing cultural contexts, surgical outcomes, and parents' feedback., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

To describe the long-term treatment course of bone-anchored maxillary protraction (BAMP) and evaluate orthognathic surgical indications after BAMP., Retrospective case series., Craniofacial/Cleft Palate Program at the Orthopaedic Institute for Children in Los Angeles, CA., Twelve male patients with cleft palate (CP), unilateral cleft lip and palate (UCLP), or bilateral cleft lip and palate (BCLP) and Class III malocclusion treated with BAMP (mean age: 11.4 ± 2.6 years) were included., BAMP treatment was performed by placement of bone-anchored maxillary and mandibular plates connected with intraoral Class III dental elastics or maxillary plates connected to a facemask., We retrospectively assessed BAMP treatment variables, including age at surgery, revision surgeries, and treatment duration. The primary goal was correction to class I occlusion., Twelve patients underwent BAMP treatment for an average of 4.4 ± 2.4 years. Two patients were corrected to class I occlusion at the time of this report. Le Fort I advancement was no longer required in two patients (16.7%), it was required for nine patients (75.0%) and was completed for one patient following BAMP treatment (8.3%)., This preliminary report demonstrated that BAMP treatment may be associated with a minimal reduction in the requirement for Le Fort I advancement at skeletal maturity. Future studies with larger sample sizes are necessary to confirm this association., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. JCL is a medical education consultant for Stryker.

Objective: Objective measurement of pre-operative severity is important to optimize evidence-based practices given that the wide spectrum of presentation likely influences outcomes. The purpose of this study was to determine the correlation of objective measures of form with a subjective standard of cleft severity., Design: 3D images were ranked according to severity of nasal deformity by 7 cleft surgeons so that the mean rank could be used as the severity standard., Patients: 45 patients with unilateral cleft lip and 5 normal control subjects., Interventions: Each image was assessed using traditional anthropometric analysis, 3D landmark displacements, and shape-based analysis to produce 81 indices for each subject., Main Outcome: The correlation of objective measurements with the clinical severity standard., Results: Lateral deviation of subnasale from midline was the best predictor of severity (0.86). Other strongly-correlated anthropometric measurements included columellar angle, nostril width ratio, and lateral lip height ratio (0.72, 0.80, 0.79). Almost all shape-based measurements had tight correlation with the severity standard, however, dorsum deviation and point difference nasolabial symmetry were the most predictive (0.84, 0.82)., Conclusions: Quantitative measures of severity transcend cleft type and can be used to grade clinical severity. Lateral deviation of subnasale was the best measure of severity and may be used as a surrogate of uncoupled premaxillary growth; it should be recorded as an index of pre-operative severity with every cleft lip repair. The correlation of other measures evaluated clarify treatment priorities and could potentially be used to grade outcomes., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To compare patient-reported outcomes (PROs) in internationally adopted patients with cleft lip and palate to those in non-adopted peers., Design: Cross-sectional study., Setting: Multidisciplinary cleft team at tertiary care hospital., Patients: Patients aged ≥ 8 with cleft lip and palate attending routine cleft team evaluations September 2021 - September 2022., Main Outcome Measure: CLEFT-Q PRO scores., Results: Sixty-four internationally adopted patients and 113 non-adopted patients with a mean age of 13 years were included. Compared to non-adopted peers, adopted patients demonstrated worse satisfaction with face appearance (mean 59 vs. 66, p  = .044), speech function (mean 69 vs. 78, p  = .005), and speech distress (mean 80 vs. 84, p  = .032). No significant differences were observed on the nose, nostrils, teeth, lips, lip scar, jaws, psychological function, or social function scales ( p  > .05). Objective clinical evaluation corroborated these findings, with adopted patients demonstrating worse Pittsburgh Weighted Speech scores (mean 3.0 vs 1.9, p  = .027) and greater incidence of articulation errors (64% vs 46%, p = .021). No significant differences were observed in rates of mood, anxiety, or behavior concerns identified on psychosocial assessment ( p = .764). Among adopted patients, undergoing palatoplasty prior to adoption was associated with worse satisfaction with speech, appearance, school, and social function ( p  < .05)., Conclusions: Patient-reported outcomes among internationally adopted adolescents and young adults with cleft lip and palate show slightly lower satisfaction with facial appearance and speech but otherwise demonstrate similar results to non-adopted peers on most appearance and psychosocial measures. PRO data correlated well with objective speech assessment and did not portend worse psychosocial function., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The present cross-sectional study was undertaken to evaluate the periodontal and microbiological parameters in patients with surgically repaired unilateral cleft lip and palate (UCLP) undergoing orthodontic correction in comparison to patients without any cleft or orthodontic treatment., Methods: A total of 120 patients, out of initial 148 patients, between the age group 6 and 18 years were enrolled and divided into four groups with 30 patients each: non-cleft patients without orthodontic treatment in Group 1, non-cleft patients undergoing fixed orthodontic treatment in Group 2, patients with UCLP without any orthodontic treatment in Group 3, and patients with UCLP undergoing fixed orthodontic treatment in Group 4. Periodontal parameters including plaque index (PI), gingival index (GI), gingival bleeding index (GBI), community periodontal index of treatment needs (CPITN) index, pocket probing depth (PD), and tooth mobility were measured in all the groups. The subgingival plaque samples of all the patients were subjected to microbial evaluation using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF-MS) for clinical diagnosis., Results: The periodontal parameters were significantly raised in Group 4, followed by Group 3 and Group 2 in comparison to Group 1 (p < 0.01), thereby suggesting poor periodontal health in patients with UCLP undergoing orthodontic treatment. Statistically significant differences (p < 0.01) in counts of micro-organisms among the groups were observed for P. gingivalis, P. intermedia, Veillonella, and Capnocytophaga, with the highest proportions in Group 4, indicating a deteriorating oral health in these patients., Conclusion: Poor periodontal and microbial health in patients with UCLP undergoing orthodontic treatment indicates a need for reinforcement of oral hygiene practices among these patients., Plain Language Summary: Patients with clefts of lip extending to the palate are prone to a number of oral health issues and often undergo treatment with fixed braces for teeth alignment. This may compromise the oral hygiene practice and alter the microbial flora of the oral cavity. The present study evaluated the oral health and microbial flora in patients with cleft lip and palate undergoing treatment with fixed braces in comparison to patients without any cleft or any treatment for teeth alignment. A total of 120 patients were divided into four groups. Group 1 had normal healthy individuals without any cleft or treatment for teeth alignment; Group 2 had individuals without any cleft but undergoing treatment with fixed braces for teeth alignment; Group 3 had patients with cleft lip and palate but no treatment for teeth alignment, whereas the patients undergoing treatment with fixed braces were included in Group 4. All the groups were checked for indices assessing the oral health, and microbial evaluation was also done. Patients with cleft lip and palate undergoing treatment with fixed braces were found to have poor oral health along with elevated microbial counts, signifying a need for improving oral hygiene practices in these patients., (© 2024 American Academy of Periodontology.)

This retrospective study aimed to investigate the impact of orthognathic surgery with maxillary advancement (MA) on the velopharyngeal function (VF) in individuals with cleft lip and palate (CLP). The study included 651 patients with repaired CLP, both sexes, aged over 18 years who underwent MA alone or in combination with nasal procedures and/or mandibular osteotomy, operated between 2000 and 2019. The main outcome measures were nasalance (nasal text-NT and oral text-OT) and velopharyngeal orifice area measurement (VA), determined by nasometry and pressure-flow technique, respectively. Preoperatively, mean nasalance scores for NT and OT indicated normality, and VA demonstrated borderline-inadequate velopharyngeal closure in all patients. Following MA, a significant increase in nasalance scores for NT and OT occurred (p < 0.001), revealing hypernasality in those undergoing MA combined with nasal procedure (MAN, N = 191), bimaxillary orthognathic surgery with nasal procedure (BON, N = 227) and bimaxillary orthognathic surgery (BO, N = 151). Conversely, nasalance scores remained within the normal range for those undergoing isolated maxillary advancement (IMA, N = 82). VA exhibited a significant increase leading to the classification of VF as inadequate in the BON and MAN groups. Overall, MA contributed to VF deterioration, resulting in the appearance of hypernasality and increased VA, particularly when combined with nasal procedures., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Secondary alveolar bone grafting (SABG) during mixed dentition is the standard of care for patients with complete cleft of lip and palate. Early SABG (E-SABG; 4 to 7 y) occurs before the eruption of lateral incisors, whereas late SABG (L-SABG; 8 to 12 y) occurs before the eruption of maxillary permanent canines. This study compares outcomes of E-SABG versus L-SABG among patients with unilateral cleft of lip and palate (UCLP). A prospective cohort study was conducted evaluating nonsyndromic patients with UCLP who underwent SABG from April 2018 to January 2020, 48 consecutive patients with UCLP were included. Preoperative and 6 to 10-month postoperative cone beam computed tomography imaging were obtained to assess graft and periodontal outcomes. Among 48 patients with UCLP, of which 21 were in the E-SABG group (6.9 ± 1.1 y), and 28 were in the L-SABG cohort (10.4 ± 1.6 y). The initial alveolar cleft width is significantly smaller in the E-SABG cohort compared with the L-SABG cohort (5.1 ± 1.5 versus 6.5 ± 2.0 mm, P = 0.008). Compared with the L-SABG cohort, the E-SABG cohort had higher rates of bony bridge formation (77.3% versus 65.4%, P = 0.367), thicker bony bridges (5.7 ± 2.1 versus 3.9 ± 1.5 mm, P = 0.004), lower Bergland scores [1.5 (interquartile range: 1 to 2) versus 2.25 (interquartile range: 1.5 to 3.5), P = 0.026], and greater alveolar bone coverage (79.8 ± 16.7% versus 67.9 ± 18.1%, 0.024). The authors' findings suggest that patients who undergo E-SABG at ∼7 years may have better graft outcomes and benefits to the periodontal bone support on cleft-adjacent incisor compared with L-SABG at 11 years., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Objective: To assess the factors influencing the type and timing of Alveolar Bone Grafting (ABG) among cleft centers throughout India. To examine the decision-making criteria for orthodontic treatment and the timing of ABG., Design: Cross sectional survey., Method: This survey was based on a convenience-based sample selected from cleft teams across India. The survey was formulated using the SurveyMonkey platform and emailed to 40 cleft teams. The survey included questions on demographics, timing, surgical protocol, orthodontic protocol, radiograph prescription rate, assessment methods for the success of ABG and three scenarios for evaluating the timing of the bone graft. The Chi-squared test was performed to evaluate the difference in opinion between specialists. The inter-examiner reliability was assessed using Kappa statistics., Results: Thirty-five units completed the questionnaire. Most units operate with 1-2 surgeons, with 42.9% of them treating cleft patients for under 5 years. Only 11.4% of centres routinely advised oblique occlusal radiographs for post-surgery evaluation, and 31.4% prescribed CBCT. However, 40% of cleft teams did not perform audits to evaluate the success of ABG, and less than 50% advised radiographs six months post-surgery. Around 26% of centres do not routinely provide orthodontic treatment pre-ABG. The inter-examiner reliability for case scenarios showed poor agreement between the clinicians., Conclusion: The survey showed a serious lack of consensus in the ABG treatment among cleft teams in India and emphasises the need for standardised protocols for the treatment of children with cleft palate. There is an urgent need to develop core outcome set in cleft., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Geopolitical conflicts in the Middle East have led to mass migrations, with Turkey becoming a major host country. This influx has strained the health care system, particularly regarding specialized care for conditions like cleft lip and palate (CLP). Timely intervention is crucial for optimal outcomes, but cultural, socioeconomic, and logistical barriers often cause delays, impacting physical, functional, and psychosocial development., Methods: This retrospective study analyzed 72 immigrant pediatric CLP patients treated in Turkey between 2012 and 2022. Data on demographics, medical history, surgical interventions, complications, and treatment delays were collected. Surgical timing was compared with American Cleft Palate Craniofacial Association guidelines, and the impact of socioeconomic status on delays was assessed., Results: Seventy-two patients underwent a total of 91 surgical interventions, including 29 cleft lip repairs, 22 cleft palate repairs, 6 pharyngeal flaps, 15 fistula closures, 8 corrections of secondary lip scars and whistling deformities, and 11 alveolar bone graftings. A majority (73.6%) had poor socioeconomic status. The average delays for cleft lip, cleft palate, and alveolar bone grafting surgeries were 5.3±4, 7.3±6.1, and 34.1±23.5 months, respectively, and were significantly longer for patients with poor socioeconomic status ( P =0.00502, 0.030741, and 0.041878). The average delay for pharyngeal flap surgery, performed in patients with poor socioeconomic status (except for one), was 43.7±14.1 months., Conclusions: This study highlights the challenges and disparities in CLP care for immigrant children in Turkey due to geopolitical conflict. While surgical complication rates are similar to established data, delays in treatment, especially among those with lower socioeconomic status, are a significant concern. The findings emphasize the need for comprehensive, culturally sensitive care and systemic interventions to improve access and outcomes for this vulnerable population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Objective: To perform a systematic review and meta-analysis to determine if day case cleft lip surgery has an impact on complications and 30-day readmission rate., Design: A systematic review was conducted using PRISMA guidelines. Databases included; PubMed, Science Direct, Ovid and Cochrane. Search terms; "Day Case", "Day Care", "outpatient", "Ambulatory" AND "Cleft", "Cleft Lip". Meta-analysis was performed using RevMan 5., Setting: Eligible study types included; randomised controlled trials, observational studies (prospective and retrospective) and case series., Patients/participants: Paediatric patients undergoing primary cleft lip repair., Interventions: Day case surgery versus inpatient admission post-operative., Main Outcome Measure(s): Primary outcome measure: Primary cleft lip repair performed as a day case in paediatric patients. Secondary outcome measures: 1. Complication rates and 30-day re-admission to hospital rate. 2. Patient suitability for day case surgery., Results: Ten papers with 13 804 patients undergoing primary cleft lip repair were included, 28% were discharged on the day of surgery (Range 17%-81%). There was no significant difference in complication rate between the inpatient and day case cohorts. There was a significant reduction in 30-day readmission rates in the day case cohort., Conclusions: This meta-analysis indicates there is no difference in complication rates for patients discharged on the day of surgery compared to those admitted overnight. Complications encountered were infrequent, non-life threatening and often occurred more than 24 h following discharge. There was an observed reduction in 30-day readmission rates for day-case patients. This is likely to represent a variation in baseline characteristics which deemed them suitable for day case surgery pre-operatively., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The surgical requirement for cleft lip and palate repair remains unmet in many developing areas of the world, including remote regions of Ghana. This article reviews the utilization of Internet education and online consultation for cleft lip and palate surgical training in Sunyani Regional Hospital (SRH), Ghana., Methods: The cleft lip and palate treatment was promoted to patients in remote areas of Sunyani, Ghana region, through a charitable outreach program. These basic designs and settings were managed by local participants such as doctors, residents, nurses, and staff in SRH, Ghana., Results: From November 2014 to December 2020, the authors collaborated in surgical treatment for 84 cases that were diagnosed with unilateral cleft lip, bilateral cleft lip, hard and soft palate cleft, and microstomia. The type of surgery has varied and has included cheiloplasty, palatoplasty, and others. The average scores of esthetic outcome evaluation were nasal form=2.4, symmetry of the nose=2.9, and vermillion border=2.9. Through the program, the surgeons and residents became significantly more proficient at cleft lip and palate surgery. The seminar topics have covered essential and sustainable topics based on SRH's current needs and showed the effectiveness in the current coronavirus disease-19 pandemic situation., Conclusions: The shortage of orofacial cleft surgeons working in rural areas like Sunyani, Ghana, remains an obstacle that poses a challenge to any effort to improve health care quality in these rural communities. Sustainable remote education is essential for the training of local cleft surgeons to fill this local need; our collaborative and charitable program could be a recommended education design for cleft surgeons and institutes for their sustainable education., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Objective: Craniofacial clefts, characterized by congenital disruptions in the development of facial and cranial tissues, often present alongside orbital hypertelorism (ORH), an abnormal increase in the interorbital distance. These conditions pose significant challenges in craniofacial surgery due to the complex anatomical and functional considerations involved. This single-center cohort study retrospectively analyzed 22 patients diagnosed with craniofacial cleft syndromes and ORH who were treated at the Craniofacial Centre, Fatima Plastic and Reconstructive Surgery Hospital between July 2016 and October 2023., Methods: This study outlines the preoperative evaluations, surgical interventions, and postoperative outcomes of these cases. Surgical techniques varied according to the severity and type of deformity, guided by Tessier's classification system. Procedures included spectacle osteotomy, box osteotomy, and facial bipartition osteotomy, with each approach tailored to address the unique anatomical challenges presented by ORH and associated craniofacial anomalies., Results: There was a 9% incidence of postoperative infections and a 22.7% incidence of CSF leakage, with a subset of these leading to meningitis. These complications underscore the complexity of managing craniofacial clefts and ORH, highlighting the necessity for meticulous surgical planning and postoperative care., Conclusions: Despite the challenges, the study demonstrates that individualized, protocol-driven surgical interventions can achieve significant aesthetic and functional improvements in patients with these congenital anomalies.

Given the overlap in specialties performing secondary correction of velopharyngeal incompetence (VPI), the present study investigated the specialty distribution for surgical providers of cleft care from 2004 to 2021. Data were obtained from 45 hospitals from 2004 to 2021 through the Pediatric Health Information System database. Cases of secondary surgical management of VPI were retrieved, identifying the year of surgery and specialty of the providing surgeon. A total of 7090 procedures were included in this study, of which 36.0% were secondary palatoplasty/lengthening, 34.1% were sphincter pharyngoplasty, and 29.8% were pharyngeal flap. Secondary management of VPI was performed by plastic surgeons (67%), otolaryngologists (31%), and oral and maxillofacial surgeons (OMFS, 12%). Palatal revision and/or lengthening procedures were the most common secondary procedure performed by plastic surgeons (42%) and OMFS (64%), whereas sphincter pharyngoplasty was the most common procedure performed by otolaryngologists (55%; P <0.001). The proportion of sphincter pharyngoplasty performed by plastic surgeons significantly decreased from 2017-2021 ( P <0.05). Plastic surgeons performed most procedures for secondary management of VPI from 2004 to 2021, followed by otolaryngologists and OMFS. The type of procedure selected for secondary management of VPI differed significantly between the provider's specialty, with otolaryngologists more likely to perform sphincter pharyngoplasty., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Background: There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plate fixation. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate and determine stability differences between patient-specific and stock plates., Methods: Consecutive patients with cleft lip and palate who underwent isolated LFI by one surgeon (B.L.P.) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (nasion to A point) and horizontal planes (basion to A point) at 1 year after LFI using 3-dimensional cone beam computed tomography. Statistical analysis included independent samples t , Mann-Whitney U , Fisher exact, and chi-square tests. Values of P < 0.05 were significant., Results: The sample included 63 subjects; 23 in the patient-specific group (36.5%) and 40 in the stock group (63.5%). Groups were comparable by sex, race, age at surgery, cleft type, presence of pharyngeal flap, and magnitude of horizontal movement ( P > 0.136 for all). Subjects who underwent patient-specific plate fixation were less likely to have greater than or equal to 1-mm change at 1 year in the horizontal (4.3% versus 50.0%; P < 0.001) and vertical planes (4.3% versus 65.0%; P < 0.001) compared with stock plates. For patients who had greater than 10-mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific plates, 0.105 ± 0.317 mm; stock plates, 1.888 ± 1.125 mm; P = 0.003)., Conclusion: Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after 1 year than stock plates., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Restrictive policies on termination of pregnancy (TOP) may lead to more infants with congenital abnormalities. This study aimed to assess the association between statewide enactment of TOP restriction and cleft lip and/or palate (CL/P) incidence, and to identify mediating demographic characteristics., Methods: The authors examined state-specific trends in CL/P incidence in infants before and after implementation of laws restricting TOP in Michigan compared with New York, where no such laws were passed. The percentage change of CL/P incidence per 1000 live births in postpolicy years (2012 to 2015) compared with prepolicy years (2005 to 2011) was compared, with adjustments for confounding factors in multivariate models., Results: The incidence of CL/P changed significantly in Michigan (19.1%) compared with New York (-7.31%). Adjusting for sex, race/ethnicity, median household income level, and expected payer, the adjusted percentage difference between Michigan and New York was 53.3% ( P < 0.001). Stratification by race/ethnicity and median household income demonstrated that changes were only significant among Black (139%; P < 0.001) and Hispanic (125%; P = 0.045) patients and among those from the lowest (50.3%; P < 0.001) and second lowest (40.1%; P = 0.01) income quartiles., Conclusion: The authors' research, combined with the recent Supreme Court decision in Dobbs v Jackson Women's Health Organization allowing states to place further restrictions on TOP, suggests that more infants in the future will be born in need of treatment for CL/P., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Cases of severe bilateral Tessier 4 cleft with unilateral Tessier 3 cleft and additional involvement of the amniotic band syndrome are rarer. This case reports a very rare case of ABS with severe facial cleft. Postoperative progress was satisfactory and the patient achieved functional recovery. The patient underwent several miner reconstructive surgeries and appropriate surgical treatment is necessary to restore the patient's social life., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To define "high osteotomy" and determine the feasibility of performing this procedure., Design: Single institution, retrospective review., Setting: Academic tertiary referral hospital., Patients, Participants: 34 skeletally mature, nonsyndromic patients with unilateral CLP who underwent Le Fort I osteotomy between 2013 and 2020. Patients with cone-beam computed tomography (CBCT) scans completed both pre- (T1) and post-operatively (T2) were included. Patients with bilateral clefts and rhinoplasty prior to post-operative imaging were excluded., Interventions: Single jaw one-piece Le Fort I advancement surgery., Main Outcome Measures: Measurements of the superior ala and inferior turbinates were taken from the post-operative CBCT., Results: The sample included 26 males and 8 females, 12 right- and 22 left-sided clefts. The inferior turbinates are above the superior alar crease at a rate of 73.53% and 76.48% on the cleft and non-cleft sides, respectively. One (2.9%) osteotomy cut was above the level of the cleft superior alar crease, and no cuts were above the level of the non-cleft superior ala. On average, the superior ala was 2.63 mm below the inferior turbinates. The average vertical distances from the superior alar crease and the inferior turbinates to the base of the non-cleft side pyriform aperture were 12.17 mm (95% CI 4.00-20.34) and 14.80 mm (95% CI 4.61-24.98), respectively. To complete a "high osteotomy," with 95% confidence, the cut should be 20.36 mm from the base of the pyriform aperture., Conclusions: A "high" osteotomy is not consistently possible due to the relationship between the superior alar crease and the inferior turbinate., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Any impediment to the development of midline structures i.e. hypothalamus, pituitary and oral cavity may cause anatomical and functional issues. We aimed to determine the association of endocrine disorders with anatomic defects of midline structures i.e. cleft types and syndromes, as well as their impact on postoperative intensive care unit (ICU) admissions and complications., Methods: A total of 6000 patients from the Cleft Lip and/or Palate (CLP) Treatment Center between September 2014 - February 2022 were included. Patients with physical findings or biochemistry that may indicate endocrine disorders were examined by the Division of Pediatric Endocrinology. Data concerning sex, operation age, cleft types, coexisting endocrine disorders, syndromes, echocardiography, postoperative complications as well as postoperative intensive care unit (ICU) admissions were recorded., Results: The study group consisted of 78 patients with endocrine disorders, with a mean follow-up time of 59±7 months. One hundred and nine CLP operations were performed. The most common endocrine disorders coexisting in CLP patients were hypothyroidism (44.8%) and growth hormone (GH) deficiency (14.1%). Of the patients, 29.4% had genetic syndromes. The median age of operation in patients with endocrine disorders was 5 months (Q1-Q3: 4-8 months) for cleft lip and 15 months (Q1-Q3: 12-20 months) for cleft palate repair. Of the patients with CLP and endocrine disorders, 24% required postoperative ICU admission. Age of operation and ICU admission rates were higher compared to the general population of patients with CLP in our center (p<0.01)., Conclusions: Endocrine disorders, particularly hypothyroidism and GH deficiency, are frequent in CLP. Furthermore, our data suggest that endocrine disorders may complicate the postoperative course. Thus, investigation of these problems is crucial for appropriate treatment as well as adopting measures to successfully manage the postoperative course., Competing Interests: The authors declare that there is no conflict of interest.

Background: The purpose of this study was to analysis the nostril symmetry and nasal stability following secondary rhinoplasty performed with either nasal septal cartilage implantation (G1) or simple alar cartilage suspension and internal fixation (G2) in patients with unilateral secondary cleft nasal deformity., Methods: Nostril and alar symmetry were analyzed retrospectively in 13 consecutive patients in G1 and 17 in G2. Assessment of three indexes was first performed using photogrammetric measurements of photographs at pre-operation(T1), 7 days after repair (T2), and at least 6 months after repair (T3). The ratio of the cleft side to the noncleft side for nostril width, nostril height and alar height were used to assess symmetry. Changes in the mean ratios of the cleft side to the noncleft side at three different time points for three parameters were used to assess stability., Results: In both groups, the alar height was improved after operation and remained stable in the follow-up period. The nostril width significantly decreased in G1 and G2, remaining consistent in the follow-up for G1 but increasing in G2. The nostril height significantly increased in G1 and stabilized during the follow-up, while it decreased after operation and remained so throughout the follow-up for G2., Conclusion: Both techniques can maintain stability more than six months after surgery, except for the nostril width with simple alar cartilage suspension and internal fixation technique. The nasal septal cartilage implantation technique may have advantages in improving the nasal symmetry of the nostril width and height., Competing Interests: Declarations. Ethical approval and consent to participate: Ethical approval was obtained from the institutional ethics committee at the West China School of Stomatology, Sichuan University (No: WCHSIRB-ST-2016-164). Written informed consent was taken from each participant or parents/legal guardians for pediatric patients for publication of the data and accompanying images. Consent for publication: All presentations of case reports have consent for publication. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Cleft lip and/or palate (CLP) is the most common orofacial congenital disability, presenting significant medical, psychological, and social challenges. In Pakistan, the incidence of CLP is high, estimated at one in 523 live births, but accurate data are lacking due to the absence of a birth registry. Early diagnosis and intervention are crucial for improving outcomes. This study evaluated the impact of CLP on patients' quality of life in Karachi, comparing pre- and post-surgical phases., Methods: A sequential exploratory quantitative-qualitative mixed-methods study was conducted at two tertiary care hospitals in Karachi. In the quantitative phase, 280 patients with CLP, either awaiting or post-surgery, completed the Oral Health Impact Profile (OHIP-14) questionnaire to assess oral health-related quality of life (OHRQoL). Based on questionnaire responses, 30 participants were purposively selected for in-depth, semi-structured interviews exploring their experiences. Quantitative data were analyzed using SPSS version 25; qualitative data were analyzed thematically., Results: Quantitative findings revealed significant gender disparities in cleft types and correction status; females had a higher prevalence of unilateral cleft lip, while males had more cleft palate cases. Dental and oral health issues significantly affected daily activities, with higher impacts in cleft palate patients. OHRQoL varied by gender, cleft type, and correction status, with those post-surgery reporting poorer OHRQoL. Qualitative analysis identified six themes: Diagnosis and Early Treatment, Challenges and Impact, Postsurgical Experiences, Support Systems, Healthcare Experiences, and Future Perspectives. Inconsistencies in psychological support, accessibility and financial burdens were presented as significant issues. Sentiment analysis highlighted varied emotions, from despair to hope and gratitude., Conclusions: CLP significantly affects patients' quality of life in Karachi across multiple dimensions. Early diagnosis and surgical intervention are essential but often hindered by financial and accessibility issues. Psychological effects, including low self-esteem and social isolation, highlight the need for integrated mental health support. Family and community support are critical for patient resilience. A comprehensive approach addressing medical, psychological, social, and systemic factors is necessary to improve outcomes for individuals with CLP., Competing Interests: Declarations. Ethics approval and consent to participate: The study received ethical approval from the Research and Ethics Committee of Hamdard University Dental Hospital (1245-03-24) dated 07.03.24. Informed consent was obtained from all subjects. For participants under 18, consent was also secured from parents/legal guardian/s. All experiments were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki). Consent for publication: Not applicable. Competing interests: The authors declare that there is potentially no conflict of interest related to the article., (© 2024. The Author(s).)

Introduction: The current gold standard treatment for patients with orofacial clefts is surgical repair of the palatal defect (uranostaphylorrhaphy), which is associated with growth defects and hypoplasia of the maxillofacial structures. This trial aims to evaluate the potential of a bioengineered artificial palate mucosa, created through tissue engineering with autologous stromal and epithelial cells and nanostructured fibrin-agarose biomaterials, to enhance treatment outcomes for patients with unilateral cleft lip and palate., Methods and Analysis: This phase I-IIa clinical trial aims to evaluate the feasibility and biosafety of a procedure involving grafting bioartificial palate mucosa onto the areas of denudated bone in patients undergoing uranostaphylorrhaphy. The control patients will undergo standard surgical treatment. Five patients will be included in the first biosafety phase. In the second phase, 10 patients will be randomly assigned to the intervention or control group (1:1). The intervention group will undergo standard surgical treatment followed by the application of autologous bioartificial palate mucosa. Feasibility will be analysed at the time of surgery. Nine postimplant visits will be scheduled over a 2-year follow-up period, in which local and systemic biosafety will be investigated by determining graft evolution, including signs of necrosis, rejection, inflammation and patient factors. Preliminary signs of efficiency will be explored by sequentially evaluating craniomaxillofacial development, hearing impairment, speech capability and quality of life of the family. The research will be published in journals and posted in the relevant repositories when available., Ethics and Dissemination: This study has been approved by the Committee of Ethics in Research with Medicinal Products (CEIm) and authorised by the Spanish Medicines Agency (AEMPS). The results of this study will be published in peer-reviewed journals., Trial Registration Number: NCT06408337; ClinicalTrials.gov: EuclinicalTrials. eu: 2023-506913-23-00., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To develop a reproducible, reliable clinical index of alveolar bone grafting (ABG) outcome based on the eruption position of the cleft canine tooth and determine the association between eruption position and radiographic outcome at 6 months post-grafting., Methods: Children with complete, non-syndromic, unilateral/bilateral cleft lip and palate in the West of Scotland were identified. Post-ABG radiographic outcome (Kindelan index) and canine eruption position in children with a cleft of the alveolus who had undergone ABG were documented. A Kindelan score was assigned to the 6-month post-bone-graft radiograph. Following canine tooth eruption, four-point clinical index scale (CIS) scores were assigned to maxillary occlusal images taken prior to commencement of definitive orthodontics; 1-canine eruption in alveolar crest, 2-canine eruption buccal to alveolar crest, 3-canine eruption palatal to alveolar crest, and 4-canine impaction. Intra and inter-rater reliability was assessed using Cohen and Fleiss kappa's, respectively. Duration of orthodontics treatment, number of orthodontic clinic visits, and clinical management of the cleft site space were noted., Results: Eighty-three patients representing 98 bone graft sites were identified. CIS scoring intra- and inter-rater reliability was 0.69-0.99 and 0.63-0.75, respectively. CIS score was associated with reduced visits (P = .015), months in orthodontics (P = .009), and likelihood of space closure (P = .006)., Limitations: This is a retrospective study with small numbers but is comparative to other similar studies in the literature., Conclusions: The CIS presented appears to be a reliable index of ABG outcome. It also demonstrates an association with the burden of orthodontic care post-cleft alveolar bone graft., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: Determine the main complications of orthognathic surgery in patients with cleft lip and palate., Methods: PubMed, LILACS, Cochrane, Embase, Scopus, and Google Scholar were systematically reviewed. Studies addressing the complications of orthognathic surgery in patients with cleft lip and palate were included. For the search, the strategy was used with the descriptors extracted from MeSH "Cleft Palate", "Orthognathic Surgery" and "Complications". The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the included studies. Patients of any sex, age, and ethnicity with cleft lip and palate submitted to orthognathic surgery were included in this systematic review. The study followed the PRISMA 2020 standards and was registered in PROSPERO with protocol CRD42020195927., Results: In the initial search, 1090 articles were found and after applying the inclusion and exclusion criteria, eleven studies were selected. The sample consisted of 629 patients who underwent Orthognathic Surgery, with an average age of 21.52 years. The majority of patients (390) presented unilateral transforamen proposals. In total, 150 complications were identified in the included studies, the most frequent being relapse of movement with 77 cases (51.3 %). Other reported, but less frequent, complications were gingival recession with root exposure, premaxillary mobility, intraoperative hemorrhage, fistulas and infection and velopharyngeal impairment. Most included studies did not have a control group, making meta-analysis unfeasible. Seven of the included studies presented a low risk of bias according to the NOS., Conclusions: Orthognathic surgery in cleft patients is a safe procedure, however it presents particularities and more complications when compared to a non-cleft patient. In this study, the most common complication found was the relapse, and the surgeon must be aware of this complication and others, and try to minimize its negative effects on the patient. We strongly recommend further investigations with detailed methodologies, control groups, well-described criteria for reported complications, and comprehensive sample characteristics to provide higher-quality evidence., Competing Interests: Declaration of competing interest None of the authors of the manuscript has any conflict of interest related to this study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Introduction: Vomer flap is a technique to close cleft lip and palate. This technique is a simple procedure that has many benefits. However, the vomer flap's application together with primary lip closure is still questionable., Objective: To find out whether the vomer flap's application in primary cleft lip repair can provide significant benefits., Design: A systematic review was conducted using the PRISMA methodology has been licensed in PROSPERO databases (CRD42023399487)., Setting: A comprehensive search was set out, utilizing eight data sources up to March 2023., Participants: Both cohort studies and randomized control trials regarding the use of vomer flaps performed concurrently with cleft lip repair in children up to six months old., Results: This article involved 8 studies involving 542 patients who met the inclusion criteria, consisting of 6 retrospective cohort studies, 1 RCT study, and 1 prospective cohort study. Vomer flaps provide a reduction in palatal cleft distance of 3-5 mm, a relatively small number of fistulas (0-4%), improvement of velopharyngeal function (nasal tone and nasal emission), maximal development of the maxilla although it is still controversial., Conclusion: The vomer flap's application in primary cleft lip repair provides many advantages, such as reduced palatal and alveolar clefts, decreased risk of oronasal fistula, increased velopharyngeal function, and increased maxillary growth. It is reliable for the management of cleft lip and palate., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Several factors may influence speech outcome and the rate of secondary palatal surgery in patients with cleft palate. The aim of this study was to evaluate different types of intra-velar veloplasty within an otherwise uniform surgical protocol. The impact of cleft width and the surgeon's experience on outcome measurements was examined. This cross-sectional study included 62 individuals with unilateral cleft lip and palate born in 2000-2015. Based on the surgical technique used, they were divided into three groups. The cleft width was measured on dental casts. Blinded speech and language pathologists assessed velopharyngeal function with the composite score for velopharyngeal competence (VPC-Sum) for single words. They rated velopharyngeal function on a three-point scale (VPC-R) in sentences. Target consonants in words were phonetically transcribed. The percentage of correct consonants (PCC) was calculated. Surgical technique was not associated with any outcome. Cleft width was associated with the rate of secondary palatal surgery (OR 1.141, 95% CI 1.021-1.275, p = .020) and velopharyngeal insufficiency when using VPC-R (OR 2.700, 95% CI 1.053-6.919, p = .039) but not when using VPC-Sum (OR 1.985, 95% CI.845-4.662, p = .116). PCC was not associated with cleft width and did not differ between surgical techniques. Radical muscle dissection did not exhibit superiority over intra-velar veloplasty reinforced by the palatopharyngeal muscle. Follow-ups at later ages with larger groups will be necessary to evaluate and compare surgical techniques accurately. Cleft width had a greater impact on the rate of secondary surgery and velopharyngeal function than surgical technique, but neither affected the PCC., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Indonesia is a multicultural Asian country with a high incidence of cleft. This study contextualizes how patients' sociocultural backgrounds hinder cleft management in a diverse nation., Material and Methods: This study involved 202 families of cleft patients attending six tertiary care hospitals in South Sulawesi between 2021 and 2022. A mixed-methods, descriptive cross-sectional study employed semi-structured interviews and focus group discussions. Thematic content analysis was done using Murdock's causal attribution of illness. Knowledge of the treatments and surgery expectations used open coding. We held medical team focus group discussions to validate education on treatments. Cleft management education was thematically analyzed based on Indonesia's Minister of Health Decree., Results: Two hundred-two families and ten medical teams participated. Thematic content analysis revealed common beliefs and factors that hinder medical treatments. The participants were 109 Buginese, 57 Makassarese, 16 Durinese, 8 Luwunese, 8 Torajanese, and 4 Mandarese. 22.3 % were unaware of causation, while 29.2 % attributed it to natural causes. About half of the interviewees believed in supernatural attribution. Even though 40 % of participants knew little about the surgery, they agreed that surgery improves appearance and speech. Medical treatments are delayed due to a lack of treatment knowledge, parents' concerns about surgical safety, and beliefs about causes., Discussion: Indigenous societies in South Sulawesi believe in supernatural causes of cleft. Most had incomplete surgical treatment information. An intensive educational health program about causes, treatments, medical specialists, and treatment goals is warranted to enhance patient compliance with medical treatment, ultimately leading to improved health outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Masson SAS.)

Objectives: Presurgical infant orthopedic appliances, such as presurgical nasoalveolar molding (PNAM) devices, are used to attain optimal conditions for primary repair of the lip and nose (PRoLN) in patients with cleft lip. We aimed to analyze the three-dimensional (3D) outcomes of PNAM using an LED surface scanner., Methods: Fifteen patients with unilateral cleft lip and palate (CLP) were included in this study and treated using a PNAM device. The patients' faces were digitized pre- and post-PNAM using an Artec Space Spider scanner, and the scanned data were analyzed using 3D software (Geomagic Control X and ANSYS SpaceClaim). The columellar angle (CA), nostril curvature (NC) on the affected (NC&#95;A) and unaffected (NC&#95;U) sides, gap of cleft lip (GCL), alar width (AW), and nasal tip angle (NTA) were measured., Results: CA increased significantly by 10.00° and NC&#95;A by 0.030 mm -1 (p < 0.001). GCL decreased by 4.98 mm 2 on average and NC&#95;U by 0.015 mm -1 (p = 0.029 and 0.046, respectively). AW also decreased by approximately 1.22 mm pre- and post-treatment (p = 0.002), and NTA, which shows a lateral profile, decreased by approximately 3.32° (p = 0.002)., Conclusions: This study confirmed the orthopedic benefits of PNAMd treatment through 3D analysis using an LED surface scanner. Further studies involving a larger number of participants are warranted to study the effects of PNAM and analyze longitudinal changes in patients with CLP., Clinical Significance: This study shows that PNAM effectively corrects columellar deviation and nostril shape in patients with unilateral cleft lip, with 3D scanners enhancing primary lip and nose repair outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Deviation and asymmetry relapse after secondary unilateral cleft rhinoplasty with septal extension graft is a common yet serious problem especially among Asian patients. Therefore, finding an effective approach to reduce deformity relapse remains a great challenge to plastic surgeons., Methods: In this study, authors established finite element models to simulate different nasal cartilage-corrected options and different reinforcing strategies in secondary unilateral cleft rhinoplasty. A load of 0.01N was given to the nasal tip to simulate the soft tissue pressure, while two loads of 0.5N were separately given to the anterior and posterior part of the septal extension graft to simulate the rhinoplasty condition. Maximum deformations were evaluated to make stability judgments., Results: The maximum deformation of different cartilage correction models in ascending order was: UCL deformity with septum correction, normal nasal cartilage, UCL nasal deformity, and UCL nasal deformity with lower lateral cartilage correction. When applied L-strut reinforcement graft was harvested from the perpendicular plate of the ethmoid bone, the maximum deformation of the models decreased significantly, and strong fixation of the septum could further enhance this decreasing effect., Conclusions: Correcting the septum and lower lateral cartilage together could improve the structural stability and symmetry in secondary unilateral cleft rhinoplasty. To keep the corrected septum stable and thus reduce deformity relapse, reinforcing the L-strut with perpendicular plate of ethmoid graft while strongly anchoring the septal cartilage to the anterior nasal spine was proved to be effective in both finite element analysis and clinical observation., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., Competing Interests: Declarations. Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics Approval: All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The experiments were approved by Investigational Review Board. All participants provided informed consent., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Objective: To evaluate the role of postoperative nasal stenting in preserving nasal shape and preventing nostril stenosis in cleft rhinoplasty, and to develop a classification system for postoperative nasal stents., Design: Systematic review., Methods: Electronic and manual searches of scientific literature were conducted from 3 databases (PubMed, SCOPUS, OVID). Primary evidence that described postoperative nasal stenting in cleft rhinoplasty were included. Exclusion criteria included secondary evidence, non-English articles, and studies focusing on preoperative nasal stents., Patients and Participants: Patients with cleft lip/nose of any type were included., Main Outcome Measure(s): Role in preservation of nasal shape & symmetry, role in prevention of nostril stenosis, complications with the use of postoperative nasal stent., Results: Of the 13 articles, 9 papers described the preservation of nasal shape with nasal stents and three studies with a control group showed improved symmetry score. No studies evaluated the prevention of nostril stenosis; however, 2 studies reported improvement of nostril stenosis in secondary cleft rhinoplasty. The results of the included studies had significant heterogeneity. Nasal stents were classified into five types: Type I-spare parts assembled, Type II-prefabricated commercial, Type IIIa-patient specific 3D-printed static, Type IIIb-patient specific dynamic, and Type IV-internal absorbable. Total complications were 6.0%, including irritation (0.9%), infection (0.3%), and stent loss (4.6%)., Conclusion: Despite the lack of consensus with postoperative nasal stents, this review suggests its safety and role in preserving shape and improving stenosis. Our classification system highlights variability and the need for better quality studies to determine the efficacy of nasal stents., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: This study aimed to compare the impacts of undertaking symmetrical bone repair of the nasal alar base combined with nasolabial deformity repair versus nasolabial deformity repair alone on the improvement in nasal deformity of patients with unilateral cleft lip and alveolar cleft., Methods: Fifty patients presenting with unilateral cleft lip and alveolar cleft were evaluated. Among them, 20 underwent nasolabial deformity repair solely (non-bone grafting group), whereas 30 patients received bone repair in conjunction with nasolabial deformity repair (bone-repair group). Preoperative measurements and one-year follow-up results were assessed through photographic anthropometric analysis. According to the Farkas anthropometric standard, the nasal anatomic landmarks were located, and 10 nostril indicators were measured. The operative effects of two groups were compared., Results: In contrast to the non-bone-grafting group, the nasal deformity of patients in the bone-repair group demonstrated significant improvement one year post-operation. The symmetry parameters of the nasal columella more closely approximated 1, the columella deviation angle more closely approached 90°, and the sub-alare inclination angle and the inclination angle of the nasal alar were smaller ( P <0.05)., Conclusions: The accomplishment of symmetrical bone repair of the nasal alar base is conducive to enhancing nasal deformity after cleft-lip surgery in patients with unilateral cleft lip and alveolar cleft. This strategy has a positive influence on nasal symmetry, the morphology of the nasal alar, and nasal base deformity.

When performing a unilateral incomplete cleft lip repair, it is essential to create a good sub-structure of the upper lip contour, reconstruct the orbicularis oris muscle, and prevent an unwanted scar. The aim of this study was to investigate the clinical effect of muscle reconstruction using a five-flap method with a short straight-line incision in unilateral incomplete cleft lip repair. Thirty-two infants with unilateral incomplete cleft lip were treated with this method between April 2020 and February 2023. A short straight-line incision was designed along the philtral column. The orbicularis oris muscle was reconstructed with a five-flap method in three areas: nasal base area, white lip area, and red lip area. Patient outcomes were assessed through subjective evaluation and anthropometric measurements. No patient experienced any postoperative complications. The philtral column and Cupid's bow were well reconstructed. Deviation of nasal columella was corrected and the nasal floor was elevated. Functionally and aesthetically satisfactory outcomes were obtained in all patients over long-term follow-up. In conclusion, this technique was able to create a good sub-structure of the nasolabial contour and bring a significant improvement in bilateral symmetry, showing it to be an effective method for incomplete unilateral cleft lip repair with minimal scarring., Competing Interests: Competing interests None., (Copyright © 2024 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Children with cleft lip and/or palate (CL/P) are at increased risk for Sleep Disordered Breathing (SDB), particularly Obstructive Sleep Apnea (OSA). At our institution, routine screening for SDB is performed using the Chevrin Pediatric Sleep Questionnaire (PSQ). This analysis is a practice audit looking at the outcomes of screening children with CL/P., Design/setting/patients/participants: A single-center, retrospective analysis was done of all non-syndromic patients with CL/P over the age of 36 months over a 4-year period. Children with known OSA were eliminated from analysis., Main Outcome Measures: Univariate logistic regression was used to assess predictors for SDB (PSQ score > 8) amongst various patient, disease, and treatment characteristics. Outcomes of those screened were tracked., Results: Of the 239 patients in the study cohort, 43 (18%) had positive PSQs. These subjects were more likely to have class III dental occlusion with maxillary retrusion (OR = 2.65, 95% CI: 1.2-5.8, p = 0.02). There were no differences amongst age, type of cleft, Veau classification, BMI, or history of pharyngeal surgery. One third of the group did not complete recommended testing. Twenty-five subjects with positive sleep screening underwent subsequent polysomnography and 21 (84%) had OSA., Conclusion: Routine screening reveals a significant proportion of patients with CL/P with symptoms suggestive of OSA. While several patients did not complete confirmatory testing, those who completed a PSG had a high rate of identification of OSA. After excluding children with known OSA, patients with SDB are also likely to have class III dental occlusion and maxillary retrusion., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study aimed to assess the 3-dimensional quantitative characteristics of the surgical occlusion setup in surgery-first cleft orthognathic surgery, and to evaluate its influence on postsurgical skeletal stability., Methods: This prospective study was composed of 35 patients with unilateral cleft lip and palate and class III deformity who consecutively underwent 2-jaw surgery with the surgery-first approach. Digitized dental models were analyzed to quantify the 3-dimensional characteristics of the final surgical occlusion setup. Cone-beam computed tomography was used to measure the 3-dimensional surgical skeletal movement and postsurgical skeletal stability. The correlation between skeletal stability and surgical occlusal contact or surgical skeletal movement was also evaluated., Results: Patients treated with the surgical occlusion setup had a large incisor overjet and positive overbite, as well as buccal cross-bite and open bite on second molars. Occlusal contact on 3 segments was present in 51.4% of the patients, and the average number for tooth contact was 4.3 teeth. No correlation was found between maxillary or mandibular stability and surgical occlusal contact. However, a significant correlation was found between maxillary and mandibular stability and the surgical skeletal movement., Conclusions: The surgical occlusion for correction of cleft-associated class III deformity using the surgery-first approach was characterized by large overjet and positive overbite, along with posterior cross-bite and open bite. On average, there was occlusal contact on 4 to 5 teeth; half of surgical occlusion setups had contact on 3 segments. The postsurgical skeletal stability was related not to the surgical occlusal contact but to the surgical skeletal movement., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Aim: The primary goal of the present comprehensive systematic review is to assess the treatment results attained through PSIO in individuals with NSCLP, as well as to explore its effectiveness. This will be accomplished by examining a range of existing published studies that focus on patient groups who have undergone PPIO., Materials: A comprehensive search strategy was devised by a single author for each database without language restrictions. The databases searched were PubMed, Cochrane library Google Scholar, Web of Science and Scopus. The search period was limited to the years 2001 to 2023. Duration and study design filter was used. Furthermore, conference proceedings, abstracts, and reference lists of relevant studies were sought to obtain additional records., Conclusion: The examined protocols for passive presurgical infant orthopaedics (PPIO) in individuals with CLP typically did not reveal notable treatment outcomes when compared to a lack of treatment across a range of domains. These domains encompass feeding patterns, facial aesthetics, maxillary dentoalveolar factors, cephalometric measurements, speech and language-related aspects, dental arch alignments, economic assessments, as well as occurrences of adverse effects or complications associated with applied appliances or procedures.

Aim: Speech difficulties are common in children with cleft palate, but research on foreign-born children is limited. This study aimed to compare speech outcomes, surgery and speech intervention in 5-year-old foreign-born and Swedish-born children with cleft palate with or without cleft lip., Methods: This retrospective study analysed data from the Swedish cleft lip and palate registry for children born between 2009 and 2016 using Pearson's Chi-squared test and binary logistic regression., Results: Among 160 foreign-born (106 boys, 54 girls) and 847 Swedish-born (479 boys, 368 girls) 5-year-olds, foreign-born children had significantly lower rates of sufficient velopharyngeal competence (77% vs. 86%), age-appropriate consonant production (28% vs. 60%), and speech without non-oral speech errors (70% vs. 86%). Differences remained after adjustment for cleft type, gender and additional diagnosed conditions. After further adjustments for age at completed primary palatal surgery, differences in age-appropriate consonant production and speech without non-oral speech errors remained significant. Foreign-born children underwent completed primary palatal surgery at older ages and received more secondary palatal surgery and speech intervention than Swedish-born peers., Conclusion: Foreign-born children showed poorer speech outcomes than Swedish-born peers, despite more secondary palatal surgery and speech intervention. Age at completed primary palatal surgery could partly explain these differences., (© 2024 The Author(s). Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Cleft lip and palate deformities are usually accompanied by abnormal external nasal morphology which seriously affects facial aesthetics and quality of life. In-depth understanding of the growth pattern of external nasal morphology in patients with cleft lip and palate is essential for deciding the optimal timing of surgical intervention and for furthering improvements in surgical technique. In this review we systematically depict the cross-sectional changes in external nose morphology during growth in the normal population and in patients with clefts, and summarise the iatrogenic impacts on growth of the cleft nose, aiming to provide a reference to further improve the management of the nose in patients with clefts., Competing Interests: Conflict of interest We have no conflicts of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Secondary unilateral cleft lip nasal deformity is a prevalent condition in the world, and surgical repair remains a formidable challenge. The objective of the study is to investigate functionally and aesthetically outcomes of a new technique using a complex of autologous costal cartilage and fascia grafts to repair the secondary unilateral cleft lip nasal deformity., Methods: First, the autologous costal cartilage and fascia were harvested from a total of 34 patients with secondary unilateral cleft lip nasal deformity, who were undergoing treatments at the First Affiliated Hospital of Xi'an Jiaotong University from April 2020 to June 2023. Then, the cartilage was sub-divided into 6 pieces and placed on the depressed alar base, nasal columella, lower lateral cartilage, and nasal tip. At the same time, the fascia was trimmed to cover the nasal tip cap graft and augment the dorsum of the nose. Patient outcomes were assessed through subjective evaluation and objective anthropometric measurements. In addition, associated complications were also examined., Results: All were primary healing incisions, and no patients were encountered with any clinical complications. We found that the overall mean score of the Independent Rhinoplasty Outcome Score (IROS) was very good during the subjective assessment. Also, the objective measurements indicated an excellent nasal symmetry. Furthermore, both functionally and aesthetically satisfactory outcomes were obtained in all the patients during long-time follow-up., Conclusions: Secondary rhinoplasty using the complex of autologous costal cartilage and fascia grafts is a safe and effective approach for unilateral cleft lip nasal deformity repair., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: This study sought to explore the unexamined capabilities of ChatGPT in describing the surgical steps of a specialized operation, the Fisher cleft lip repair., Design: A chat log within ChatGPT was created to generate the procedural steps of a cleft lip repair utilizing the Fisher technique. A board certified craniomaxillofacial (CMF) surgeon then wrote the Fisher repair in his own words blinded to the ChatGPT response. Using both responses, a voluntary survey questionnaire was distributed to residents of plastic and reconstructive surgery (PRS), general surgery (GS), internal medicine (IM), and medical students at our institution in a blinded study., Setting: Authors collected information from residents (PRS, GS, IM) and medical students at one institution., Main Outcome Measures: Primary outcome measures included understanding, preference, and author identification of the procedural prompts., Results: Results show PRS residents were able to detect more inaccuracies of the ChatGPT response as well as prefer the CMF surgeon's prompt in performing the surgery. Residents with less expertise in the procedure not only failed to detect who wrote what procedure, but preferred the ChatGPT response in explaining the concept and chose it to perform the surgery., Conclusions: In applications to surgical education, ChatGPT was found to be effective in generating easy to understand procedural steps that can be followed by medical personnel of all specialties. However, it does not have expert capabilities to provide the minute detail of measurements and specific anatomy required to perform medical procedures., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Aberrant facial growth in individuals affected by orofacial clefts can result in maxillary retrusion and class III malocclusion, with a proportion requiring surgical correction at cessation of growth. This study aimed to evaluate occlusal and cephalometric outcomes of combined orthodontic-orthognathic treatment., Material and Methods: Retrospective cohort study in a United Kingdom cleft center. Participants included twenty-seven patients (20 males, 7 females) with cleft (n = 16 UCLP :7 BCLP :4 ICP) who consecutively underwent combined surgical treatment for Class III malocclusion between January 2013 and December 2017. Records were collected pre-treatment (T0), pre-surgery (T1) and at debond (T2). Models were scored using the Peer Assessment Rating (PAR) index and cephalometric radiographs were traced and analyzed. Outcomes were assessed by an independent rater., Results: Mean age at surgery was 21.4 years (SD 4.9). Le Fort 1 advancement (mean 6.1 mm, SD 4.0) was performed in all cases. Additional procedures included mandibular setback (n = 2), cortico-cancellous bone grafting (n = 6) and genioplasty (n = 1). Mean T0 PAR score was 44.8 (SD 11.7), reducing to 3.6 (SD 2.0) at T2, indicating a mean % PAR score reduction of 91.6% (SD 4.7). Class III skeletal profiles improved from a mean T0 ANB of -2.1º (SD 2.2), to 2.8º (SD 1.6) at T2. Mean T0 overjet was -3.3 mm (SD 2.3), increasing to 2.6 mm (SD 1.3) at T2., Conclusion: Cleft orthognathic surgery differs in complexity and approach to routine orthognathics, however, these results demonstrate that occlusal outcomes can still be comparable with non-cleft populations. Outcome data can be used for comparison with other centers providing cleft orthognathic treatment., (© 2024 The Author(s). Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.)

Objective: There is only one study in the literature in which 3D evaluation of sphenoid sinus volume in patients with cleft lip and palate was used. This shows that this issue has not been adequately evaluated. The present study aimed to compare the volume of the sphenoid sinuses in patients with cleft lip and palate on cone-beam computed tomography images, and to compare them with healthy controls. The high variability of sphenoid sinus volumes poses a risk for iatrogenic lesions during surgical procedures. Because the degree of pneumatization due to increased volume increases the likelihood of exposure of vital neurovascular structures such as the internal carotid artery, maxillary nerves, and optic nerves., Design: Retrospective cohort study., Setting: University Hospital., Patients: A total of 64 patients (32 cleft palate, 32 controls) over 18 years of age who had sphenoid sinuses in the image area were included in our study., Outcomes: Sphenoid Sinus Volume., Results: When the groups were compared in terms of total sinus volume, there was a statistically significant difference between them. Total sinus volume was significantly mean 2.806,87 mm lower in patients with cleft lip and palate compared to the healthy group ( P  = .015)., Conclusion: To be aware this lower volume of the sphenoid sinus in cleft lip and palate patients will be useful for the surgical approach to sphenoid sinus. However, the literature on the subject is insufficient, more comprehensive clinical and radiological studies are needed on a larger sample., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.