This second special issue of The Cleft Palate-Craniofacial Journal highlights early career researchers and their novel contributions to the interdisciplinary field of cleft and craniofacial science and care. These 16 manuscripts span clinical and basic science, reflecting the journal's commitment to evidence-based, team-centered care and promoting the work of those early in their careers. This year's showcase also highlights the emerging trends in digital innovation, patient-centered language and outcomes, and advances in interdisciplinary and translational science.

OBJECTIVES:Despite the popularity of electronic nicotine delivery systems (ENDS), there is currently a lack of regulation and consistency regarding the formulation of the e-liquids that undergo combustion in use. The two main constituents of most e-liquids are the humectants propylene glycol (PG) and glycerol (vegetable glycerin, VG). E-liquids consist of a ratio of these two components with PG utilized to increase the "throat hit" effect and VG used to increase visible vapor. As PG-based e-liquids are known to generate more carcinogenic carbonyls and increase the uptake of nicotine, many commercial products have moved toward a more VG-centric formulation to reduce potential harm. The purpose of this study was to test the hypothesis that a common VG-based formulation (30/70 PG/VG) would result in fewer negative effects on craniofacial growth compared to an evenly concentrated formulation (50/50 PG/VG) in the absence of nicotine. MATERIALS AND METHODS:Adult breeder mice were utilized to generate in utero ENDS component exposed litters including free air exposure (control), 30/70 PG/VG, and 50/50 PG/VG groups. The resulting pups were assessed at postnatal day 14 for skull morphology. RESULTS:Data demonstrate significant reductions in body weight, facial, and cranial dimensions, where there was a significant reduction in growth for the 30/70 PG/VG exposed group. There were no significant differences found between control and 50/50 PG/VG. CONCLUSIONS:These results suggest the overall movement to a more VG-centric ENDS formulation may not result in reduced profile for health concerns. Further, it suggests that PG/VG are not a harmless carrier and now popular nicotine-free ENDS formulation may not be considered safe for use in pregnant populations.

A special issue of the Cleft Palate-Craniofacial Journal was curated to highlight early-career researchers of the American Cleft Palate-Craniofacial Association and their innovative research contributions. This collection of 13 manuscripts, all led by early-career researcher authors of diverse disciplines and training, represents a wide variety of topics related to the science surrounding craniofacial care.

The Center for Disease Control's National Birth Defects Prevention Study data suggests that maternal nicotine use may increase the incidence of craniofacial birth defects and growth anomalies like craniosynostosis, cleft palate, and/or lip in offspring. Craniofacial growth proceeds by expansion at fibrous sutures and synchondroses. In the cranial base, synchondroses, which are cartilaginous joints, play a major role in craniofacial development including neurocranial expansion and facial outgrowth. Our previous data showed alterations in craniofacial structures with intrauterine exposure to nicotine. As the use of nicotine is increasing among youths, especially through use of electronic nicotine delivery systems, there is a great need to investigate the critical periods of nicotine exposure during pregnancy and postnatal development. Alterations in craniofacial growth that occur in response to maternal nicotine use must be understood in order to prevent debilitating conditions. For this investigation, we utilized cephalometric and histomorphometric analyses to investigate how nicotine exposure alters craniofacial development in offspring modeling maternal nicotine exposure either during pregnancy and lactation or post-partum lactation only compared with unexposed controls. Our results in mice showed significant changes in craniofacial dimensions and some specificity for effects in the synchondroses across the three experimental groups including significant changes in the cellular and the extracellular collagen matrix components of these growth centers. The most dramatic effects segregated to the lactation only exposed group, which is a major target from a prevention point of view as there is a common misconception among the public that nicotine cessation during pregnancy is sufficient for prevention of ill effects in the offspring.

Nicotine exposure during neural development presents a significant public health concern. Nicotine, the primary addictive component of tobacco, influences the central nervous system by interacting with various cell types, including the glial cell termed astrocytes. Astrocytes are cells that are critical for supporting neurons, regulating neurotransmitter balance, and managing neuroinflammation. This current study explored nicotine’s effects on astrocytes, examining cellular activity and gene expression within an acute exposure period. Murine C8D1A astrocytic (garnered as a cell line from postnatal day 8 tissue) cells were treated with nicotine (0–500 ng/mL) in vitro, with assays measuring cell viability and apoptosis at 12, 18, 24, and 48 hours to establish a critical concentration gradient for nicotine. Nicotine exposure increased astrocyte viability at later time points (24 and 48 hours), while apoptosis rose initially but declined over time allowing for the establishment of pharmacologically and clinically relevant nicotine concentrations of 25,50 and 100ng/ml for subsequent experiments. Real-time quantitative PCR revealed that nicotine influenced inflammatory signaling, with pro-inflammatory (A1) markers (IL-6, IFNγ, TNFα) increasing in a dose- and time-dependent manner, while anti-inflammatory (A2) markers (ARG1, IL-10, TGFβ) displayed a more complex pattern after nicotine exposures to astrocytes. These results suggest that nicotine disrupts astrocyte function and inflammatory balance, which may contribute to neurodevelopmental disruptions and heightened neuroinflammatory risks in adults. Further research is needed to investigate the prolonged impact of nicotine on brain health, addiction, and associated neurological conditions.

Objective Develop a model for the study of Electronic Nicotine Device (ENDS) exposure on craniofacial development. Design Experimental preclinical design followed as pregnant murine dams were randomized and exposed to filtered air exposure, carrier exposure consisting of 50% volume of propylene glycol and vegetable glycine (ENDS Carrier) respectively, or carrier exposure with 20 mg/ml of nicotine added to the liquid vaporizer (ENDS carrier with nicotine). Setting Preclinical murine model exposure using the SciReq exposure system. Participants C57BL6 adult 8 week old female pregnant mice and exposed in utero litters. Interventions Exposure to control filtered air, ENDS carrier or ENDS carrier with nicotine added throughout gestation at 1 puff/minute, 4 h/day, five days a week. Main Outcome Measures Cephalometric measures of post-natal day 15 pups born as exposed litters. Results Data suggests alterations to several facial morphology parameters in the developing offspring, suggesting electronic nicotine device systems may alter facial growth if used during pregnancy. Conclusions Future research should concentrate on varied formulations and exposure regimens of ENDS to determine timing windows of exposures and ENDS formulations that may be harmful to craniofacial development.

Manzamine-A is a marine-derived alkaloid which has anti-viral and anti-proliferative properties and is currently being investigated for its efficacy in the treatment of certain viruses (malaria, herpes, HIV-1) and cancers (breast, cervical, colorectal). Manzamine-A has been found to exert effects via modulation of SIX1 gene expression, a gene critical to craniofacial development via the WNT, NOTCH, and PI3K/AKT pathways. To date little work has focused on Manzamine-A and how its use may affect bone. We hypothesize that Manzamine-A, through SIX1, alters bone cell activity. Here, we assessed the effects of Manzamine-A on cells that are responsible for the generation of bone, pre-osteoblasts and osteoblasts. PCR, qrtPCR, MTS cell viability, Caspase 3/7, and functional assays were used to test the effects of Manzamine-A on these cells. Our data suggests Six1 is highly expressed in osteoblasts and their progenitors. Further, osteoblast progenitors and osteoblasts exhibit great sensitivity to Manzamine-A treatment exhibited by a significant decrease in cell viability, increase in cellular apoptosis, and decrease in alkaline phosphatase activity. In silico binding experiment showed that manzamine A potential as an inhibitor of cell proliferation and survival proteins, i.e., Iκb, JAK2, AKT, PKC, FAK, and Bcl-2. Overall, our data suggests Manzamine-A may have great effects on bone health overall and may disrupt skeletal development, homeostasis, and repair.

The use of traditional nicotine delivery products such as tobacco has long been linked to detrimental health effects. However, little work to date has focused on the emerging market of aerosolized nicotine delivery known as electronic nicotine delivery systems (ENDS) or electronic cigarettes, and their potential for new effects on human health. Challenges studying these devices include heterogeneity in the formulation of the common components of most available ENDS, including nicotine and a carrier (commonly composed of propylene glycol and vegetable glycerin, or PG/VG). In the present study, we report on experiments interrogating the effects of major identified components in e-cigarettes. Specifically, the potential concomitant effects of nicotine and common carrier ingredients in commercial "vape" products are explored in vitro to inform the potential health effects on the craniofacial skeleton through novel vectors as compared to traditional tobacco products. MC3T3-E1 murine pre-osteoblast cells were cultured in vitro with clinically relevant liquid concentrations of nicotine, propylene glycol (PG), vegetable glycerin (VG), Nicotine+PG/VG, and the vape liquid of a commercial product (Juul). Cells were treated acutely for 24 h and RNA-Seq was utilized to determine segregating alteration in mRNA signaling. Influential gene targets identified with sparse partial least squares discriminant analysis (sPLS-DA) implemented in mixOmics were assessed using the PANTHER Classification system for molecular functions, biological processes, cellular components, and pathways of effect. Additional endpoint functional analyses were used to confirm cell cycle changes. The initial excitatory concentration (EC50) studied defined a target concentration of carrier PG/VG liquid that altered the cell cycle of the calvarial cells. Initial sPLS-DA analysis demonstrated the segregation of nicotine and non-nicotine exposures utilized in our in vitro modeling. Pathway analysis suggests a strong influence of nicotine exposures on cellular processes including metabolic processes and response to stimuli including autophagic flux. Further interrogation of the individual treatment conditions demonstrated segregation by treatment modality (Control, Nicotine, Carrier (PG+VG), Nicotine+PG/VG) along three dimensions best characterized by: latent variable 1 (PLSDA-1) showing strong segregation based on nicotine influence on cellular processes associated with cellular adhesion to collagen, osteoblast differentiation, and calcium binding and metabolism; latent variable 2 (PLSDA-2) showing strong segregation of influence based on PG+VG and Control influence on cell migration, survival, and cycle regulation; and latent variable 3 (PLSDA-3) showing strong segregation based on Nicotine and Control exposure influence on cell activity and growth and developmental processes. Further, gene co-expression network analysis implicates targets of the major pathway genes associated with bone growth and development, particularly craniofacial (FGF, Notch, TGFβ, WNT) and analysis of active subnetwork pathways found these additionally overrepresented in the Juul exposure relative to Nicotine+PG/VG. Finally, experimentation confirmed alterations in cell count, and increased evidence of cell stress (markers of autophagy), but no alteration in apoptosis. These data suggest concomitant treatment with Nicotine+PG/VG drives alterations in pre-osteoblast cell cycle signaling, specifically transcriptomic targets related to cell cycle and potentially cell stress. Although we suspected cell stress and well as cytotoxic effects of Nicotine+PG/VG, no great influence on apoptotic factors was observed. Further RNA-Seq analysis allowed for the direct interrogation of molecular targets of major pathways involved in bone and craniofacial development, each demonstrating segregation (altered signaling) due to e-cigarette-type exposure. These data have implications directed toward ENDS formulation as synergistic effects of Nicotine+PG/VG are evidenced here. Thus, future research will continue to interrogate how varied formulation of Nicotine+PG/VG affects overall cell functions in multiple vital systems.

OBJECTIVES:Despite data linking smoking to increased risk of fetal morbidity and mortality, 11% of pregnant women continue to smoke or use alternative nicotine products. Studies confirm that nicotine exposure during pregnancy increases the incidence of birth defects; however, little research has focused on specific anatomic areas based on timing of exposure. We aim to determine critical in utero and postnatal periods of nicotine exposure that affect craniofacial development, specifically palate growth. Malformation of the palatal structures can result in numerous complications including facial growth disturbance, or impeding airway function. We hypothesized that both in utero and postnatal nicotine exposure will alter palate development. MATERIALS AND METHODS:We administered pregnant C57BL6 mice water supplemented with 100 μg/mL nicotine during early pregnancy, throughout pregnancy, during pregnancy and lactation, or lactation only. Postnatal day 15 pups underwent micro-computed tomography (μCT) analyses specific to the palate. RESULTS:Resultant pups revealed significant differences in body weight from lactation-only nicotine exposure, and μCT investigation revealed several dimensions affected by lactation-only nicotine exposure, including palate width, palate and cranial base lengths, and mid-palatal suture width. CONCLUSIONS:These results demonstrate the direct effects of nicotine on the developing palate beyond simple tobacco use. Nicotine exposure through tobacco alternatives, cessation methods, and electronic nicotine delivery systems (ENDS) may disrupt normal growth and development of the palate during development and the postnatal periods of breastfeeding. Due to the recent dramatic increase in the use of ENDS, future research will focus specifically on this nicotine delivery method.

Selective serotonin re-uptake inhibitors (SSRI) widely used in the treatment of depression, anxiety, obsessive compulsive disorder, fibromyalgia, and migraine are among the most heavily prescribed drug class in the United States (US). Along with an overall rise in SSRI use, these medications are increasingly used by pregnant individuals and recent preclinical and clinical studies have indicated that SSRIs may increase the prevalence of congenital abnormalities and birth defects of the craniofacial region. Our group has developed pre-clinical models of study, including those that mimic the clinical use of SSRI in mice. Here we designed a study to interrogate a commonly prescribed SSRI drug, Citalopram, for its effects on craniofacial and dental development when introduced in utero. Pre-natal exposure to a clinically relevant dose of citalopram resulted in changes in craniofacial form identified by an increase in endocast volume in SSRI exposed postnatal day 15 mouse pups. More specifically, cranial length and synchondrosis length increased in SSRI exposed pups as compared to control pups of the same age. Additionally, growth center (synchondrosis) height and width and palate length and width decreased in SSRI exposed pups as compared to control un-exposed pups. Effects of SSRI on the molars was minimal. Craniofacial growth and development continue to be an area of interest in the investigation of in utero pharmaceutical drug exposure. Altogether these data indicate that prenatal SSRI exposure affects craniofacial form in multiple tissues and specifically at growth sites and centers of the skull.

Post-traumatic stress disorder (PTSD) is associated with osteopenia, osteoporosis and increased fracture risk in the clinical population. Yet, the development of preclinical models to study PTSD-induced bone loss remains limited. In this study, we present a previously unreported model of PTSD in adult female C57BL/6 mice, by employing inescapable foot shock and social isolation, that demonstrates high face and construct validity. A subset of mice exposed to this paradigm (i.e. PTSD mice) display long-term alterations in behavioral and inflammatory indices. Using three-dimensional morphometric calculations, cyclic reference point indentation (cRPI) testing and histological analyses, we find that PTSD mice exhibit loss of trabecular bone, altered bone material quality, and aberrant changes in bone tissue architecture and cellular activity. This adult murine model of PTSD exhibits clinically relevant changes in bone physiology and provides a valuable tool for investigating the cellular and molecular mechanisms underlying PTSD-induced bone loss.

Students often find human anatomy courses to be difficult due to the large amount of content covered at a fast pace, which can result in students failing to retain pertinent information. Superheroes are at the forefront of today's popular culture, with many students identifying with specific characters. Utilizing aspects of students' lives, or their agency, that they can resonate with in the classroom, such as their interests in superheroes or personal connections to fictional characters, may help drive students' motivation to learn course content. This study investigated if the use of superheroes in an anatomy curriculum helped undergraduate students learn, apply, and improve their anatomical knowledge. Two courses at The Ohio State University-Columbus Campus, one with a superhero-based curriculum and one with a traditional anatomy curriculum were compared over three semesters using quizzes and survey data. Results from this project found that the use of superheroes/pop culture in anatomy education is an effective way to teach content. The study also showed that most students found the use of superheroes increased their motivation to learn, helped them gain a deeper understanding of the material, and helped them find the content more approachable and enjoyable. In summary, anatomy curricula can still be taught and explained through these creative and "marvel"-ous examples as it can help students connect the material to their own agency and drive motivation to learn.

The urgent need for SARS-CoV-2 controls has led to a reassessment of approaches to identify and develop natural product inhibitors of zoonotic, highly virulent, and rapidly emerging viruses. There are yet no clinically approved broad-spectrum antivirals available for beta-coronaviruses. Discovery pipelines for pan-virus medications against a broad range of betacoronaviruses are therefore a priority. A variety of marine natural product (MNP) small molecules have shown inhibitory activity against viral species. Access to large data caches of small molecule structural information is vital to finding new pharmaceuticals. Increasingly, molecular docking simulations are being used to narrow the space of possibilities and generate drug leads. Combining in-silico methods, augmented by metaheuristic optimization and machine learning (ML) allows the generation of hits from within a virtual MNP library to narrow screens for novel targets against coronaviruses. In this review article, we explore current insights and techniques that can be leveraged to generate broad-spectrum antivirals against betacoronaviruses using in-silico optimization and ML. ML approaches are capable of simultaneously evaluating different features for predicting inhibitory activity. Many also provide a semi-quantitative measure of feature relevance and can guide in selecting a subset of features relevant for inhibition of SARS-CoV-2.

Introduction Alveolar bone grafting aims to restore bony continuity of the alveolus and provide optimal periodontal support for teeth adjacent to the cleft. We created a survey of cleft surgeons to assess the current standard of care regarding this procedure. Methods A multiple choice survey was implemented using Qualtrics software and emailed to a list of 708 surgeons from the ACPA membership directory. Correlation between various provider factors and treatment practices was assessed with Fisher's exact test and likelihood ratio tests. Results The response rate was 17.5%. Eighty-seven percent of providers preferred to perform grafts prior to secondary canine eruption while 10% favored before central incisor eruption. Eighty-one percent favored palatal expansion prior to bone grafting. Wide variability existed regarding the time to initiate postoperative orthodontics; 43% waited 4 to 6 months. Sixty-four percent of surgeons now utilize cone beam CT to assess graft take. The majority of respondents utilized cancellous bone autograft (92%) from the anterior iliac crest (97%) as graft material. Seventy percent used three or more modalities for post-operative pain control management. Early career surgeons (0-5 years) appeared more likely to use non-autologous materials (p < .01) for grafting. Conclusion Alveolar bone grafting prior to secondary canine eruption remains the most common strategy but other protocols are employed. Surgeons utilize multiple modalities for radiographic evaluation and most often use autologous cancellous bone as the primary grafting material. There is no true consensus on the perioperative timing and sequencing of orthodontic manipulation while principles of multimodal perioperative pain control appear widely accepted.

Objectives The aim of the present study is to broaden our knowledge of the ontogeny of cranial base cartilaginous joints in primates. Materials and Methods A cross-sectional age sample of 66 specimens from four platyrrhine and three strepsirrhine genera were studied using microcomputed tomography, histology, and immunohistochemistry. Specimens were segmented, reconstructed, and measured using Amira software. Ontogenetic scaling of palatal, presphenoid, and basisphenoid length relative to cranial length was examined using standardized major axis regression. After histological sectioning, selected specimens were examined using immunohistochemistry of antibodies to proliferating cell nuclear antigen. Results Our results support the hypothesis that the presphenoid in platyrrhines grows more rapidly compared with strepsirrhines, but this study establishes that most or all of this growth discrepancy occurs prenatally, and mostly at the presphenoseptal synchondrosis (PSept). All species have prolonged patency (here meaning absence of any bony bridging across the synchondrosis) of the intrasphenoidal and spheno-occipital synchondroses (ISS). However, immunohistochemical results suggest growth is only rapid throughout infancy, and mitotic activity is slowing during juvenile ages. The same is indicated for the PSept. Discussion These results demonstrate that platyrrhines and strepsirrhines do not follow the pattern of early fusion of ISS seen in humans. In addition, these primates have a more prolonged patency and growth at PSept compared with humans. Finally, results reveal that in bushbabies and tamarins, as in humans, synchondroses remain cartilaginous for a prolonged period after chondrocyte proliferation has slowed or ceased. In light of these results, it is time to reassess related processes, such as differences in timing of brain expansion.

Purpose: The purpose of this study was to characterize the histologic contents of the salpingopharyngeal fold. The primary objective was to observe the presence of salpingopharyngeus (SP) muscle fibers, particularly at the section near the muscle origin at the torus tubarius (TT). Method: Histologic samples of the salpingopharyngeal fold from 10 cadavers (six females and four males) were analyzed. Following a head bisection, a tissue sample measuring 5 mm in length along the course of the salpingopharyngeal fold was collected from one side (i.e., right or left). The tissue sample was taken from the estimated base of the TT to a point 5 mm inferiorly. Slides were prepared using a standard histological approach and basic pathological staining and analyzed via bright-field microscopy. Results: Skeletal muscle fibers were identified in eight of the 10 tissue blocks of the salpingopharyngeal fold, with dense connective tissue identified in the remaining two tissue blocks. Glandular material was also identified in all 10 tissue blocks. Conclusions: Skeletal muscle fibers and/or dense connective tissue can be consistently identified in the section of the salpingopharyngeal fold near the TT. Glandular material is also consistently present in this same region of the salpingopharyngeal fold. These findings are discussed in relation to possible functional roles of the salpingopharyngeal fold contents, including the SP muscle.

OBJECTIVES:Antidepressants, specifically Selective Serotonin Re-uptake Inhibitors (SSRIs), that alter serotonin metabolism are currently the most commonly prescribed drugs for the treatment of depression. There is some evidence to suggest these drugs contribute to birth defects. As jaw development is often altered in craniofacial birth defects, the purpose of this study was to interrogate the effects of in utero SSRI exposure in a preclinical model of mandible development. MATERIALS AND METHODS:Wild-type C57BL6 mice were used to produce litters that were exposed in utero to an SSRI, Citalopram (500 μg/day). Murine mandibles from P15 pups were analysed for a change in shape and composition. RESULTS:Analysis indicated an overall shape change with total mandibular length and ramus height being shorter in exposed pups as compared to controls. Histomorphometric analysis revealed that first molar length was longer in exposed pups while third molar length was shorter in exposed as compared to control. Histological investigation of molars and surrounding periodontium revealed no change in collagen content of the molar in exposed pups, some alteration in collagen composition in the periodontium, increased alkaline phosphatase in molars and periodontium and decreased mesenchymal cell marker presence in exposed mandibles. CONCLUSION:The results of this study reveal SSRI exposure may interrupt mandible growth as well as overall dental maturation in a model of development giving insight into the expectation that children exposed to SSRIs may require orthodontic intervention.

Aims: Evidence suggests alterations of thyroid hormone levels can disrupt normal bone development. Most data suggest the major targets of thyroid hormones to be the Htra1/Igf1 pathway. Recent discovery by our group suggests involvement of targets WNT pathway, specifically overexpression of antagonist Sfrp4 in the presence of exogenous thyroid hormone. Main methods: Here we aimed to model these interactions in vitro using primary and isotype cell lines to determine if thyroid hormone drives increased Sfrp4 expression in cells relevant to craniofacial development. Transcriptional profiling, bioinformatics interrogation, protein and function analyses were used. Key findings: Affymetrix transcriptional profiling found Sfrp4 overexpression in primary cranial suture derived cells stimulated with thyroxine in vitro. Interrogation of the SFRP4 promoter identified multiple putative binding sites for thyroid hormone receptors. Experimentation with several cell lines demonstrated that thyroxine treatment induced Sfrp4 expression, demonstrating that Sfrp4 mRNA and protein levels are not tightly coupled. Transcriptional and protein analyses demonstrate thyroid hormone receptor binding to the proximal promoter of the target gene Sfrp4 in murine calvarial pre-osteoblasts. Functional analysis after thyroxine hormone stimulation for alkaline phosphatase activity shows that pre-osteoblasts increase alkaline phosphatase activity compared to other cell types, suggesting cell type susceptibility. Finally, we added recombinant SFRP4 to pre-osteoblasts in combination with thyroxine treatment and observed a significant decrease in alkaline phosphatase positivity. Significance: Taken together, these results suggest SFRP4 may be a key regulatory molecule that prevents thyroxine driven osteogenesis. These data corroborate clinical findings indicating a potential for SFRP4 as a diagnostic or therapeutic target for hyperostotic craniofacial disorders.

OBJECTIVE:We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients.METHODS:Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P < .05.RESULTS:Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P = .9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P = .02]; ac-ac [C-AA; P = .00; H-AA; P = .04]; al-al [C-AA; P = .00; H-AA; P = .001]) and labial length (sn-ls [C-AA; P = .041]; sn-sto [C-AA; P = .005]; Cphs-Cphi L [C-AA; P = .013]; Cphs-Cphi R [C-AA; P = .015]). Interrater reliability was good to excellent and significantly correlated for all measures.CONCLUSIONS:African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction.