Klaus Sinko

Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients

Objective Evaluation of esthetic, functional, and health-related quality-of-life (HRQoL) outcomes in adult patients with a repaired cleft lip and palate. The treatment for all patients was based on the so-called Vienna concept. Patients/Design Seventy adult patients with a repaired complete cleft lip and palate, ranging in age from 18 to 30 years, were included in the study. Esthetic and functional outcomes were assessed by the patients themselves and by five experts using a visual analog scale. Patients also completed the MOS Short-Form 36 questionnaire to evaluate health-related quality of life. Results Patients rated their esthetic outcome significantly worse than the experts did. No significant differences were observed in the ratings for function. Female patients, especially, were dissatisfied with their esthetic outcomes. In a personal interview, nearly 63% of them asked for further treatment, particularly for upper-lip and nose corrections. The health-related quality-of-life questionnaire revealed low scores for only two subscales, namely social functioning and emotional role. In most subscales of health-related quality of life, patients who desired further treatment had significantly lower scores than did patients who desired no further treatment. Conclusion Surgery of the lip and nose appears to be of prime importance for patients with a cleft lip and palate. Cleft patients who do not request secondary treatment are not always satisfied with the treatment. Patients with realistic expectations in regard to further treatment should be treated by specialists, whereas those with unrealistic expectations should be referred to a clinical psychologist.

Maxillomandibular advancement for treatment of obstructive sleep apnea syndrome: a systematic review.

PURPOSE To perform a systematic review of the published data concerning maxillomandibular advancement for the treatment of obstructive sleep apnea syndrome. MATERIALS AND METHODS A systematic literature search was performed in the PubMed database. Original articles in the English language were reviewed to obtain information about patient data, success rates, and outcome measures. RESULTS The systematic literature search yielded 1,113 citations, of which 101 articles met our inclusion criteria. After a review of the full text, 39 studies were included in the analysis. Most articles were classified as evidence level 4, and 5 met the inclusion criteria for level 2b. The only prospective randomized controlled study had been published in January 2010 and was assigned level 1b. CONCLUSIONS A recommendation grade of A to B was achieved with regard to the levels of evidence-based medicine. Our results have shown that maxillomandibular advancement is the most successful surgical therapy, and the postoperative polysomnography results are comparable to those under ventilation therapy.

The Goslon Yardstick in Patients With Unilateral Cleft Lip and Palate: Review of a Vienna Sample

Objective: To compare a Vienna unilateral cleft lip and palate (UCLP) patient sample with the Eurocleft samples using the GOSLON score, to determine the intra- and interrater agreement between several raters and ratings, and to establish whether training with the original GOSLON models enhances accuracy. Patients and Methods: One hundred twenty-three plaster casts of UCLP patients born between 1970 and 1997, with an average age of 9.2 years and all treated with the same regimen, were rated according to the GOSLON score. Results: Of the patients, 71.5% were ranked GOSLON 1 or 2. Only 8.9% were rated GOSLON 4 or 5. There were no significant differences between the different raters and the ratings. Training with the original GOSLON models increased kappa from 0.57 before training to 0.84 after training. Conclusion: The “Vienna concept” was found to be a good regimen for treating UCLP patients in regard to maxillary growth. Personal training on the original GOSLON models appears to improve the accuracy of rating.

Importance of Soft Tissue for Skeletal Stability in Maxillary Advancement in Patients With Cleft Lip and Palate

OBJECTIVE Assessment of stability of the advanced maxilla after two-jaw surgery and Le Fort I osteotomy in patients with cleft palate based on soft tissue planning. SUBJECTS Between 1995 and 1998, 15 patients with cleft lip and palate deformities underwent advancement of a retruded maxilla, without insertion of additional bone grafts. Eleven patients had bimaxillary osteotomies and four patients only a Le Fort I osteotomy. Relapse of the maxilla in horizontal and vertical dimensions was evaluated by cephalometric analysis after a clinical follow-up of at least 2 years. RESULTS In the bimaxillary osteotomies, horizontal advancement was an average 4 mm at point A. After 2 years, there was an additional advancement of point A of an average of 0.7 mm. In the mandible, a relapse of 0.8 mm was seen after an average setback of 3.9 mm. In the four patients with Le Fort I osteotomy, point A was advanced by 3.8 mm and the relapse after 2 years was 0.9 mm. Vertical elongation at point A resulted in relapse in both groups. Impaction of the maxilla led to further impaction as well. CONCLUSION Cephalometric soft tissue analysis demonstrates the need for a two-jaw surgery, not only in severe maxillary hypoplasia. Alteration of soft tissue to functional harmony and three-dimensional correction of the maxillomandibular complex are easier to perform in a two-jaw procedure. It results in a more stable horizontal skeletal position of the maxilla.

Facial aesthetics and the assignment of personality traits before and after orthognathic surgery

Processing and interpreting the face is generally very important because one is often required to make rapid decisions in life on the basis of meagre information. Ninety-two volunteers used a computer-assisted test battery to assess 40 profiles of patients (8 skeletal Class II and 8 skeletal Class III patients, each pre- and postoperatively, with 8 skeletal Class I photographs serving as controls). On a 7-point Likert scale the raters were asked to evaluate aesthetics and a few relevant personality traits (e.g. unintelligent, inhibited, aggressive, brutal). The photographs of the two patient groups were rated significantly less attractive and intelligent prior to surgery than the photographs of the control group. In respect of personality traits, the photographs of the skeletal Class III group differed more strongly from normal ones. In respect of aesthetics and intelligence, both patient groups benefited markedly from surgery. For some personality traits, significant interactions were found between the two groups on pre-post comparison. The method underlying the study is useful for evaluating the outcome of orthognathic surgery, but also indicates the strongly generalized and unconscious processes involved in the estimation of peoples personality traits, especially when these concern deviations from the socially normal condition.

Late Reconstruction of the Orbit With Patient-Specific Implants Using Computer-Aided Planning and Navigation

PURPOSE Reconstruction of orbital deformities is a challenging task. Virtual 3-dimensional (3D) planning and the use of patient-specific implants (PSIs) could improve anatomic and functional outcomes in the orbital region. MATERIALS AND METHODS A retrospective study was performed of patients who underwent late orbital reconstruction from 2009 to 2013. To be included in the study, patients had a unilateral orbital deformity by involvement of at least 2 orbital wall defects. No orbital osteotomies could be used to correct the deformity. All patients underwent 3D virtual treatment planning. The unaffected orbit was mirrored onto the affected orbit. The PSI was fabricated according to this plan. Navigation was used to check the implant position. RESULTS Six patients were included in this study. All patients had diplopia or motility limitations and enophthalmos. The ophthalmic parameters showed improvement in all patients. Enophthalmos was corrected adequately by the PSI. Four patients received a poly-ether-ether-ketone PSI. Two patients received a titanium mesh PSI. The position of the PSI was controlled by intraoperative navigation. Superimposition of the planned and postoperative positions of the PSI showed good correlation. CONCLUSION PSIs placed with intraoperative navigation facilitate late or secondary correction of orbital deformities.

Facial esthetics and the assignment of personality traits before and after orthognathic surgery rated on video clips

Typically, before and after surgical correction faces are assessed on still images by surgeons, orthodontists, the patients, and family members. We hypothesized that judgment of faces in motion and by naïve raters may closer reflect the impact on patients’ real life, and the treatment impact on e.g. career chances. Therefore we assessed faces from dysgnathic patients (Class II, III and Laterognathia) on video clips. Class I faces served as anchor and controls. Each patient’s face was assessed twice before and after treatment in changing sequence, by 155 naïve raters with similar age to the patients. The raters provided independent estimates on aesthetic trait pairs like ugly /beautiful, and personality trait pairs like dominant /flexible. Furthermore the perception of attractiveness, intelligence, health, the persons’ erotic aura, faithfulness, and five additional items were rated. We estimated the significance of the perceived treatment related differences and the respective effect size by general linear models for repeated measures. The obtained results were comparable to our previous rating on still images. There was an overall trend, that faces in video clips are rated along common stereotypes to a lesser extent than photographs. We observed significant class differences and treatment related changes of most aesthetic traits (e.g. beauty, attractiveness), these were comparable to intelligence, erotic aura and to some extend healthy appearance. While some personality traits (e.g. faithfulness) did not differ between the classes and between baseline and after treatment, we found that the intervention significantly and effectively altered the perception of the personality trait self-confidence. The effect size was highest in Class III patients, smallest in Class II patients, and in between for patients with Laterognathia. All dysgnathic patients benefitted from orthognathic surgery. We conclude that motion can mitigate marked stereotypes but does not entirely offset the mostly negative perception of dysgnathic faces.

Facial Aesthetics in Young Adults after Cleft Lip and Palate Treatment over Five Decades

Cleft Lip and Palate (CLP) - a common facial malformation in newborns – is typically corrected by surgical intervention to allow for normal speech development, psychosocial adjustment, and facial attractiveness. The long term treatment outcome can be evaluated after a number of years, possibly in adulthood. We investigated the aesthetics of the nasolabial region by subjective ratings. To compare various surgical approaches we recruited 12 raters to evaluate 429 patients. Expert and lay raters judged photographs from patients, who have completed treatment with one of three different surgical strategies performed in our institution over 50 years. Facial photographs were cropped, presented to the raters in a randomized sequence, and judged by the raters on a 5 point Likert scale. The subjective ratings between the raters revealed a fair to substantial inter-rater reliability. The average ratings of the surgical outcome improved continuously over the investigated 5 decades. Despite possible differences between raters and rater groups this overall result was consistently seen in the gender groups (male/female), or expertise related groups (expert/lay). Our analysis revealed that patients with bilateral CLP scored worse than patients with unilateral CLP when treated in the fifties; more recently treated patients of both groups scored similarly.

Assessment of nasalance and nasality in patients with a repaired cleft palate

In patients with a repaired cleft palate, nasality is typically diagnosed by speech language pathologists. In addition, there are various instruments to objectively diagnose nasalance. To explore the potential of nasalance measurements after cleft palate repair by NasalView®, we correlated perceptual nasality and instrumentally measured nasalance of eight speech items and determined the relationship between sensitivity and specificity of the nasalance measures by receiver-operating characteristics (ROC) analyses and AUC (area under the curve) computation for each single test item and specific item groups. We recruited patients with a primarily repaired cleft palate receiving speech therapy during follow-up. During a single day visit, perceptive and instrumental assessments were obtained in 36 patients and analyzed. The individual perceptual nasality was assigned to one of four categories; the corresponding instrumental nasalance measures for the eight specific speech items were expressed on a metric scale (1–100). With reference to the perceptual diagnoses, we observed 3 nasal and one oral test item with high sensitivity. However, the specificity of the nasality indicating measures was rather low. The four best speech items with the highest sensitivity provided scores ranging from 96.43 to 100%, while the averaged sensitivity of all eight items was below 90%. We conclude that perceptive evaluation of nasality remains state of the art. For clinical follow-up, instrumental nasalance assessment can objectively document subtle changes by analysis of four speech items only. Further studies are warranted to determine the applicability of instrumental nasalance measures in the clinical routine, using discriminative items only.