Scientific Abstract Presentations: Craniomaxillofacial 8 Sunday, October 29 Sun, Oct 29 8:00-9:30 a.m. CDT

Introduction: Disruptive mood disorders are psychiatric conditions characterized by impulsivity, and include common diagnoses, e.g., attention deficit hyperactivity disorder (ADHD), as well as less common disorders, e.g., oppositional defiant disorder (ODD). Children with these disorders may have different risks of sustaining facial trauma; additionally, their mechanisms of injury, management, and outcomes have the potential to be influenced by their diagnosis. The objective of this retrospective study was to identify the risks associated with facial fractures in pediatric patients with psychological comorbidities.

Methods: A retrospective review was conducted of all pediatric facial fractures seen at a single, level I pediatric trauma center from 2006 to 2021. Patient charts were reviewed, and all patients with documentation of ADHD or ODD were included. Variables including type of injury, mechanism of injury, type of medical intervention, and outcomes, were compared in patients with and without positive history of these psychiatric conditions.

Results: Of 3,334 children with facial fractures, 198 (6%) patients had a prior diagnosis of ADHD and 20 (1%) patients had prior diagnosis of oppositional defiant disorder (ODD). Patients with a diagnosis of ADHD or ODD were significantly older than the rest of the cohort (13.6 years vs. 11.2 years, p<0.05). Compared to children without prior diagnosis of a disruptive mood disorder, violence was significantly more likely to cause injury (30% vs 11%, p<0.05). In fact, violence was the leading primary cause of injury in patients with ODD. Patients with ADHD or ODD were found to have significantly more concomitant injuries compared with the overall patient cohort (76% ADHD, 90% ODD, 67.1% overall p<0.05). The most common of these were soft tissue injuries (64.3%) and neurologic injuries (20.1%). These patients were more likely to be admitted (45% vs. 32%) but were less likely to receive surgical management for their fracture compared with the overall pediatric facial fracture population (p<0.05).

Conclusion: In conclusion, the presence of psychological conditions is a barrier to optimal clinical management of pediatric facial fractures. The impact of psychiatric impulsivity is associated with more violent injuries requiring more hospitalizations yet less surgical intervention. Craniofacial surgeons, pediatricians, and emergency department physicians should use this data to inform clinical efforts, advocate, and improve treatment outcomes for pediatric patients impacted by the complexities of psychological comorbidities.

BACKGROUND: Nasal reconstruction utilizing the forehead flap has undergone many modifications. Early techniques inset the flap along the nose and did not create a tube. Presently, tubing of the flap base is consistently described as part of the flap creation. This report involves a direct inset of the forehead flap without tubing of the base. METHODS: Patients with defects of the nose requiring reconstruction with a paramedian forehead flap underwent the technique. A local anesthetic solution (0.05% xylocaine with 1/200,000 concentration) was liberally injected across the forehead and nose. The flap was designed and incised as a central column over the forehead, limiting the incision on the side of the supratrochlear vessels supplying the flap. On the opposite side, the incision was carried directly on the lateral aspect of the nose down to the defect. The flap was elevated with a scalpel, assisted by electrocautery, and blunt dissection was utilized to free the adhesions at the base of the flap around the vessels. The long incision along the nose was widened slightly with subcutaneous dissection to accommodate the width of the flap. The flap was then rotated inferiorly and sutured distally to cover the defect. The forehead site was closed in a straight line and the entire flap, with the turnover bulge, inset and sutured. Secondary surgery included excision of the flap-base bulge and dorsal irregularities, and cartilage grafting at 3 to 8 weeks. RESULTS: Twenty-seven patients over a twelve-year period underwent a forehead flap reconstruction of the nose without tubing of the flap base. The group was comprised of 17 women and 10 men. Flap extension or distal reach was considerably increased by avoiding the tubing of the flap base. Thirteen large defects required a second local flap to close the wound. No primary cartilage grafting was utilized as alar reconstructions in eight patients were achieved with island naso-labial turnover flaps. Five patients had secondary cartilage grafting for alar support which involved a return to the operating room. Flap base revisions and small skin excisions in twenty-two patients were performed with simple local anesthesia in an office procedure room. The flap inset did not significantly widen the nose as the flap and nasal skin contracted and re-draped. No flap loss occurred and distal-tip necrosis was minimal and self-limiting. DISCUSSION: Contemporary forehead flap techniques include tubing of the base and extension over intact skin. The forehead flap need not become an interpolated flap with bridging causing potential problems with vascularity, congestion, and length limitation. Extension of the tube over the thickness of the forehead tissue physically limits the flap. With direct inset the flap reach is extended, and the flap will cover distant defects with less tension. Secondary surgery dividing the tube is obviated and revision of nasal dorsal irregularities under local anesthesia more likely. Nasal width is minimally impacted. Direct Inset of the paramedian forehead flap, along the length of the nose, is a simple and valuable modification that should be considered for nasal reconstruction.

Purpose: Orofacial clefting (OFC) is one of the most common birth defects in the United States. Patients with OFC need long term, multi-disciplinary treatment. Orthodontic care is critical in the management of patients with OFC, as it optimizes the dentition for feeding, speech and for future surgery. Nationally, orthodontic care is difficult to access for patients with OFC due to limited numbers of specialized providers, high rates of insurance denials, as well as disparities between the number of patients with state-funded insurance and the number of providers accepting these forms of coverage. The federal and state governments have attempted to enforce insurance coverage for these patients, but barriers to care still persist due to funding shortfalls. An attempt was made to assess the barriers to obtaining orthodontic care for patients with OFC in a Florida-based cleft/craniofacial center from both a family and orthodontic provider perspective.

Methods: A 4-question multiple choice question (MCQ) survey was sent to orthodontic members of the Florida Orthodontic Association. Guardians of patients who attended the JHACH cleft and craniofacial clinic were administered a 17 question MCQ survey.

Results: The orthodontist survey was completed by 38 participants. The survey showed that 71% of orthodontists treated cleft/craniofacial patients. None underwent a dedicated cleft/craniofacial fellowship and majority (55%) had limited experience treating craniofacial patients during residency. Only 37% of orthodontists accepted Medicaid, 55% have provided pro-bono care, while self-pay and private insurance were the most commonly accepted (89% and 87% respectfully). Poor reimbursement was the most common barrier to providing care (58%), while lack of relationship with a cleft team (47%) and lack of referrals (42%) were also common. Lack of comfort with providing care to this population was the least common barrier (18%). The survey of patients' guardians was completed by 48 participants, 29 (60%) had initiated care with an orthodontist outside of the cleft team setting. The majority were insured by Medicaid (67%). Majority of patients (55%) were charged out of pocket expenses for their orthodontic care with most being charged for braces or palatal expanders/other appliances (44% each). For patients that had to pay out-of-pocket for care, most (31%) had to pay in the range of $2000-$5000 US, with 25% being charged greater than $5000 out of pocket for their care.

Conclusion: Despite both federal and state mandates, many barriers still exist in accessing orthodontic care and majority of patients experience significant out-of-pocket expenses despite statutorily mandated insurance coverage for these services. Solutions would include building relationships between orthodontists and cleft teams, promotion of orthodontists into full time roles in hospital cleft teams as well as additional federal policies and oversight bodies to advocate for these patients and ensure access to care.

Purpose: Success of Alveolar Bone Grafting (ABG) is dependent on appropriate timing of the procedure related to dental eruption. Up to 50% of patients with orofacial clefts (OFC) are dependent on Medicaid. Accessing care through Medicaid funding may be difficult due to low provider participation in Medicaid and added administrative burdens. The Affordable Care Act (ACA) sought to lower systematic costs and improve access to timely care by expanding coverage to millions. Only 38 states expanded their Medicaid programs. An attempt was made to assess the impact Medicaid expansion has had on cleft care by assessing the demographics of patients undergoing ABG in states with and without Medicaid expansion.

Methods: The Pediatric Health Information System (PHIS) database contains clinical data from 49 children's hospitals across the United States. The database was queried using selected International Classification of Diseases (ICD) 9 and 10 procedural codes for patients with an OFC who underwent an ABG between 1/6/2010 – 7/5/2022. Demographic data and variables related to their surgical encounter were identified. Two Tailed T tests were performed to assess the effect of insurance on the timing of ABG.

Results: In total, 1,233 ABG procedures were identified. Procedures done after the announcement of the Corona Virus pandemic were removed (48), leaving 1,185 procedures (Figure 1). 57% of patients were white, 5% were African-American, 19% were Asian and 14% identified as other. 17% identified as Hispanic. 59% of patients had private insurance and 31% had Medicaid. The average age at which the procedure was performed was 123.4 months (9.8 years). Patients with Medicaid insurance had procedures done at a later age compared to those with Private insurance (128.1 > 120.4 months; p=0.002). Sub-analysis was completed of patients in the 38 states that underwent Medicaid expansion comparing procedure details before and after expansion (Figure 2). Again, patients with Medicaid insurance had procedures done at a later age compared to those with Private Insurance (126.3 > 119.6 months; p=0.02). Patients undergoing ABG with private insurance exhibited no statistically significant change in the in the age at which these procedures were performed (117.3 vs 121.3 months; p=0.2). At the same time, patients whose procedures were funded by Medicaid exhibited a significant increase in the age at which ABG was completed (118.0 vs 131.1 months; p=0.01).

Conclusions: ABG is a time sensitive procedure which requires coordinated care between orthodontics and surgery. Delayed care may impact outcomes as ideal treatment protocols necessitate grafting prior to dental eruption. Our data indicates patients with Medicaid funding underwent ABG 7.7 months later than those with private insurance funding. Interestingly, in expanded states patients with Medicaid experienced worsening delay in the time of ABG, after expansion, by 13.1 months. We hypothesize that increased access to care without administrative reforms or increased reimbursement rates resulted in more patients attempting to access an already strained system and increased delays in management.

Background: Submucous cleft palate (SMCP) is a congenital anomaly, affecting 1 in 1200 live births. Early detection facilitates proactive speech therapy and development of compensatory speech mechanisms. However, SMCP is a subtle exam finding, contributing to delays in diagnosis. Though the timing and necessity of repair remains controversial, literature suggests an increased risk of persistent velopharyngeal insufficiency (VPI) with delayed care. This study aims to analyze the relationships between patient demographics, age of diagnosis and repair, and post-operative outcomes in patients with SMCP.

Methods: A retrospective review was conducted of patients with surgical indications for SMCP who underwent palatoplasty at an urban academic children's hospital from 2003-2022. Patient socioeconomic characteristics, medical history, and postoperative outcomes were collected. Patients were compared based on insurance type and government assistance utilization. Statistical analyses including Independent T-test, Wilcoxon Ranked Sum test, Chi-Squared analyses, Fisher's Exact Test, and Univariate/Multivariate logistic regression were performed using RStudio version 4.2.1.

Results: Upon review, 1,552 patients were identified with cleft palate, of which 105 had a SMCP. Among those with SMCP, 69.5% (n=73) had public insurance and 30.5% (n=32) private insurance. Patients with public insurance were diagnosed later (5.5±4.6 vs. 2.6±2.4 years old; p<0.001) and underwent palatoplasty later (7.3±4.1 vs. 4.4±3.4 years old; p<0.001) than those with private insurance. Patients receiving government assistance experienced higher rates of post-surgical persistent VPI (74.5% vs. 44.8%; p=0.006). The average length of follow up was 3.9±3.8 years.

Conclusion: Our results suggest a disparity in the recognition and treatment of surgical SMCP. Hence, financially vulnerable populations may experience an increased risk of inferior speech outcomes and subsequent therapies and procedures.

Purpose: Historically, patients with wide clefts would have undergone nasoalveolar molding (NAM) pretreatment; however, the introduction of early cleft lip repair (ECLR) has challenged the efficacy of the traditional technique and its impact on improving nasal symmetry for these patients. This study compares the revision rate between ECLR and TLR with NAM (TLR+NAM) among patients with the most severe cleft width ratio (CWR).

Methods & Materials: A retrospective review was conducted on patients with UCL who underwent cleft lip repair from 2011-2022. Patients with craniofacial syndromes were excluded. Demographics, corrected gestational age, cleft phenotype, NAM use, revisions, and follow-up time were collected. Patients with a pretreatment cleft width ratio (CWR) greater than 0.5 (classified as severe) were included. Fisher exact, independent t-test, and Kaplan-Meier analysis were performed.

Results: Upon review, 236 patients with UCL and nasal deformities were identified, of which 131 (55.5%) underwent ECLR and 105 (45.5%) TLR+NAM. Thirty-two ECLR and 24 TLR+NAM patients were identified to have a severe CWR (0.59±0.08 vs. 0.54±0.06; p=0.003). Average age of repair was 1.0±0.5 months and 3.6±0.9 months for ECLR and TLR+NAM cohorts, respectively (p<0.001). Average follow-up time was 4 and 7 years for each group, respectively. Additionally, 9.4% of patients undergoing ECLR underwent revision compared to 45.8% in the TLR+NAM cohort (p=0.004). The five-year revision rate of the TLR+NAM cohort (42.0%) was significantly higher compared to the ECLR cohort (10.3%; p=0.042). Overall follow-up time was 4.9±2.7 years.

Conclusion: These results demonstrate that despite more severe cleft phenotypes, ECLR is associated with a lower revision rate compared to TLR+NAM.Access to and execution of ECLR when feasible could contribute to improved outcomes and decreased burden of care for families and patients with UCL, as well as facilitate a more expedient repair.

Background/Purpose: Alveolar bone grafting (ABG) is a procedure utilized in alveolar cleft repairs that promotes maxillary arch stabilization, facilitates closure of oronasal fistulae, and corrects the nasal alar bases. Traditionally, ABG has been classified according to chronological age as primary ABG (~2 years), early secondary ABG (2-5 years), secondary ABG (6-12 years), and tertiary/delayed ABG (12+ years). Ideal timing of ABG has yet to be standardized for patients with cleft lip and palate. This study aims to investigate the impact of the timing of ABG on the incidence of adverse postoperative events.

Methods/Description: A retrospective review using the National Surgical Quality Improvement Program-Pediatric (NSQIP-PEDS) database was performed. Patients who underwent ABGfrom 2012 to 2020 were included. Patient characteristics, comorbidities, complications, readmission rates, and reoperations rates were collected and analyzed. Pearson's chi-squared, independent t-test, and multiple logistic regression were used for statistical analysis. Additionally, receiver operating characteristic (ROC) curve analysis was performed to determine the appropriate cutoff values for patient subgroups.

Results: Among 863,860 patients in the database, 5,719 patients underwent ABG, of which 103 (1.8%) had documented postoperative complications. Analysis of the data indicated that patients who had complications were older compared to those that did not (10.8±3.6 vs 10.1±2.8 years, p=0.021). A ROC curve analysis indicated a cutoff age of 12 years (AUC 0.57, p=0.044). Patients above the 12-year cutoff had higher rates of postoperative complications compared to those younger than 12 years of age (1.7% vs. 1.0%; p=0.030).

Conclusion: Appropriate timing of ABG is essential for the successful management of alveolar clefts. This analysis demonstrates a unique age-dependent rise in postoperative complications beyond 12 years of age. Surgeons performing ABG should consider early surgical intervention. A 12-year threshold should be considered for patients with alveolar clefts to reduce the risk of complications. Future studies should assess additional factors such as postoperative bone quality to further characterize the optimal timing.

Introduction: Lambdoid craniosynostosis (LC) results in a classically trapezoid-shaped cranium. Cephalometric study in these individuals has largely remained in areas with well-defined landmarks such as the face and skull base. Detailed analysis of the smooth calvarium remains limited. With the implementation of automated systems which can better measure a smooth surface, better cranial shape measurement is possible. Understanding preoperative morphology will allow for improved pre- and post-operative evaluation as well as differentiation of this population from the morphologically similar but benign pathology, positional plagiocephaly (PP).

Methods: The Wake Forest Cranial Imaging Database, a multicenter imaging database, was used to identify individuals with lambdoid craniosynostosis (n=53). A control group was established using 200 consecutive patients with positional plagiocephaly. A single preoperative CT or 3D-photograph was used to create a cranial surface model of each individual which was then mirrored as needed so that posterior flattening was oriented on the left in all individuals. Cartesian grids were created on the scalp's surface based on the head's length, width, and height. To control for head size, length, width, and height at each point were measured relative to an individual's total cranial length, width, or height. Population averages at each point were calculated and compared so that regional trends could then be analyzed using population trends. Finally, these trends were captured in a succinct tool to create an index that could differentiate between the two groups. Diagnostic performance was evaluated using Area Under the Curve Analysis (AUC).

Results: On the side of posterior restricted growth, individuals with LC have more severely restricted length, width, and height. Restriction increased at more lateral points but was relatively unaffected by height. On the contralateral posterior side, this leads to compensatory growth measured as increases in length, width, and height which occur to a greater extent at more superior regions as the distance from the fused suture increases. In the anterior cranium, individuals with LC were relatively longer, wider, and taller in all regions with the exception of ipsilateral to posterior restriction where width is relatively similar to that of individuals with positional plagiocephaly. Overall in LC, posterior restriction is more severe leading to compensatory growth that is largely contralateral in both the anterior and posterior cranium. By measuring anterior compensatory growth and differences in posterior width asymmetry, the most effective tool for differentiating LC and PP was created. Of note, performance lessened with measurement of posterior length, thus indicating that while restriction is greater in craniosynostosis, those with the most severe plagiocephaly obtain a similar morphology. This final index functions near the level of CT imaging (AUC: 0.999, Sensitivity: 100%, Specificity: 98.5%).

Conclusion: By aiding clinicians in the objective measurement of lambdoid craniosynostosis, physical exam, operative planning and post-operative follow-up can be augmented by a tool that accurately measures the abnormality. This detailed measurement functions near the level of CT imaging without the need for sedation or radiation.

Introduction: Facial muscles viability declines as time progresses in patients with facial paralysis, thereby making facial reanimation a time-sensitive procedure. Wallerian degeneration leads to degradation of intramuscular nerve fibers, resulting in a decrease in motor-units, muscle atrophy and an increase in connective tissue. As a result, reinnervation becomes increasingly difficult over time. Therefore, providing re-innervation to the facial muscles after facial nerve injury of any kind, is of high importance. In 1984, Terzis presented the 'babysitter' procedure, which uses 40% of the fiber of the hypoglossal nerve to sustain muscle tissue, as the axon fibers grow along the Cross-Face-Nerve-Grafts (CFNG). This technique gained great popularity ever since. In recent years however, dual nerve reinnervation techniques have emerged, slowly replacing the traditional single nerve procedures. In particular, the hypoglossal nerve and the masseter nerve are frequently utilized for facial reanimation. The aim of this study was to compare two different surgical techniques of dual innervation using the masseter and hypoglossal nerve. Methods: Twenty-one patients with facial paralysis underwent the dual "babysitter' procedure with the masseter branch of the trigeminal nerve and hypoglossal nerve prior to CFNGs. In one group, the masseter branch was coaptated to the upper division of the injured facial nerve, whereas the lower division was sutured to 35% of the hypoglossal nerve fibers. In the second group, the masseter branch was coaptated to only the zygomatic branch of the facial nerve and 45% of the hypoglossal nerve fibers were sutured to the entire facial nerve trunk. Surgical outcomes of both groups were evaluated after 6 months, 9 months and 12 months by utilizing automated facial landmark recognition (Emotrics) and by assessing the severity of facial paralysis using the House-Brackmann score. Results: This retrospective study included 21 patients, 12 female and 9 males, with an average age of 35 years (+/- 20 years). The youngest patient included was 7 years old. Group one consisted of 8 patients, whereas group two included 13 patients. The etiology of facial paralysis varied from bell's palsy, intracranial malignancy, intracranial bleed, cavernous malformation and traumatic injury. The average time of denervation in group one was 13 months (+/- 5 months) and in group two 15 months (+/- 4 months). Both methods yielded satisfying outcomes and presented with different advantages and disadvantages. Conclusion: Both dual- "babysitter' procedures showed promising results as they increased symmetry, facial tone and facial movement. This study provides crucial information comparing two different methods for achieving reinnervation in facial paralysis patients.

BACKGROUND: Disruption of the growth plate of long bones is known to affect normal development, but it is unknown how osteotomies of the newborn skull might affect development of certain features, such as the frontal sinus. The purpose of this study was to compare frontal sinus volume in children who underwent lower frontal osteotomies vs those who did not undergo cranial osteotomies.

METHODS: Retrospective study was conducted of children with maxillofacial CT scans older than 5 years of age. The experimental group included patients who previously underwent lower frontal osteotomies for frontoorbital advancement in early childhood, whereas the control group included patients who had never undergone cranial vault surgery.

RESULTS: There were 7 pediatric patients older than 5 years returning for a CT scan after previous surgery for craniosynostosis; these patients were 6.2 months old at surgery, and their CT scan was 5.01 years after surgery. There were 80 control patients older than 5 years undergoing CT scan for other indications with no prior cranial surgery.

Patients with previous lower frontal osteotomies have significantly smaller frontal sinus volume than control patients without cranial osteotomies (p=.021, 1431 mm3 vs 4020 mm3). Over half of the patients (57.1%, n=4 of 7) with previous cranial vault surgery with lower frontal osteotomies developed no appreciable pneumatization of the frontal sinus, whereas only a few control patients (8.8%, n=7 of 80) developed no appreciable pneumatization of the frontal sinus (p<.001).

CONCLUSIONS: Patients with previous lower frontal osteotomies are associated with significantly lower pneumatization of the frontal sinus than patients without lower frontal osteotomies.

Background Composite cranial defects result from pathological conditions that lead to loss or sacrifice of scalp soft tissue in addition to the underlying calvarium.1 Reconstruction of these defects is particularly challenging and there is currently no consensus on the ideal approach to the management of this more difficult subcategory of cranial defects.2, 3 We investigated the outcomes of composite cranial defect reconstruction with alloplastic material or autologous bone, with scalp reconstruction by adjacent tissue transfer or microvascular free flap coverage in three high-volume institutions.

Methods An IRB-approved chart review was performed on patients 6 years old and older undergoing cranioplasty with scalp reconstruction in the last 35 years. Patients were divided in three groups, those who underwent calvarium reconstruction using titanium mesh, other alloplastic material or autologous bone. In addition, scalp reconstruction was analyzed depending if soft tissue reconstruction was accomplished with locoregional flaps or with distant free tissue transfer. Predictive variables including demographics, comorbidities, risk factors and defect etiology and characteristics were collected. Retention and complication rates were compared among groups.

Results A total of 298 cranioplasties with scalp reconstruction were performed in 202 patients across all institutions between January 2010 and December 2020. The most common reason for cranioplasty was relief if intracranial pressure (34%). 103 patients had calvarium reconstruction using titanium mesh (n=28), other alloplastic material (n=59), or a combination of both (n=16). Autologous bone was used in 194 cranioplasties. Overall, 121 patients had scalp reconstruction with loco-regional flaps while 81 had free flaps. Calvarial reconstruction with titanium mesh had worse retention rates than other alloplastic material and autologous bone, (56% vs 69% vs 88%, respectively) (p<0.05). There was no difference in retention rates when comparing scalp reconstruction among groups (p = 0.12).

Conclusion Successful reconstruction of composite cranial defects remains a challenge, owing to high rates of postoperative wound breakdown, with the risk of associated infection and CSF leak. This study supports our previous work, in a larger, multi-institutional scale, and helps elucidate the best clinical practice in patients requiring cranioplasty with scalp reconstruction.

References: 1. Goldstein JA, Paliga JT, Bartlett SP. Cranioplasty: indications and advances. Current opinion in otolaryngology & head and neck surgery. 2013;21(4):400-409. 2. Zanotti B, Zingaretti N, Verlicchi A, Robiony M, Alfieri A, Parodi PC. Cranioplasty: review of materials. Journal of Craniofacial Surgery. 2016;27(8):2061-2072. 3. Kwiecien GJ, Rueda S, Couto RA, et al. Long-term outcomes of cranioplasty: titanium mesh is not a long-term solution in high-risk patients. Annals of Plastic Surgery. 2018;81(4):416-422.

Background: Alveolar bone grafting remains a challenge in the reconstructive sequence for children suffering from unilateral or bilateral clefts. In many instances, children may require multiple procedures to create a stable bony foundation for eruption of teeth adjacent to the cleft.1 Extracorporeal shock wave therapy (ESWT), which consists of targeted acoustic waves, has been utilized as adjunctive modality to increase bone mineral density, trabecular thickness and increase expression of growth factors during mandibular distraction osteogenesis.2,3 Here, we look at the efficacy and safety of applying ESWT as an adjunct to secondary alveolar bone grafting.

Methods: A retrospective review was conducted of all children that underwent secondary alveolar cleft bone grafting with adjunctive ESWT between 2019 and 2021. All patients were treated with ESWT intraoperatively, and twice post-operatively. Patient variables abstracted from the medical record included age, gender, cleft type, cleft width, pre-operative cleft dentition, volume of bone graft placed intraoperatively, and ESWT settings. Primary outcome of interest was percentage of viable graft volume as a percentage of initial graft placed, as measured by cone bean computed tomography (CBCT). Secondary outcomes included pain medication utilization, length of stay (LOS), and incidence of complications.

Results: Twenty patients met inclusion criteria. Mean age at surgery was 9.9 years (range 8-16). Four (20%) patients were female; 16 (80%) were male. Eight (40%) patients had bilateral alveolar clefts; 12 (60%) had unilateral clefts. Mean energy applied was greatest intraoperatively (5136 mJ), followed by second and third applications at an average of 9 and 25 days post-operatively, respectively (~2000 mJ). First CBCT performed at an average of 106 days post-operatively found an approximate 19.5% take, when compared to initial graft volume. Second CBCT performed at an average 291 days post-operative, measured a mean of 29.0% graft take, representing a 50% increase in volume from initial measurement. All patients (100%) were discharged on the day of surgery. Only twelve (60%) patients required narcotic medication post-operatively, for an average of 2 doses of narcotic medication in the entire cohort (range 0-6.5). Three (15%) patients experienced minor complications.

Conclusions: This preliminary report describes a protocol for safely implementing perioperative ESWT for children undergoing alveolar bone grafting harvested from the iliac crest using a minimally invasive approach. Initial outcomes suggest that this therapy may expedite visualization of bone consolidation without any associated increase in complications. The utility of ESWT has been advocated by other surgical specialties and may represent an opportunity to improve care and outcomes in craniofacial surgery. Pertinent considerations, the role of standardized assessment protocols, and future directions will be reviewed.

1. Weissler EH, Paine KM, Ahmed MK, Taub PJ. Alveolar Bone Grafting and Cleft Lip and Palate: A Review. Plast Reconstr Surg. 2016;138(6):1287-1295. doi:10.1097/PRS.0000000000002778
2. Ginini JG, Maor G, Emodi O, et al. Effects of Extracorporeal Shock Wave Therapy on Distraction Osteogenesis in Rat Mandible. Plast Reconstr Surg. 2018;142(6):1501-1509. doi:10.1097/PRS.0000000000004980
3. Ginini JG, Emodi O, Sabo E, Maor G, Shilo D, Rachmiel A. Effects of Timing of Extracorporeal Shock Wave Therapy on Mandibular Distraction Osteogenesis: An Experimental Study in a Rat Model. J Oral Maxillofac Surg. 2019;77(3):629-638. doi:10.1016/j.joms.2018.07.018

Background Orofacial clefting (OC) is the most common congenital anomaly affecting the face(1). OCs are variable in presentation and require multidisciplinary care from infancy to facial maturity to fully restore form and function. Rates of OC have historically varied among different regions and ethnic groups. However, many prior reports have been limited in scope and studied a homogenous population that is not reflective of the diverse United States (US) population. Therefore, this study aims to better define the US incidence, identify the geographic variability, and clarify the impact of sociodemographic factors of OC. Methods Aggregated and de-identified data was sourced from EPIC CosmosTM, a data collective that amalgamates patient records from 180 participating institutions in the US that utilize EPIC medical records. Patients born between November 2012 and November 2022 were included in this study. Data was sourced directly from the Cosmos pre-built interface (SlicerDicerTM), in which categorical variables are reported as counts, and continuous variables are reported as means and standard deviations. In this study, eight cohorts of OC patients were identified using a combination of ICD codes. Following cohort identification, descriptive analyses of demographic variables including race, sex, ethnicity, regional and temporal incidence trends, and social determinant associations were conducted. The Social Vulnerability Index (SVI), developed by the CDC and initially intended for identification of at-risk communities, was used to identify social determinants of health among the included cohorts. Univariate analysis, Student t-tests, and Cochrane Armitage tests were used to evaluate differences in trends of SVI variables. Results There were 15,697,366 patients identified between November 2012 and November 2022, of which 31,216 patients were diagnosed with any OC, for an incidence rate of 19.9 (95% CI: 19.7-20.1) per 10,000 live births. Incidence rates of OC were observed to be highest among Asian (27.5 CI:26.2-28.8) and Native American (including native Hawaiian, Alaskan and Pacific Islanders) patients (32.8 CI:30.4-35.2) and lowest among Black patients (12.96 CI:12.5-13.4). Male and Hispanic patients exhibited higher OC incidence than female and non-Hispanic patients. There were no differences in incidence rates among metropolitan (20.23 per10,000), micropolitan (20.18 per 10,000), and rural (20.02 per 10,000) populations. When stratifying SVI analysis by three different racial/ethnic groups (White, Black, Hispanic), results were largely similar. Notably, however, socioeconomic metrics, including uninsured status, poverty, and unemployment, were correlated with OC primarily among White and Hispanic patients while these variables were less significant among Black patients. Further, communities with a higher proportion of minority language speakers correlated with decreased OC incidence, and this correlation was most notable among Hispanic identified patients. Conclusions This study examines the largest cohort of oral cleft patients reported to date and reports the contemporary US OC incidence rates, which demonstrate a marginal increase from previous estimates. Importantly, we found that percent below the poverty line was most strongly correlated with OC, reinforcing the impact of social determinants on health. These findings can help to screen and counsel expectant families and direct future research.

References 1. Middleton W, Kurtz A, Hertzberg B. Fetal Central Nervous System: Head and Spine. In: Ultrasound. 2nd ed. Elsevier; 2004:374-413.