OBJECTIVE:Children with cleft lip and palate (CLP) often require palatal expansion before secondary alveolar bone grafting (SABG). As individuals with CLP frequently experience speech disorders, the expander may further impact speech due to the space it occupies intraorally. This study aimed to evaluate the effects of expansion and cleft type on speech outcomes. METHODS:This was a prospective cohort study of 30 patients (37% females; mean age 8.95 ± 1.04 y) with CLP, including 16 bilateral CLP and 14 unilateral CLP. Speech recordings and self-perception questionnaires were obtained at 6 time points: before expansion (T1), after expander insertion (T2), during expansion (T3), during retention (T4), after expander removal (T5), and after SABG (T6). The main outcome measures were self-perception questionnaire ratings from patients and parents; consonant spectral center of gravity (CoG) of /ʃ/, /s/, and /z/; the first (F1) and second (F2) vowel formants of /a/, /i/, and /u/; and nasalance scores. The effects of time point and cleft type were analyzed using a linear mixed-effects model with post hoc Tukey-Kramer tests. RESULTS:Significant changes in speech ratings over time were observed ( P <0.01), but cleft type had no effect. Both time and cleft type significantly influenced consonant CoG and high vowel formants ( P <0.05). Speech nasality was unaffected by cleft type or time point. CONCLUSIONS:Expansion adversely affected self-perceived and acoustic speech measures, with cleft type further influencing acoustic outcomes. Clinicians can use the results to counsel patients on the speech effects of palatal expansion and improve treatment acceptance.

The accurate assessment of oral-nasal balance disorders in children with cleft lip and palate is a perennial problem in Speech-Language Pathology. Nasalance scores obtained with a nasometer can contribute to the diagnosis of oral-nasal balance disorders. The present study investigated how consistent such classifications are over time. Twenty-seven children with cleft lip and palate were recorded six times with a nasometer headset over the course of an orthodontic palatal expansion treatment. Nasalance scores were considered hypernasal when they were higher than 30% for a non-nasal sentence and hyponasal when they were below 50% for a nasal sentence. Based on the nasalance scores, normal nasalance was found in 42.6%, hyponasality in 34.0%, and hypernasality in 23.5% of 162 sound recordings. Only 7/ 27 (25.9%) of the children had the same nasalance-based classification over the six sessions. The others demonstrated variability that straddled two adjacent categories in 15/ 27 (55.6%) of cases and all three categories in 5/ 27 (18.5%) of cases. While clinicians may wish to assign a permanent oral-nasal balance classification to their patients, the study demonstrated that a subset may show unexpected variability over time. More research is needed to establish whether it would be beneficial in some cases to explore this potential for variability before long-term decisions about a patient's clinical management are made.

Introduction: The goal of the present study was to analyze the auditory-perceptual and acoustic characteristics of sibilant and vowel sounds over the course of rapid palatal expansion treatment in children with cleft lip and palate (CLP). Methods: A Nasometer headset was used to record vowel-consonant-vowel (VCV) nonwords with the sibilants "s, z, sh" and the vowels "a, i, u" in 28 children with CLP at six time points. Auditory-perceptual and acoustic analyses of 4,500 VCV productions were obtained. Results: Perceived sibilant errors increased after expander insertion (T2) and gradually returned to pretreatment levels. The s-sound was distorted most frequently (38.3%), while the fewest errors were noted for sh (28.6%). Auditory-perceptual and acoustic measures of nasality increased from the baseline before expander insertion (T1) to the final time point after secondary alveolar bone-grafting (T6). Variability between repeated productions was noted for 26.6% of consonant productions. A cluster analysis showed that 13 children with a higher error rate of 43.9% at T1 had a lower rate of 37.4% at T6 while 15 children with a lower error rate of 16.1% at T1 had a higher rate of 26.6% at T6. Conclusion: Speech errors increased at T2, followed by gradual improvement until T6. The cluster analysis found that some patients in this study showed an increase of pathological speech characteristics over the course of the palatal expansion treatment. More research is needed to investigate how the cleft team can identify and mitigate possible adverse effects for speech.

ObjectiveTo identify, describe, and characterize computer-aided design and computer-aided manufacturing (CAD/CAM) methods for nasoalveolar molding (NAM) based on a structured search of scientific literature.DesignScoping review was conducted following the PRISMA-ScR guidelines. Searches were done in MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus. Screening and data extraction were performed.PatientsInfants with unrepaired, nonsyndromic, complete unilateral cleft lip and palate (UCLP), or bilateral cleft lip and palate (BCLP).InterventionCAD/CAM NAM.Main Outcome MeasuresOutcome measures were the digitization, virtual modeling, and manufacturing protocols.ResultsThirteen articles were included. CAD/CAM NAM involved digitizing the maxilla, designing step-by-step (stepwise) alveolar movements or expansion of plates, then manufacturing plates manually or through 3D printing. Four methods were characterized based on the virtual modeling and manufacturing techniques employed: stepwise alveolar molding and manually fabricated plates (SM_MP); stepwise alveolar molding and 3D-printed plates (SM_3P); stepwise plate expansion and 3D-printed plates (SPE_3P); and semi-automated plate expansion and 3D-printed plates (SAPE_3P). The SM_MP method was the most common, followed by the SM_3P, SPE_3P, and SAPE_3P methods. All methods were applied to treat infants with UCLP, whereas only the SM_MP and SM_3P methods were used for infants with BCLP.ConclusionsThis scoping review provides an overview of 4 CAD/CAM methods for NAM. The SM_MP and SM_3P methods simulate alveolar molding; however, the SM_3P method exhibits more advanced design and manufacturing of plates. The SPE_3P and SAPE_3P methods design consecutively enlarged plates, with the latter employing a semi-automated protocol.

INTRODUCTION:This study investigates the impact of the Coronavirus disease 2019 (COVID-19) pandemic on orthodontically associated cleft lip/palate and craniofacial surgeries, focusing on lip repairs, alveolar bone grafting (ABG), and orthognathic surgeries (OGS). METHODS:A retrospective chart review of 571 participants in a single hospital setting who underwent surgical lip repairs, ABG or OGS was conducted. Clinical data were retrieved from patients' electronic medical records. The data were used to quantify and compare the number of surgeries and surgical wait times pre-COVID versus post-COVID, using independent t tests and regression models, adjusting for various sociodemographic and clinical variables. RESULTS:The proportion of lip repairs and ABG performed was not significantly different between the pre-COVID and post-COVID (P=0.90 and 0.94, respectively); however, OGS significantly decreased post-COVID compared with pre-COVID (P<0.0001). Although no significant differences were found in surgical wait times for lip repairs across time periods (P=0.07), wait times for both ABG and OGS were significantly longer post-COVID compared with pre-COVID (both P<0.0001). Regression analyses showed similar associations after adjusting for several covariates. CONCLUSION:COVID-19 significantly impacted ABG and OGS procedures. Prolonged surgical wait times raise concerns regarding adverse outcomes on patients' physical and mental health. Emphasis should be placed on prioritizing essential procedures and implementing flexible scheduling. Further research is needed to assess the long-term effects of these delays on patient-centered outcomes.

OBJECTIVE:To assess differences in root development between the cleft side (CS) and noncleft side (NCS) for permanent maxillary central incisor and canine longitudinally in patients with nonsyndromic complete unilateral cleft lip and palate (cUCLP) who received secondary alveolar bone grafting (SABG) and to evaluate the effects of SABG on the acceleration of root development of these teeth. MATERIALS AND METHODS:Permanent maxillary central incisors and canines of 44 subjects with nonsyndromic cUCLP who had all their cleft-related surgeries performed by the same surgeon were analyzed retrospectively from chart notes and radiographs. Panoramic and periapical radiographs at time point 1 (T1) (age, 7.55 years), at SABG (time point 2 [T2], 10.13 years), and a minimum of 2 years after SABG were studied. Root development rating scores on the NCS and CS were compared using paired t-tests and analyses of proportions. RESULTS:Mean root development score differences (NCS - CS) for canines and central incisors were greatest at T2 but diminished at time point 3 (T3). A larger proportion of teeth on the CS trailed the teeth on the NCS by at least 1 point at T2 than at T1 or T3, with the smallest proportion being observed at T3. The change in root development scores from T1 to T2 and from T2 to T3 showed relative CS acceleration from T2 to T3, indicating a catch-up of root development of cleft-adjacent teeth after SABG. CONCLUSIONS:Root development of cleft-adjacent central incisors and canines is slow in comparison with their noncleft analogs. Root development of these teeth accelerates following SABG.

Ankylosis of the temporomandibular joint (TMJ) is associated with restricted mandibular movements, with deviation to the affected side. The management of TMJ ankylosis involves surgery to mitigate the effects of ankylosis, and adjunctive appliance therapy to supplement the results achieved through surgery. Several appliances have been used to help maintain jaw mobility postsurgery, but have been rarely documented in the literature.Our systematic review aimed to examine the clinical outcomes of various appliances for TMJ ankylosis management. A comprehensive electronic search of the literature was performed in July 2022 to identify eligible articles that had tested the use of orthodontic or physiotherapy appliances for the management of TMJ ankylosis. In total, 13 publications were included in the narrative synthesis. Both generic and custom-made appliances were used, with overall findings suggesting that using these appliances improved mouth opening and reduced chances of re-ankylosis.This review was the first to describe appliances used for TMJ ankylosis management. No universally accepted appliance was found to be utilized, and the criteria used for appliance selection were unclear. The field of research in developing appliances for the treatment of TMJ ankylosis is open to advancement, and this review will help guide future research in this area.

OBJECTIVE:To characterize the presurgical infant orthopedics (PSIO) and gingivoperiosteoplasty (GPP) protocols across the American Cleft Palate-Craniofacial Association (ACPA) approved and international cleft palate (CP) and craniofacial teams.DESIGN:Cross-sectional survey.SETTING:ACPA approved and international CP and craniofacial teams.RESULTS:Respondents from 115 out of 215 ACPA approved and international CP and craniofacial teams permitted to contact (out of a total of 259 total teams) completed the survey (response rate  =  53.5%). There were 89 (77.4%) ACPA approved teams and the remaining international teams were mainly located in Europe (13.0%). Seventy-eight CP and craniofacial teams (67.8%) provided PSIO and 65 (83.3%) of these teams used alveolar molding (AM). Twenty-two CP and craniofacial teams (19.1%) provided GPP. A mean of 9.5  ±  2.6 different specialists were on the cleft team with the most common being orthodontists (97.4%), speech therapists (96.5%), and plastic/craniofacial surgeons (90.4%).CONCLUSIONS:Most ACPA approved and ACPA registered international CP and craniofacial teams provided PSIO techniques by orthodontists using lip taping (LT) and AM, while few provide GPP.

Rapid palatal expanders (RPEs) are commonly used in patients with cleft lip and palate (CLP) prior to secondary alveolar bone grafting (SABG). Their position and size can impede tongue movement and affect speech. This study assessed changes in perception and production of speech over the course of RPE treatment.Prospective longitudinal.Tertiary university-affiliated hospital.Twenty-five patients with unilateral CLP treated with Fan-type RPEs, and their parents.Patient and parent speech questionnaires and patient speech recordings were collected at baseline before RPE insertion (T1), directly after RPE insertion (T2), during RPE expansion (T3), during RPE retention (T4), directly after RPE removal but before SABG (T5), and at short-term follow-up after RPE removal and SABG (T6).Ratings for patient and parent questionnaires, first (F1) and second (F2) formants for vowels /a/, /i/, and /u/, and nasalance scores for non-nasal and nasal sentences, were obtained and analyzed using mixed model analyses of variance.Ratings worsened at T2. For the vowel /a/, F1 and F2 were unchanged at T2. For the vowel /i/, F1 increased and F2 decreased at T2. For the vowel /u/, F1 was unchanged and F2 decreased at T2. Nasalance was unchanged at T2. All outcome measures returned to T1 levels by T4.RPE insertion resulted in initial adverse effects on speech perception and production, which decreased to baseline prior to removal. Information regarding transient speech dysfunction and distress may help prepare patients for treatment.

INTRODUCTION:Successful eruption of the maxillary canine after secondary alveolar bone grafting (SABG) improves dentoalveolar outcomes in the final occlusal rehabilitation of patients with cleft lip and palate (CLP). We aimed to study eruptive positions of the maxillary canine in CLP post-SABG.METHODS:This retrospective longitudinal study included 27 patients with complete unilateral CLP who received standardized SABG from the same surgeon. Rigorous selection criteria enabled a relatively homogeneous sample. Using panoramic radiographs, angulation, horizontal and vertical positions of the maxillary canines were recorded 3 times. Linear proportions along with sectorial methods were used. Linear regression and t tests were performed to assess and compare the position of the canine on the cleft side (CS) and noncleft side from pre-SABG (T1) to a minimum 2 years post-SABG (T3); to evaluate its displacement and identify predictors for its impaction, and to analyze the characteristics of the impacted canines vs the nonimpacted canines at T3.RESULTS:The CS maxillary canine was more acutely angulated and more apically positioned than the noncleft side canine at all times. It was relatively more distally positioned at T1 and exhibited significantly greater mesial movement from T1 to T3 (P <0.0001). Canine impaction on the CS was associated with a more apical position at 1-year post-SABG (P = 0.022) and a more acute angulation of this tooth.CONCLUSION:More acute angulation and more apical position of the CS maxillary canine before SABG may be associated with an increased risk of its impaction after SABG.

We report a case of secondary alveolar bone grafting (ABG) without removal of a supernumerary tooth in a patient with unilateral cleft lip and palate. A conical supernumerary tooth located distal to the upper left central incisor within the cleft site was left in situ at the time of ABG. The tooth within the ABG site commenced resorption from both the apical and incisal edges until only minor tooth remnants remained at 22 months. Although external root resorption of teeth neighboring a cleft site has been described previously, this is the first report of almost complete tooth resorption following ABG.

Introduction: For patients with complete unilateral cleft lip and palate (CUCLP), secondary alveolar bone grafting (SABG) can be performed before or after the emergence of the cleft side permanent canine (pre-CE and post-CE, respectively). The controversy regarding dental outcomes related to the timing of SABG remains unsettled. The objective of this study was to evaluate dental survival and specific dental outcomes of cleft-adjacent teeth in children with CUCLP who received either pre-CE or post-CE SABG. Methods: The permanent maxillary canines and the central and lateral incisors of 21 pre-CE and 23 post-CE SABG subjects with nonsyndromic CUCLP and all cleft-related surgeries performed by the same surgeon were analyzed retrospectively. Intraoral radiographs and clinical chart notes were collected at age 7 years, at the time of the SABG, and approximately 4 years after the grafting. Dental survival, spontaneous canine eruption, planned prosthetic replacement, root development, and root resorption were analyzed. Results: Dental outcomes on the noncleft side were better than those on the cleft side. On the cleft side, dental survival of the cleft-adjacent teeth was not significantly different between the pre-CE and post-CE SABG groups (P > 0.05). Most teeth completed root development after grafting, and the cleft side canine root development in the pre-CE SABG group appeared to accelerate after SABG. Trends showed that the pre-CE SABG group suffered less root resorption (16.28%; post-CE: 22.73%; P > 0.05) and received fewer planned prosthetic replacements (14.29%; post-CE: 26.01%; P > 0.05) but required a greater number of canine exposures (33.33%; post-CE: 4.55%; P = 0.02). Conclusions: Pre-CE SABG showed better dental outcomes in patients with CUCLP, with fewer adverse dental outcomes than post-CE SABG.

Cleft orthognathic surgery is an important component of a comprehensive cleft care plan. Applying combined orthodontic and orthognathic treatment principles to a cohort of patients with cleft lip and palate raises many challenges not encountered in conventional orthognathic care. Cleft patients share a commonality in their midfacial anatomy that is characterized by a 3-dimensionally deficient maxilla. The residual sequelae of multiple previous surgeries along with dental differences and unhealed fistulae are considerations when embarking on treatment. This article describes many of these challenges and highlights approaches that are used to address the specific needs of this special group of patients.

Introduction: Rapid palatal expanders (RPEs) have attachments cemented to the teeth and a screw that covers the palate. Because of their position and relative size, RPEs can affect speech. Our objective was to assess speech perturbation and adaptation related to RPE appliances over time. Methods: RPEs were planned for the treatment of 22 patients in the orthodontic clinic at the University of Toronto in Canada. Speech recordings were made at 6 time points: before RPE placement, after placement, during expansion, during retention, after removal, and 4 weeks after removal. The speech recordings consisted of 35 sentences, from which 3 sentences were chosen for analysis. Speech acceptability was assessed perceptually by 10 listeners who rated each sentence on an equal-appearing interval scale. The vowel formants for /i/and the fricative spectra for /s/ and /integral/ were measured with speech analysis software. Repeated-measures analysis of variance with post-hoc paired t tests was used for statistical analysis. Results: When the appliance was placed, speech acceptability deteriorated. Over time, the ratings improved and returned to baseline when the appliance was removed. For the vowel /i/, the first formant increased, and the second formant decreased in frequency, indicating centralization of the vowel. The formants returned to the pretreatment levels during treatment. For the fricatives (/s/ and /integral/), low-to-high frequency ratios indicated that the fricatives were distorted when the appliance was placed. The ratios returned to baseline levels once the appliance was removed. The results for the spectral moments indicated that spectral mean decreased and skewness became more positive. Repeated-measures analysis of variance showed significant effects for time for all acoustic measures. Conclusions: Speech was altered and distorted when the appliance was first placed. The patients' speech gradually improved over time and returned to baseline once the appliance was removed. The results from the study will be useful for pretreatment counseling of patients and their families. (Am J Orthod Dentofacial Orthop 2011; 140: e67-e75)