Objectives: The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment. Methods: This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed. Results: Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas. Discussion: In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental–alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.

Objective: The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular. Setting/Participants: This is a retrospective review of 20 adult patients with SND after endoscopic endonasal approach (EEA) for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center. Outcome Measures: Fifteen measurements related to SND were obtained on pre-and post-operative imaging. Statistical analyses were performed to evaluate differences between pre- and post-operative anatomy. Results: The most common EEA was transsellar. Reconstruction techniques included 9 free mucosal grafts alone, 8 vascularized nasoseptal flaps (NSF), 1 combined free mucosal graft/abdominal fat graft, and 1 combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection and nasolabial angle post-operatively. Sub-group analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2mm, p=0.039) and increased alar base width (1.2mm, p=0.046) post operatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on post-operative imaging, in contrast to those with functional adenomas who had no measurable significant changes. Conclusions: Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.

Dens invaginatus is a rare developmental anomaly characterized by an infolding of the enamel organ within the crown or root of a tooth, and it is an example of a dental anomaly that has a higher incidence in patients with CL/P. If undiagnosed, dens invaginatus can lead to severe, acute pain and pulpal necrosis since it can permit direct entry of bacteria into the dental pulp. Treatment of dens invaginatus includes prophylactic sealant or composite restoration, endodontic therapy if pulpal involvement has already occurred, or extraction if aberrant tooth morphology precludes endodontic therapy. Few studies report on the incidence of dens invaginatus in patients with CL/P. The purpose of this article is to describe 4 cases of dens invaginatus in patients with CL/P which were encountered in a cleft-craniofacial orthodontic clinic. Each case describes dens invaginatus in a maxillary lateral incisor, and treatments ranged from sealant application to endodontic therapy to extraction. These cases highlight the importance of awareness of this dental anomaly among cleft team providers to facilitate early diagnosis in patients with CL/P.

Purpose: Despite the interplay between orthodontics and orthognathic surgery, trainees in plastic surgery and oral and maxillofacial surgery do not receive formal training in orthodontics and associated hardware. This study aims to help surgical trainees better understand the role of orthodontic treatment in achieving enhanced dental occlusion and alignment and optimize surgical decision making. Methods: A review of recent literature was conducted to consolidate current practices for the use of orthodontic devices commonly used in orthognathic surgical patients. Results: Orthodontic treatments may be preventive, interceptive, and/or corrective. Braces and clear aligners are popular devices used to correct tooth positioning via 3 orders of control: first (“in-out” and rotation), second (mesio-distal angulation or “tip”), and third order (inclination or torque). Further, various treatments exist for skeletal and dental malocclusions, which may occur in transverse (crossbites, narrow arches) and/or sagittal (over/underbites) planes. Palatal expanders such as the Hyrax or Haas assist in correction of transverse deficiencies. Appliances for sagittal corrections typically take advantage of patient’s remaining growth and include a variety of headgear types (cervical, high-pull, occipital, reverse-pull), functional appliances (fixed or removable), or simply the use of interdental elastics. Conclusion: As patients are increasingly seeking orthodontic care in conjunction with surgery, it is important for surgical trainees to develop a strong understanding of the various orthodontic devices used.

Objective To describe a novel orthodontic appliance to prevent pedicle trauma in patients undergoing double-opposing buccal flap surgery for secondary palatal lengthening. Design Case series. Setting Cleft and craniofacial clinic, Johns Hopkins Children's Center. Patients, Participants Four patients undergoing double-opposing buccal flap surgery for repair of velopharyngeal insufficiency. Interventions Patients were fitted with the device, which consists of a lower lingual holding arch with acrylic bite blocks. Main Outcome Measure Presence of pedicle trauma postsurgery and tolerability of the device. Results The appliance was well tolerated in all 4 patients and no biting trauma to the pedicles was observed. Conclusions A reliable appliance has been developed to prevent biting trauma to the pedicles in patients undergoing double-opposing buccal flap surgery in the permanent dentition stage.