Comparison of Treatment Outcomes of Two Palatal Repair Methods Using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices

Comparison of Treatment Outcomes of Two Palatal Repair Methods Using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Treatment Outcomes of Two Palatal Repair Methods Using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices Kimia Baghaei, Shabnam Ajami, Niloofar Azadeh, Aylar Afshari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6420449/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background. Unilateral cleft lip and palate (UCLP) is a congenital defect affecting speech, appearance, and maxillofacial growth, often requiring surgical interventions. Comparative studies are needed to evaluate the outcomes of different palatoplasty techniques for improved treatment planning. Objectives. To compare the outcomes of Nadjmi's modified Furlow palatoplasty and pushback palatoplasty techniques in UCLP patients utilizing the Modified Huddart index, EUROCRAN Yardstick, and the 5-year-old index. Methods. Forty non-syndromic UCLP patients from Shiraz Cleft Lip and Palate Clinic were included: 19 underwent Nadjmi’s modified Furlow palatoplasty, and 21 pushback palatoplasty. Study models were rated by three orthodontists using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices. The data was analyzed using a general linear model, with p < 0.05 designated as the significance level. Results. According to the 5-year-old index and EUROCRAN dental arch relationships, there was a significant difference ( p = 0.003) between the two groups. However, palatal morphology was not significantly different between the two techniques ( p = 0.838). Mean mHB scores were − 2.45 for Nadjmi’s modified Furlow and − 8.76 for the pushback palatoplasty group ( p < 0.001). Moreover, the oronasal fistula rate was 15% in Nadjmi’s modified Furlow and 47% in the pushback palatoplasty group. Conclusions. Nadjmi’s modified Furlow palatoplasty offers superior outcomes in maxillary growth and dental arch relationships, with fewer complications. However, based on the EUROCRAN index, palatal morphology outcomes were similar for both techniques. Moreover, further longitudinal studies are needed to confirm the results of the present study. Cleft Lip Cleft Palate Dental Arch Plastic Surgery Procedures Treatment Outcome Figures Figure 1 Figure 2 Introduction One of the most prevalent birth abnormalities is unilateral cleft lip and palate (UCLP) (1). CLP occur in about 1.7 out of 1000 live births with regional and ethnic variations (2). Long-term negative consequences for social integration and health can result from the effects of CLP on a patient’s speech, hearing, appearance, and psychology. In general, children afflicted with these disorders require multidisciplinary management from infancy through the adult years. They also experience greater morbidity and mortality than the general population throughout their life span (2). To repair this anomaly, patients born with UCLP require numerous surgeries and/or other intricate procedures. Patients born with UCLP are usually treated with surgical repair of both the lip (usually at the age of 3 months) and the palate, which could be done at any point between the ages of 6 and 18 months (3). Regardless of the surgical method, good speech ability, favorable nasolabial appearance, and dentoskeletal growth are the primary goals for both patients and the cleft team. As there is a disagreement about the optimal procedure for cleft surgery, different variations have been made based on various surgical type, approach, and sequence of lip and palate surgery in UCLP treatment (4). To compare the effectiveness of each cleft treatment, the quality of the malocclusion of the dental arches and the midfacial growth as outcome measures should be considered (5). Arch connections are one of the primary results following cleft repair as they show the maxillary growth in anterior-posterior, transverse, and vertical dimensions. Regarding the results of surgery for either palate or lip restorations, there is still no consensus over the optimal surgical procedure (6, 7). The goal of the surgery, variations in case severity, and the experience, skill, and preferences of the surgeon may also have an impact on the outcomes of the surgery (5). In this regard, Abdel-Aziz and Ghandour conducted a study comparing the V-Y pushback and the Furlow techniques and found that the Furlow technique performed better in terms of treatment outcomes than the V-Y pushback method.(8) In contrast, in another study, the V-Y pushback method had a positive prognosis for speech (9). A previous study used the 5-year-old Index and the modified Huddart/Bodenham scoring system to examine the dental arch relationship (overjet, overbite, and sagittal occlusion) on plaster casts of UCLP patients aged from 5 to 6 who underwent different surgical protocols. The findings indicated that, based on sagittal occlusion, their dental arch relationship was clinically equal, even though their treatment protocols differed significantly. Besides, they stated that while a properly executed treatment plan is crucial for cleft patients, the surgeon's competence and caseload both play a significant role in the caliber of the outcomes (10). Fudalej et al. graded the palatal morphology and dental arch relationship employing the EUROCRAN index and dental casts to evaluate the relationship between the dental arch and the UCLP following one-stage and three-stage surgical procedures. They found that the morphology of palate in the single-stage sample was superior to that of the three-stage group (11). The modified Huddart/Bodenham scoring system (mHB) was utilized in observational studies to assess how well patients with complete UCLP (CUCLP) responded to treatment. They found that the likelihood of adverse treatment outcomes was higher for cases treated with the Veau-Wardill-Kilner method (palatoplasty) and the modified Millard approach (cheiloplasty) (12). Objectives Several indices have been introduced in the literature to measure these outcomes of different surgical methods for UCLP patients. Despite the availability of various palatoplasty techniques (13–15), comparative studies evaluating outcomes using standardized indices like the Modified Huddart/Bodenham scoring system remain scarce. This study aims to address this gap by comparing two techniques (Nadjmi's modified Furlow palatoplasty and pushback Palatoplasty) and their implications for treatment planning in UCLP patients using three different indices, including the Modified Huddart index, EUROCRAN Yardstick index, and the 5-year-old index. Material and methods This retrospective cross-sectional study was conducted in 2016 at the Department of Cleft Lip and Palate, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran. The study complied with all relevant principles of the Declaration of Helsinki and was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.DENTAL.REC.1400.065). The inclusion criteria were children with non-syndromic UCLP who were between the ages of 5 and 12 at the time of study. Consequently, all patients with CUCLP who were treated at Cleft Lip and Palate Clinic, Shiraz University of Medical Sciences and had lip repair followed by palatal closure using one of the two techniques (i.e., Nadjmi’s Modified Furlow palatoplasty and Wardill kilnery [Push back] palatoplasty), were included in the study. Due to the limited number of patients who underwent palatal closure through Nadjmi’s modified Furlow technique, all patients satisfying the inclusion criteria entered the study and formed the sample size. Each family received an explanation from a social worker about the purpose and procedures of the study, as well as the fact that participation was completely voluntary. In total, 40 non-syndromic UCLP patients with the male/female ratio of 21/19 were included in the study. Written informed consent was obtained from the parents or guardians of each patient who participated in the study. Patients who underwent palatoplasty with the push-back technique were subsequently matched for age and sex with the aforementioned group and entered the study. Then, the medical records and photo documentation of all patients were retrieved. Patients with missing medical records and incomplete data were excluded from the study. In addition, patients with Simonart’s band, syndromes, and craniofacial anomalies in relation with UCLP were excluded from the study. After that, study models were prepared from all the subjects through alginate impressions. All models were orthodontically trimmed and polished (Fig. 1 ). Before the orthodontic intervention and alveolar bone grafting, evaluations were performed based on gathered data. Three skilled orthodontists who were trained to use the three indices evaluated the models. To provide a blind examination, the dental models were numbered. A display of reference models that were indicative of the scales specified in each index gave each rater the chance to compare any combination of models to be rated (16). During the rating process, raters were not allowed to confer or talk with one another. For statistical purposes, the median values of the three raters were taken into account. About 20% of the dental models underwent a second evaluation, which took place at least a month following the initial assessment. Statistical analysis SPSS software, version 21.0 (SPSS Inc., Chicago INC, USA), was utilized for data analysis. The frequency, percentages, and mean ± SD of the collected data were displayed. Also, the mean ± SD of indices were determined for each variable (patient sex and palate repair technique). A general linear model (GLM) was used to analyze the variables indicated above. Various comparisons were conducted using the Tukey post-hoc test. The Kappa index was used to calculate agreements between the inter and intra-raters. Moreover, p ≤ 0.05 was considered statistically different. Results A sample of 40 non-syndromic UCLP patients was included in the present research. The total ratio of male/female was almost 1/1. In our study 19 patients underwent Nadjmi’s Modified Furlow palatoplasty, and 21 Wardill kilnery (Pushback) palatoplasty. The sex distribution was not significantly different between the two groups ( p = 0.75). However, the male age distribution of the two groups was significantly different ( p = 0.004). The patients’ demographic characteristics are described in Table 1 . Table 1: The Demographic information of the participants of the study Variables Nadjmi’s modified Furlow Technique Pushback Technique P value Number of samples, n (%) 19 (47.5) 21 (52.5) 0.7518 Sex Male 8 13 0.2752 Female 11 8 0.4913 Mean age at the time of data collection (years) (mean±SD) 7.13±1.12 8.88±2.25 0.0040 * Kappa score was used to assess reliability within and between the examiners for the 5-year-old index and the EUROCRAN index. The intra- and inter-rater reliability scores were 0.32. Pearson correlation was used to measure the reliability of the mHB scoring system, and there was perfect agreement within and between the raters for the mHB scoring system ( p < 0.001). Five-year-old index Table 2 presents the mean score and mean score distribution of the 5-year-old index. As indicated, 57.9% of the patients who underwent Nadjmi’s modified Furlow palatoplasty scored 1 and 2, 21.1% scored 3, and 21.1% scored 4 and 5, with a total mean score of 3.254. However, in the pushback palatoplasty group, 9.5% scored 1 and 2, 38.1% scored 3, and 52.4% scored 4 and 5, with a total mean score of 2.193. The Mann-Whitney test showed a significant difference between the two groups ( p = 0.003) (Table 3 ). Table 2 Numerical and Percentage distribution of the 5-Year-Old Index scores Scores Pushback Group N (%) Nadjmi’s modified Furlow Group N (%) 1(Excellent) 0 (0) 4 (21.1) 2(Good) 2 (9.5) 7 (36.8) 3(Fair) 8 (38.1) 4 (21.1) 4(Poor) 9 (42.9) 3 (15.8) 5(Very poor) 2 (9.5) 1 (5.3) N, number Table 3 Comparison of 5-Year-Olds’ Index score among two groups (p value = 0.003) Groups Sample size 5-Year-Old Index score Mean ± SD P value Nadjmi’s modified Furlow 19 2.1930 ± 1.09045 0.003* Pushback 21 3.2540 ± 0.80211 SD, standard deviation; *, significant EUROCRAN Table 4 shows the mean score of both palatal morphology and dental arch relationship of the two groups. Moreover, the score distribution of the EUROCRAN index for dental arch relationship is illustrated in Fig. 2 . Table 4 Comparison of EUROCRAN Index score among two groups Groups Dental arch relationship (Mean ± SD) Palatal Morphology (Mean ± SD) Nadjmi’s modified Furlow 2.0105 ± 1.149 2 ± 0.667 Pushback 3 ± 0.836 2.38 ± 0.589 SD, standard deviation Pearson Chi-square test showed that the distributions among the two methods was significantly different ( p = 0.030). Thus, Nadjmi’s modified Furlow palatoplasty technique had a significant association with a favorable dental arch relationship, in contrast with the pushback technique. On the other hand, the analysis demonstrated that the mean score of palatal morphology among the two methods was not significantly different ( p = 0.838). The mHB scoring system Table 5 shows the mean modified Huddart and Bodenham scores. The mean total score for Nadjmi’s modified Furlow group and Pushback group were − 2.45 and − 8.76, respectively. Significant differences ( p < 0.001) were observed between these two methods using independent t-tests. Table 5 Comparison of modified Huddart and Bodenham scores among two groups Groups Number of patients Mean ± SD P value Nadjmi’s modified Furlow 19 -2.4561 ± 5.36358 P < 0.001* Pushback 21 -8.7619 ± 3.61193 SD, standard deviation; * significant Fistula formation The distribution of the presence of fistula in the two groups of Nadjmi’s modified Furlow and pushback palatoplasty was as follows: In Nadjmi’s modified Furlow group only 15% (n = 3) had fistula, however, this percentage in the pushback group was 47% (n = 10). According to the Chi-Square test, the two methods were significantly different compared to each other ( p = 0.032). Spearman Correlation test analysis showed that there was a strong positive correlation between the 5-year-old index and the EUROCRAN dental arch relationship scoring system (Correlation Coefficient = 0.874). Additionally, a strong negative correlation between the mHB scoring system and the 5-year-old index as well as between the mHB and EUROCRAN dental arch relationship index (Correlation Coefficient = -0.922) was observed. In contrast, the correlation between EUROCRAN palatal morphology and the other three indices was not significant ( p > 0.05). Discussion Gaining normal speech ability, promoting maxillofacial growth, and preventing fistula formations, are the ultimate objectives of treatment in patients with cleft palates. Regarding the results of surgery for lip and palate restoration, there is still no agreement concerning the optimal surgical procedure. The present retrospective cross-sectional study evaluated treatment outcomes of two different palatoplasty techniques, (i.e., Nadjmi’s Modified Furlow palatoplasty and pushback palatoplasty) in UCLP patients. The 5-year-old index, mHB, and EUROCRAN dental arch relationship indices showed that the treatment outcomes of the patients who underwent Nadjmi’s modified Furlow palatoplasty were significantly better than those of patients who underwent pushback palatoplasty. Moreover, the prevalence of fistula formation was significantly less prevalent in Nadjmi’s modified Furlow palatoplasty technique than in the pushback technique. Nonetheless, there was no discernible difference in the palatal morphology of these two groups in the present investigation. These findings align with previous studies that have emphasized the advantages of the Furlow technique, particularly in promoting favorable maxillary growth and reducing post-surgical complications such as fistula formation. To minimize the impact of the confounding variables, the patients were matched for age and sex between the two groups. The indices that were used in the study measured the relative relationship of the maxilla and mandible in the same individual. Therefore, it is believed that the impact of sex differences could almost be disregarded (17). Moreover, the subjects were chosen among the non-syndromic CUCLP with an Iranian ethnical background. Patients who underwent orthodontic treatments or alveolar bone graft surgery were also excluded from the study to reduce the effect of factors other than the primary surgical procedures on the results of our research. The findings regarding the EUROCRAN index are consistent with those of Kato et al. (2022) (17), who reported that patients undergoing the Furlow technique exhibited superior dental arch relationships compared to other methods, including pushback palatoplasty. As mentioned, the 5-year-old index, mHB index, and EUROCRAN index were used in our research comparing the outcome of the two different palatoplasty techniques. The 5-year-old index, suggested as the gold standard for surgical results at the age of 5 years, can assess the surgical result and potential future correction of the malocclusion in addition to the skeletal and dental relationships in terms of anteroposterior, transverse, and vertical discrepancies. However, as it is a general indicator, it cannot verify the specifics of the disparities (18). Because of this, we have additionally checked the results of our study using the two other indices. For evaluating UCLP patients, the EUROCRAN index is a relatively new, unique, and somewhat inventive technique (19). In contrast to the other two indices that can only assess the dental arch relationship, the EUROCRAN index can also evaluate the post-surgical outward appearance of the palate (19). Moreover, the mHB rating system is a simple yet sensitive method for evaluating total arch constriction and surgical outcomes. Compared to the 5-year-old and the EUROCRAN index, it has a wider range and offers a more thorough explanation of treatment results. The mHB scoring system has shown a high inter- and intra-rater reliability but lacked assessment of the skeletal component of malocclusion. Our results also underscore the clinical importance of using indices like mHB, which provides a more granular assessment of dental arch constriction and treatment outcomes, compared to broader indices like the 5-year-old index. In general, the 5-year-old index and the mHB rating system has shown a substantial negative correlation, suggesting a positive relationship between the teeth and the arch. Also, the 5-year-old index and EUROCRAN index are more subjective than the mHB scoring system and require calibration (20). With accurate calibration before rating the dental casts and the blind scoring, we have reduced the systemic bias in our study. Also, the findings of our research regarding indices were in line with those of other investigations (10, 21). The clinical implications of these findings suggest that Nadjmi’s modified Furlow technique may help minimize post-surgical complications and improve long-term dental arch relationships, reducing the need for extensive orthodontic interventions later. In terms of maxillary growth and volume, the Furlow Palatoplasty was found as the most effective method for small or submucosal clefts in comparison with other methods, including the Von Langenbeck or the push-back. However, its limitations in treating wider clefts, in which tension-free closure was not possible, have been shown (22). Scar tissue formation over the raw palatal bone following palatoplasty is generally acknowledged to raise the risk of maxillary growth restriction (23). Better surgical outcomes compared to pushback palatoplasty were achieved in a study by minimally overlapped reuniting of levator muscles, avoiding exposed denuded surfaces on the soft palate, and utilizing a buccal myomucosal flap (BMF) to have a tension-free closure of the soft palate in Nadjmi's modified Furlow palatal repair which was comparable with our study (22). Lashin et al. studied the difference between the palatal length of BMF and Bardach two-flap in primary cleft palatoplasty. They observed that the length of the palate increased more in BMF compared with the other group (24). Also, Furlow repair has a strong ability to increase soft palatal length; however, it was not as efficient in wide cleft palates (25). While, the size and position of the cleft palatal could also be correlated with the maxillary growth outcome. The present study only included patients with complete palatal clefts in both study groups. Besides, the familial history of class III malocclusion that leads to reduced maxillary growth or overgrowth of the mandible in comparison with the maxilla was not considered in our study, since it was impossible to confirm. However, the influence of genetics is mostly presented after a pubertal growth spurt, and most of our subjects were before puberty. In 2017, Heliövaara et al. evaluated three different surgical procedures (Arms B, C, D) in addition to a common procedure (Arm A) utilizing the 5-year-old index. They concluded that the staging, sequencing, and timing of the cleft surgery did not influence the dental arch relationship at 5 years of age. In their study, no statistical evidence was found to support the superiority of one technique over another (26), which differs from the findings of the our investigation. The difference in the results could be because of diversities in the surgical methods and the variables that have been compared. Additionally, they asserted that rather than the surgical method, maxillofacial development can be influenced by the surgeon's expertise and proficiency in tissue management (26). However, in the present study, although the surgeons were different, they were all skilled and experienced; therefore, the effect of surgeon’s skill differences could be disregarded in our study. An oronasal fistula with the recurrence rate of 37–50% may form during surgical for CL/P patients (27). Previous studies have shown that age and sex had no bearing on the chance of developing an oronasal fistula after cleft palate surgery (28). Kahraman et al. found that Pushback palatoplasty was associated with more incidence of the fistula compared with other surgical techniques, which was in line with the result of the present study (27). Mahajan et al. compared Furlow’s Z-plasty with the straight-line intravelar veloplasty technique for cleft palatal repair. They demonstrated that Furlow's Z-plasty is a better method due to its low immediate post-operative complications and fistula development. It also has shown more intra-operative soft palate lengthening (29). Lashin et al. observed no significant difference between the fistula formation of BMF and Bardach two-flap techniques; however, the buccinator flap caused a reduction in fistula formation and rate in primary repair of cleft palate (24). Introducing other variables that influence fistula formation, Furlow underlined how crucial mattress sutures that provide eversion in the hard palate are in reducing the likelihood of fistulas (30). Moreover, it was shown that fewer relaxation incisions were associated with the highest fistula rates. In general, a non-tense closure was one of the most crucial requirements for lowering the likelihood of fistula following cleft palate repair (27). The tension-free closure of the soft palate and the absence of raw surfaces on the soft palate in Nadjmi’s modified Furlow technique could explain the lower incidence of fistula formation which was demonstrated in our study (22). In addition to normal maxillofacial growth and avoiding fistulas, one of the success criteria for cleft palate surgical treatment is speech ability, which was not investigated in this study. Although this important variable was not investigated in our study, Nadjmi et al. compared speech results between the patients who underwent Nadjmi’s modified Furlow and the patients who underwent Furlow palatoplasty. According to their findings, the first group's satisfactory palatal lengthening and tension-free soft palate closure contributed to the noticeably better speech outcomes (22). Regarding dental arch relations, our study, the mHB scoring system has provided a quantitative measure of dental arch relationships, where Nadjmi's modified Furlow palatoplasty often outperforms pushback palatoplasty. In contrast with the present study, Kato et al. reported in their 2021 study that the dental arch relationships at the age of 5 among three 2-stage palatoplasty protocols using the 5-year-olds index and Huddart/Bodenham index were not significantly different from one another (17). Similarly, Salazar investigated in 2022 whether modifications in the method of closing the soft palate or timing of surgeries of the hard palate caused occlusal alterations in patients with UCLP. The study involved three groups of children who underwent procedures of repairing soft and hard palate. The first group underwent the Perko method at the age of 1.5 years, the second group the Furlow method at the age of 1.5 years, and the third group, the Vomer flap procedure at the age of 4 years. They came to the conclusion that the dentition status remained consistent across all protocols, even after modifications (31). However, similar to our study, a recent study by Kato et al. (2022) highlighted that patients who underwent the modified Furlow technique had better dental arch relationships and fewer orthodontic issues compared to those who had pushback palatoplasty (17). The limitations of this study was that the study was retrospective and single-center, with a small sample size, which may limit generalizability. Additionally, only non-syndromic UCLP patients were included, which does not account for the variability seen in syndromic cases. Moreover, there was risk of damage, loss, and misplacement for plaster study models in studies and the need for physical storage. However, three-dimensional digital models are reproducible and reliable alternatives for rating compared to plaster casts and can overcome the mentioned limitations. Therefore, intra-oral 3D scanning would be more acceptable for patients and more reliable for scoring (10). Thus, we highly recommend future studies to be conducted using 3D scanners. In addition, we recommend further long-term and longitudinal research with bigger sample sizes that use dental casts, cephalograms, and photographs to confirm the findings of our research. Conclusions Nadjmi’s modified Furlow palatoplasty surgical outcome was more advantageous than the pushback palatoplasty technique regarding the skeletal growth of the maxilla based on the EUROCRAN dental arch relationship index, mHB scoring system, and 5-year-old index. However, according to the EUROCRAN palatal morphology index, its results were comparable to the pushback palatoplasty technique. Declarations Trial registration: Not applicable. Human Ethics and Consent to Participate declarations: The study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.DENTAL.REC.1400.065). Written informed consent was obtained from the parents or guardians of each patient who participated in the study. Data availability: The datasets supporting the findings of the current study are available from the corresponding author upon reasonable request. Funding Declaration: There was no Funding. Clinical trial number: not applicable (as the study is not a RCT). Author contributions: K.B. has made substantial contributions to the conception and design of the work, the acquisition, analysis, and interpretation of data. Also, has drafted the work. S.A. has made substantial contributions to data acquisition, analysis, and interpretation. Also, has drafted the work and substantively revised it. N.A. has made substantial contributions to the conception and design of the work. A.A. has made substantial contributions to the analysis and interpretation of data. Also, has drafted the work and substantively revised it. References Qureshi WA, Beiraghi S, Leon-Salazar V. 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Chawla O, Deacon SA, Atack NE, Ireland AJ, Sandy JR. The 5-year-olds' Index: determining the optimal format for rating dental arch relationships in unilateral cleft lip and palate. Eur J Orthod. 2012;34(6):768-72. Kato J, Mikoya T, Ito Y, Sato Y, Uematsu S, Kodama Y, et al. Dental arch relationship outcomes following 2-stage palatoplasty for Japanese patients With complete unilateral cleft Lip and palate: a 3-center study. Cleft Palate Craniofac J. 2022;59(3):355-64. Jones T, Leary S, Atack N, Chawla O, Ness A, Ireland T, et al. Are photographs a suitable alternative to dental study casts when assessing primary surgical outcome in children born with unilateral cleft lip and palate? Eur J Orthod. 2016;38(4):341-4. Haque S, Alam MK, Khamis MF. The effect of various factors on the dental arch relationship in non-syndromic unilateral cleft lip and palate children assessed by new approach: A retrospective study. BMC Pediatr. 2017;17:1-8. Altalibi M, Saltaji H, Edwards R, Major PW, Flores-Mir C. Indices to assess malocclusions in patients with cleft lip and palate. Eur J Orthod. 2013;35(6):772-82. Mikoya T, Shibukawa T, Susami T, Sato Y, Tengan T, Katashima H, et al. Dental arch relationship outcomes in one-and two-stage palatoplasty for Japanese patients with complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2015;52(3):277-86. Nadjmi N, Van Erum R, De Bodt M, Bronkhorst E. Two-stage palatoplasty using a modified Furlow procedure. Int J Oral Maxillofac Surg. 2013;42(5):551-8. Meng T, Shi B, Huang X, Zheng Q, Wang Y, Wu M, et al. Roles of different areas of palatine bone denudation on growth and development of the maxilla and dental arch: an experimental study. J Craniofac Surg. 2007;18(2):391-8. Kamal lashin M, Kadry W, al-Byale RR, Beheiri G. A novel technique predicting velopharyngeal insufficiency risk in newborns following primary cleft repair. A randomized clinical trial comparing buccinator flap and Bardach two-flap palatoplasty. Journal of Cranio-Maxillofacial Surgery. 2024;52(2):188-95. Grant III JH, Braswell AC, Soto E. Pros and cons of the Sommerlad and Furlow palate repair techniques. Frontiers of Oral and Maxillofacial Medicine. 2023;6. Heliövaara A, Skaare P, Küseler A, Shaw W, Mølsted K, Karsten A, et al. Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate. Dental arch relationships in 8 year-olds. Eur J Orthod. 2020;42(1):1-7. Kahraman A, Yuce S, Kocak OF, Canbaz Y, Guner SI, Atik B, et al. Comparison of the fistula risk associated with rotation palatoplasty and conventional palatoplasty for cleft palate repair. J Craniofac Surg. 2014;25(5):1728-33. Lu Y, Shi B, Zheng Q, Hu Q, Wang Z. Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad. Br J Oral Maxillofac Surg. 2010;48(8):637-40. Mahajan R, Tambotra A, Ghildiyal H, Singh M, Thussu T, Bhamre A, et al. Comparison of Furlow's Double Opposing Z-plasty and Straight-Line Intravelar Veloplasty as Methods of Cleft Palate Repair. Cureus. 2024;16(1):e52897. Furlow Jr LT. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78(6):724-38. Estacio Salazar AR, Kodama Y, Yuki R, Ominato R, Nagai T, Watanabe M, et al. Occlusal Evaluation Using Modified Huddart and Bodenham Scoring System Following 2-Stage Palatoplasty With Hotz Plate: A Comparison Among 3 Different Surgical Protocols. Cleft Palate Craniofac J. 2023;60(9):1061-70. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Oct, 2025 Reviews received at journal 19 Jun, 2025 Reviews received at journal 10 Jun, 2025 Reviewers agreed at journal 29 May, 2025 Reviewers agreed at journal 23 May, 2025 Reviews received at journal 22 May, 2025 Reviewers agreed at journal 22 May, 2025 Reviewers agreed at journal 14 May, 2025 Reviewers invited by journal 14 May, 2025 Editor invited by journal 22 Apr, 2025 Editor assigned by journal 16 Apr, 2025 Submission checks completed at journal 16 Apr, 2025 First submitted to journal 10 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6420449","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":457767633,"identity":"4d6cc4e6-388d-42a2-9622-ae4da0fced3a","order_by":0,"name":"Kimia Baghaei","email":"","orcid":"","institution":"Dentist, Dental Students’ Research Committee, School of Dentistry, Isfahan University of Medical","correspondingAuthor":false,"prefix":"","firstName":"Kimia","middleName":"","lastName":"Baghaei","suffix":""},{"id":457767634,"identity":"3e05790b-2b81-4bc5-946d-1d1e5a219510","order_by":1,"name":"Shabnam Ajami","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIie3RvYoCMRAH8AkDsRku7SzqO7gsLFbuqwiC1WJjJXegIFiJj5NaELRZrYU0fryAFndoc1wC6nUbS8H8CckQ8oNMAhAS8oLJ3MQAZIfY2Zo+fCQe/RNsOCJ9pDF/lCTZLX5i5uLU/NI1UOvl4Dtv1STg/rAtI5s2Mi8NAfe6pq479mIySfIyUthWWDpCqYk0WkKy6iF44V9LVJH2Iz18ikiOJpZAnoqzXvhJPBWTZjQz9rnypCr0iiR6eskIF4Z/TKZUEZ+v+jNTlfH+WEYAxAjdf7jvQHIbWHr8hk734vLE6ZCQkJD3yx8DNDxj/HPFlgAAAABJRU5ErkJggg==","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Shabnam","middleName":"","lastName":"Ajami","suffix":""},{"id":457767635,"identity":"b77b0452-21e1-4dba-b8b5-335f6d5af81f","order_by":2,"name":"Niloofar Azadeh","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Niloofar","middleName":"","lastName":"Azadeh","suffix":""},{"id":457767636,"identity":"12e6283c-16ac-4c3f-9baa-4c71cfce09ce","order_by":3,"name":"Aylar Afshari","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Aylar","middleName":"","lastName":"Afshari","suffix":""}],"badges":[],"createdAt":"2025-04-10 13:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6420449/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6420449/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83040391,"identity":"ff42ea88-427c-4d34-bc2b-2fe96115bf60","added_by":"auto","created_at":"2025-05-19 10:38:52","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135708,"visible":true,"origin":"","legend":"\u003cp\u003eOrthodontically trimmed and polished dental casts\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6420449/v1/6c2c33171c0630a55062af5f.jpeg"},{"id":83040393,"identity":"e4eb6a3f-c356-41ce-b6e0-119c738a0a6f","added_by":"auto","created_at":"2025-05-19 10:38:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3400,"visible":true,"origin":"","legend":"\u003cp\u003eScore distribution of the EUROCRAN index for dental arch relationship\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6420449/v1/2276f1339b91ba5ba7222be3.png"},{"id":83041481,"identity":"24bb3ad5-5e1d-4f56-b45f-7667059db13f","added_by":"auto","created_at":"2025-05-19 10:46:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":804987,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6420449/v1/b14e6c8e-864c-4a91-9a04-8858da35b276.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Treatment Outcomes of Two Palatal Repair Methods Using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOne of the most prevalent birth abnormalities is unilateral cleft lip and palate (UCLP) (1). CLP occur in about 1.7 out of 1000 live births with regional and ethnic variations (2). Long-term negative consequences for social integration and health can result from the effects of CLP on a patient\u0026rsquo;s speech, hearing, appearance, and psychology. In general, children afflicted with these disorders require multidisciplinary management from infancy through the adult years. They also experience greater morbidity and mortality than the general population throughout their life span (2). To repair this anomaly, patients born with UCLP require numerous surgeries and/or other intricate procedures. Patients born with UCLP are usually treated with surgical repair of both the lip (usually at the age of 3 months) and the palate, which could be done at any point between the ages of 6 and 18 months (3).\u003c/p\u003e \u003cp\u003eRegardless of the surgical method, good speech ability, favorable nasolabial appearance, and dentoskeletal growth are the primary goals for both patients and the cleft team. As there is a disagreement about the optimal procedure for cleft surgery, different variations have been made based on various surgical type, approach, and sequence of lip and palate surgery in UCLP treatment (4). To compare the effectiveness of each cleft treatment, the quality of the malocclusion of the dental arches and the midfacial growth as outcome measures should be considered (5). Arch connections are one of the primary results following cleft repair as they show the maxillary growth in anterior-posterior, transverse, and vertical dimensions.\u003c/p\u003e \u003cp\u003eRegarding the results of surgery for either palate or lip restorations, there is still no consensus over the optimal surgical procedure (6, 7). The goal of the surgery, variations in case severity, and the experience, skill, and preferences of the surgeon may also have an impact on the outcomes of the surgery (5). In this regard, Abdel-Aziz and Ghandour conducted a study comparing the V-Y pushback and the Furlow techniques and found that the Furlow technique performed better in terms of treatment outcomes than the V-Y pushback method.(8) In contrast, in another study, the V-Y pushback method had a positive prognosis for speech (9).\u003c/p\u003e \u003cp\u003eA previous study used the 5-year-old Index and the modified Huddart/Bodenham scoring system to examine the dental arch relationship (overjet, overbite, and sagittal occlusion) on plaster casts of UCLP patients aged from 5 to 6 who underwent different surgical protocols. The findings indicated that, based on sagittal occlusion, their dental arch relationship was clinically equal, even though their treatment protocols differed significantly. Besides, they stated that while a properly executed treatment plan is crucial for cleft patients, the surgeon's competence and caseload both play a significant role in the caliber of the outcomes (10). Fudalej et al. graded the palatal morphology and dental arch relationship employing the EUROCRAN index and dental casts to evaluate the relationship between the dental arch and the UCLP following one-stage and three-stage surgical procedures. They found that the morphology of palate in the single-stage sample was superior to that of the three-stage group (11).\u003c/p\u003e \u003cp\u003eThe modified Huddart/Bodenham scoring system (mHB) was utilized in observational studies to\u003c/p\u003e \u003cp\u003eassess how well patients with complete UCLP (CUCLP) responded to treatment. They found that the likelihood of adverse treatment outcomes was higher for cases treated with the Veau-Wardill-Kilner method (palatoplasty) and the modified Millard approach (cheiloplasty) (12).\u003c/p\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eSeveral indices have been introduced in the literature to measure these outcomes of different surgical methods for UCLP patients. Despite the availability of various palatoplasty techniques (13\u0026ndash;15), comparative studies evaluating outcomes using standardized indices like the Modified Huddart/Bodenham scoring system remain scarce. This study aims to address this gap by comparing two techniques (Nadjmi's modified Furlow palatoplasty and pushback Palatoplasty) and their implications for treatment planning in UCLP patients using three different indices, including the Modified Huddart index, EUROCRAN Yardstick index, and the 5-year-old index.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis retrospective cross-sectional study was conducted in 2016 at the Department of Cleft Lip and Palate, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran. The study complied with all relevant principles of the Declaration of Helsinki and was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.DENTAL.REC.1400.065).\u003c/p\u003e \u003cp\u003eThe inclusion criteria were children with non-syndromic UCLP who were between the ages of 5 and 12 at the time of study. Consequently, all patients with CUCLP who were treated at Cleft Lip and Palate Clinic, Shiraz University of Medical Sciences and had lip repair followed by palatal closure using one of the two techniques (i.e., Nadjmi\u0026rsquo;s Modified Furlow palatoplasty and Wardill kilnery [Push back] palatoplasty), were included in the study. Due to the limited number of patients who underwent palatal closure through Nadjmi\u0026rsquo;s modified Furlow technique, all patients satisfying the inclusion criteria entered the study and formed the sample size.\u003c/p\u003e \u003cp\u003eEach family received an explanation from a social worker about the purpose and procedures of the study, as well as the fact that participation was completely voluntary. In total, 40 non-syndromic UCLP patients with the male/female ratio of 21/19 were included in the study. Written informed consent was obtained from the parents or guardians of each patient who participated in the study.\u003c/p\u003e \u003cp\u003ePatients who underwent palatoplasty with the push-back technique were subsequently matched for age and sex with the aforementioned group and entered the study.\u003c/p\u003e \u003cp\u003eThen, the medical records and photo documentation of all patients were retrieved. Patients with missing medical records and incomplete data were excluded from the study. In addition, patients with Simonart\u0026rsquo;s band, syndromes, and craniofacial anomalies in relation with UCLP were excluded from the study. After that, study models were prepared from all the subjects through alginate impressions. All models were orthodontically trimmed and polished (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Before the orthodontic intervention and alveolar bone grafting, evaluations were performed based on gathered data.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThree skilled orthodontists who were trained to use the three indices evaluated the models. To provide a blind examination, the dental models were numbered. A display of reference models that were indicative of the scales specified in each index gave each rater the chance to compare any combination of models to be rated (16). During the rating process, raters were not allowed to confer or talk with one another. For statistical purposes, the median values of the three raters were taken into account. About 20% of the dental models underwent a second evaluation, which took place at least a month following the initial assessment.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSPSS software, version 21.0 (SPSS Inc., Chicago INC, USA), was utilized for data analysis. The frequency, percentages, and mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD of the collected data were displayed. Also, the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD of indices were determined for each variable (patient sex and palate repair technique). A general linear model (GLM) was used to analyze the variables indicated above. Various comparisons were conducted using the Tukey post-hoc test. The Kappa index was used to calculate agreements between the inter and intra-raters. Moreover, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered statistically different.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA sample of 40 non-syndromic UCLP patients was included in the present research. The total ratio of male/female was almost 1/1. In our study 19 patients underwent Nadjmi\u0026rsquo;s Modified Furlow palatoplasty, and 21 Wardill kilnery (Pushback) palatoplasty. The sex distribution was not significantly different between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.75). However, the male age distribution of the two groups was significantly different (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). The patients\u0026rsquo; demographic characteristics are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eTable 1: The Demographic information of the participants of the study\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width:488.75pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 220.75pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 49.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eVariables\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.45in;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 49.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eNadjmi\u0026rsquo;s modified Furlow Technique\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81.8pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 49.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003ePushback Technique\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81.8pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 49.05pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eP value\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 220.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 28.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eNumber of samples, n (%)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:1.45in;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e19 (47.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:81.8pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e21 (52.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81.8pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 28.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:15px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;background:red;'\u003e0.7518\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 55pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 12.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eSex\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 12.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eMale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:1.45in;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:81.8pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.7pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e13\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81.8pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 12.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:15px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;background:red;'\u003e0.2752\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.1pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eFemale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:1.45in;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:17.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:81.8pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:17.1pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81.8pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 17.1pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;background:red;'\u003e0.4913\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 220.75pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 28.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:justify;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003eMean age at the time of data collection (years) (mean\u0026plusmn;SD)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:1.45in;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e7.13\u0026plusmn;1.12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:81.8pt;border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:28.45pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e8.88\u0026plusmn;2.25\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81.8pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 28.45pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;line-height:150%;font-size:15px;font-family:\"Calibri\",sans-serif;text-align:center;'\u003e\u003cspan style='font-size:16px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003cspan style=\"background:red;\"\u003e0.0040\u003c/span\u003e*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003eKappa score was used to assess reliability within and between the examiners for the 5-year-old index and the EUROCRAN index. The intra- and inter-rater reliability scores were 0.32. Pearson correlation was used to measure the reliability of the mHB scoring system, and there was perfect agreement within and between the raters for the mHB scoring system (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003ch3\u003eFive-year-old index\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the mean score and mean score distribution of the 5-year-old index. As indicated, 57.9% of the patients who underwent Nadjmi\u0026rsquo;s modified Furlow palatoplasty scored 1 and 2, 21.1% scored 3, and 21.1% scored 4 and 5, with a total mean score of 3.254. However, in the pushback palatoplasty group, 9.5% scored 1 and 2, 38.1% scored 3, and 52.4% scored 4 and 5, with a total mean score of 2.193. The Mann-Whitney test showed a significant difference between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumerical and Percentage distribution of the 5-Year-Old Index scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePushback Group\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNadjmi\u0026rsquo;s modified Furlow Group\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1(Excellent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2(Good)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3(Fair)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (38.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4(Poor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5(Very poor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eN, number\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of 5-Year-Olds\u0026rsquo; Index score among two groups (p value\u0026thinsp;=\u0026thinsp;0.003)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5-Year-Old Index score\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNadjmi\u0026rsquo;s modified Furlow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1930\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePushback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2540\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80211\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, standard deviation; *, significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eEUROCRAN\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the mean score of both palatal morphology and dental arch relationship of the two groups. Moreover, the score distribution of the EUROCRAN index for dental arch relationship is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of EUROCRAN Index score among two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDental arch relationship (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalatal Morphology\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNadjmi\u0026rsquo;s modified Furlow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0105\u0026thinsp;\u0026plusmn;\u0026thinsp;1.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePushback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.836\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.589\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eSD, standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePearson Chi-square test showed that the distributions among the two methods was significantly different (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030). Thus, Nadjmi\u0026rsquo;s modified Furlow palatoplasty technique had a significant association with a favorable dental arch relationship, in contrast with the pushback technique. On the other hand, the analysis demonstrated that the mean score of palatal morphology among the two methods was not significantly different (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.838).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eThe mHB scoring system\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the mean modified Huddart and Bodenham scores. The mean total score for Nadjmi\u0026rsquo;s modified Furlow group and Pushback group were \u0026minus;\u0026thinsp;2.45 and \u0026minus;\u0026thinsp;8.76, respectively. Significant differences (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were observed between these two methods using independent t-tests.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of modified Huddart and Bodenham scores among two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNadjmi\u0026rsquo;s modified Furlow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.4561\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePushback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-8.7619\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, standard deviation; * significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFistula formation\u003c/h3\u003e\n\u003cp\u003eThe distribution of the presence of fistula in the two groups of Nadjmi\u0026rsquo;s modified Furlow and pushback palatoplasty was as follows: In Nadjmi\u0026rsquo;s modified Furlow group only 15% (n\u0026thinsp;=\u0026thinsp;3) had fistula, however, this percentage in the pushback group was 47% (n\u0026thinsp;=\u0026thinsp;10). According to the Chi-Square test, the two methods were significantly different compared to each other (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032).\u003c/p\u003e \u003cp\u003eSpearman Correlation test analysis showed that there was a strong positive correlation between the 5-year-old index and the EUROCRAN dental arch relationship scoring system (Correlation Coefficient\u0026thinsp;=\u0026thinsp;0.874). Additionally, a strong negative correlation between the mHB scoring system and the 5-year-old index as well as between the mHB and EUROCRAN dental arch relationship index (Correlation Coefficient = -0.922) was observed. In contrast, the correlation between EUROCRAN palatal morphology and the other three indices was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGaining normal speech ability, promoting maxillofacial growth, and preventing fistula formations, are the ultimate objectives of treatment in patients with cleft palates. Regarding the results of surgery for lip and palate restoration, there is still no agreement concerning the optimal surgical procedure. The present retrospective cross-sectional study evaluated treatment outcomes of two different palatoplasty techniques, (i.e., Nadjmi\u0026rsquo;s Modified Furlow palatoplasty and pushback palatoplasty) in UCLP patients. The 5-year-old index, mHB, and EUROCRAN dental arch relationship indices showed that the treatment outcomes of the patients who underwent Nadjmi\u0026rsquo;s modified Furlow palatoplasty were significantly better than those of patients who underwent pushback palatoplasty. Moreover, the prevalence of fistula formation was significantly less prevalent in Nadjmi\u0026rsquo;s modified Furlow palatoplasty technique than in the pushback technique. Nonetheless, there was no discernible difference in the palatal morphology of these two groups in the present investigation. These findings align with previous studies that have emphasized the advantages of the Furlow technique, particularly in promoting favorable maxillary growth and reducing post-surgical complications such as fistula formation.\u003c/p\u003e \u003cp\u003eTo minimize the impact of the confounding variables, the patients were matched for age and sex between the two groups. The indices that were used in the study measured the relative relationship of the maxilla and mandible in the same individual. Therefore, it is believed that the impact of sex differences could almost be disregarded (17). Moreover, the subjects were chosen among the non-syndromic CUCLP with an Iranian ethnical background. Patients who underwent orthodontic treatments or alveolar bone graft surgery were also excluded from the study to reduce the effect of factors other than the primary surgical procedures on the results of our research. The findings regarding the EUROCRAN index are consistent with those of Kato et al. (2022) (17), who reported that patients undergoing the Furlow technique exhibited superior dental arch relationships compared to other methods, including pushback palatoplasty.\u003c/p\u003e \u003cp\u003eAs mentioned, the 5-year-old index, mHB index, and EUROCRAN index were used in our research comparing the outcome of the two different palatoplasty techniques. The 5-year-old index, suggested as the gold standard for surgical results at the age of 5 years, can assess the surgical result and potential future correction of the malocclusion in addition to the skeletal and dental relationships in terms of anteroposterior, transverse, and vertical discrepancies. However, as it is a general indicator, it cannot verify the specifics of the disparities (18). Because of this, we have additionally checked the results of our study using the two other indices.\u003c/p\u003e \u003cp\u003eFor evaluating UCLP patients, the EUROCRAN index is a relatively new, unique, and somewhat inventive technique (19). In contrast to the other two indices that can only assess the dental arch relationship, the EUROCRAN index can also evaluate the post-surgical outward appearance of the palate (19). Moreover, the mHB rating system is a simple yet sensitive method for evaluating total arch constriction and surgical outcomes. Compared to the 5-year-old and the EUROCRAN index, it has a wider range and offers a more thorough explanation of treatment results. The mHB scoring system has shown a high inter- and intra-rater reliability but lacked assessment of the skeletal component of malocclusion. Our results also underscore the clinical importance of using indices like mHB, which provides a more granular assessment of dental arch constriction and treatment outcomes, compared to broader indices like the 5-year-old index.\u003c/p\u003e \u003cp\u003eIn general, the 5-year-old index and the mHB rating system has shown a substantial negative correlation, suggesting a positive relationship between the teeth and the arch. Also, the 5-year-old index and EUROCRAN index are more subjective than the mHB scoring system and require calibration (20). With accurate calibration before rating the dental casts and the blind scoring, we have reduced the systemic bias in our study. Also, the findings of our research regarding indices were in line with those of other investigations (10, 21). The clinical implications of these findings suggest that Nadjmi\u0026rsquo;s modified Furlow technique may help minimize post-surgical complications and improve long-term dental arch relationships, reducing the need for extensive orthodontic interventions later.\u003c/p\u003e \u003cp\u003eIn terms of maxillary growth and volume, the Furlow Palatoplasty was found as the most effective method for small or submucosal clefts in comparison with other methods, including the Von Langenbeck or the push-back. However, its limitations in treating wider clefts, in which tension-free closure was not possible, have been shown (22). Scar tissue formation over the raw palatal bone following palatoplasty is generally acknowledged to raise the risk of maxillary growth restriction (23). Better surgical outcomes compared to pushback palatoplasty were achieved in a study by minimally overlapped reuniting of levator muscles, avoiding exposed denuded surfaces on the soft palate, and utilizing a buccal myomucosal flap (BMF) to have a tension-free closure of the soft palate in Nadjmi's modified Furlow palatal repair which was comparable with our study (22). Lashin et al. studied the difference between the palatal length of BMF and Bardach two-flap in primary cleft palatoplasty. They observed that the length of the palate increased more in BMF compared with the other group (24). Also, Furlow repair has a strong ability to increase soft palatal length; however, it was not as efficient in wide cleft palates (25). While, the size and position of the cleft palatal could also be correlated with the maxillary growth outcome. The present study only included patients with complete palatal clefts in both study groups. Besides, the familial history of class III malocclusion that leads to reduced maxillary growth or overgrowth of the mandible in comparison with the maxilla was not considered in our study, since it was impossible to confirm. However, the influence of genetics is mostly presented after a pubertal growth spurt, and most of our subjects were before puberty.\u003c/p\u003e \u003cp\u003eIn 2017, Heli\u0026ouml;vaara et al. evaluated three different surgical procedures (Arms B, C, D) in addition to a common procedure (Arm A) utilizing the 5-year-old index. They concluded that the staging, sequencing, and timing of the cleft surgery did not influence the dental arch relationship at 5 years of age. In their study, no statistical evidence was found to support the superiority of one technique over another (26), which differs from the findings of the our investigation. The difference in the results could be because of diversities in the surgical methods and the variables that have been compared. Additionally, they asserted that rather than the surgical method, maxillofacial development can be influenced by the surgeon's expertise and proficiency in tissue management (26). However, in the present study, although the surgeons were different, they were all skilled and experienced; therefore, the effect of surgeon\u0026rsquo;s skill differences could be disregarded in our study.\u003c/p\u003e \u003cp\u003eAn oronasal fistula with the recurrence rate of 37\u0026ndash;50% may form during surgical for CL/P patients (27). Previous studies have shown that age and sex had no bearing on the chance of developing an oronasal fistula after cleft palate surgery (28). Kahraman et al. found that Pushback palatoplasty was associated with more incidence of the fistula compared with other surgical techniques, which was in line with the result of the present study (27). Mahajan et al. compared Furlow\u0026rsquo;s Z-plasty with the straight-line intravelar veloplasty technique for cleft palatal repair. They demonstrated that Furlow's Z-plasty is a better method due to its low immediate post-operative complications and fistula development. It also has shown more intra-operative soft palate lengthening (29). Lashin et al. observed no significant difference between the fistula formation of BMF and Bardach two-flap techniques; however, the buccinator flap caused a reduction in fistula formation and rate in primary repair of cleft palate (24). Introducing other variables that influence fistula formation, Furlow underlined how crucial mattress sutures that provide eversion in the hard palate are in reducing the likelihood of fistulas (30). Moreover, it was shown that fewer relaxation incisions were associated with the highest fistula rates. In general, a non-tense closure was one of the most crucial requirements for lowering the likelihood of fistula following cleft palate repair (27). The tension-free closure of the soft palate and the absence of raw surfaces on the soft palate in Nadjmi\u0026rsquo;s modified Furlow technique could explain the lower incidence of fistula formation which was demonstrated in our study (22).\u003c/p\u003e \u003cp\u003eIn addition to normal maxillofacial growth and avoiding fistulas, one of the success criteria for cleft palate surgical treatment is speech ability, which was not investigated in this study. Although this important variable was not investigated in our study, Nadjmi et al. compared speech results between the patients who underwent Nadjmi\u0026rsquo;s modified Furlow and the patients who underwent Furlow palatoplasty. According to their findings, the first group's satisfactory palatal lengthening and tension-free soft palate closure contributed to the noticeably better speech outcomes (22).\u003c/p\u003e \u003cp\u003eRegarding dental arch relations, our study, the mHB scoring system has provided a quantitative measure of dental arch relationships, where Nadjmi's modified Furlow palatoplasty often outperforms pushback palatoplasty. In contrast with the present study, Kato et al. reported in their 2021 study that the dental arch relationships at the age of 5 among three 2-stage palatoplasty protocols using the 5-year-olds index and Huddart/Bodenham index were not significantly different from one another (17). Similarly, Salazar investigated in 2022 whether modifications in the method of closing the soft palate or timing of surgeries of the hard palate caused occlusal alterations in patients with UCLP. The study involved three groups of children who underwent procedures of repairing soft and hard palate. The first group underwent the Perko method at the age of 1.5 years, the second group the Furlow method at the age of 1.5 years, and the third group, the Vomer flap procedure at the age of 4 years. They came to the conclusion that the dentition status remained consistent across all protocols, even after modifications (31). However, similar to our study, a recent study by Kato et al. (2022) highlighted that patients who underwent the modified Furlow technique had better dental arch relationships and fewer orthodontic issues compared to those who had pushback palatoplasty (17).\u003c/p\u003e \u003cp\u003eThe limitations of this study was that the study was retrospective and single-center, with a small sample size, which may limit generalizability. Additionally, only non-syndromic UCLP patients were included, which does not account for the variability seen in syndromic cases. Moreover, there was risk of damage, loss, and misplacement for plaster study models in studies and the need for physical storage. However, three-dimensional digital models are reproducible and reliable alternatives for rating compared to plaster casts and can overcome the mentioned limitations. Therefore, intra-oral 3D scanning would be more acceptable for patients and more reliable for scoring (10). Thus, we highly recommend future studies to be conducted using 3D scanners. In addition, we recommend further long-term and longitudinal research with bigger sample sizes that use dental casts, cephalograms, and photographs to confirm the findings of our research.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eNadjmi\u0026rsquo;s modified Furlow palatoplasty surgical outcome was more advantageous than the pushback palatoplasty technique regarding the skeletal growth of the maxilla based on the EUROCRAN dental arch relationship index, mHB scoring system, and 5-year-old index. However, according to the EUROCRAN palatal morphology index, its results were comparable to the pushback palatoplasty technique.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eTrial registration:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003eThe study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.DENTAL.REC.1400.065).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents or guardians of each patient who participated in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e The datasets supporting the findings of the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e There was no Funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable (as the study is not a RCT).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eK.B. has made substantial contributions to the conception and design of the work, the acquisition, analysis, and interpretation of data. Also, has drafted the work.\u003c/p\u003e\n\u003cp\u003eS.A. has made substantial contributions to data acquisition, analysis, and interpretation. Also, has drafted the work and substantively revised it.\u003c/p\u003e\n\u003cp\u003eN.A. has made substantial contributions to the conception and design of the work.\u003c/p\u003e\n\u003cp\u003eA.A. has made substantial contributions to the analysis and interpretation of data. Also, has drafted the work and substantively revised it.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eQureshi WA, Beiraghi S, Leon-Salazar V. Dental anomalies associated with unilateral and bilateral cleft lip and palate. J Dent Child. 2012;79(2):69-73.\u003c/li\u003e\n\u003cli\u003eMossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate. Lancet. 2009;374(9703):1773-85.\u003c/li\u003e\n\u003cli\u003eBuj-Acosta C, Paredes-Gallardo V, Montiel-Company JM, Albaladejo A, Bellot-Arcis C. Predictive validity of the GOSLON Yardstick index in patients with unilateral cleft lip and palate: A systematic review. PLoS One. 2017;12(6):e0178497.\u003c/li\u003e\n\u003cli\u003eWadde K, Chowdhar A, Venkatakrishnan L, Ghodake M, Sachdev SS, Chhapane A. Protocols in the management of cleft lip and palate: A systematic review. J Stomatol Oral Maxillofac Surg. 2023;124(2):101338.\u003c/li\u003e\n\u003cli\u003eSturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ. A systematic review of skills transfer after surgical simulation training. Ann Surg. 2008;248(2):166-79.\u003c/li\u003e\n\u003cli\u003eCampbell A, Costello BJ, Ruiz RL. Cleft lip and palate surgery: an update of clinical outcomes for primary repair. Oral Maxillofac Surg Clin North Am. 2010;22(1):43-58.\u003c/li\u003e\n\u003cli\u003eNaidu P, Yao CA, Chong DK, Magee III WP. Cleft palate repair: a history of techniques and variations. Plast Reconstr Surg Glob Open. 2022;10(3):e4019.\u003c/li\u003e\n\u003cli\u003eAbdel-Aziz M, Ghandour H. Comparative study between VY pushback technique and Furlow technique in cleft soft palate repair. Eur J Plast Surg. 2011;34:27-32.\u003c/li\u003e\n\u003cli\u003eJain H, Rao D, Sharma S, Gupta S. Assessment of speech in primary cleft palate by two-layer closure (conservative management). J Surg Tech Case Rep. 2012;4(1):6-9.\u003c/li\u003e\n\u003cli\u003eThierens LA, Lewyllie A, Temmerman L, De Roo NM, Verdonck A, Cadenas de Llano Perula M, et al. A retrospective intercenter comparison of two surgical protocols through the dental arch relationship of 5-to 6-year-old unilateral cleft patients. Clin Oral Investig. 2019;23:1777-84.\u003c/li\u003e\n\u003cli\u003eFudalej P, Katsaros C, Bongaarts C, Dudkiewicz Z, Kuijpers-Jagtman AM. Dental arch relationship in children with complete unilateral cleft lip and palate following one-stage and three-stage surgical protocols. Clin Oral Investig. 2011;15:503-10.\u003c/li\u003e\n\u003cli\u003eArshad AI, Alam MK, Khamis MF. Dentoalveolar cleft treatment outcome using modified Huddart-Bodenham index and regression analysis of associated factors. Cleft Palate Craniofac J. 2018;55(5):682-7.\u003c/li\u003e\n\u003cli\u003eSusami T, Ogihara Y, Matsuzaki M, Sakiyama M, Takato T, Shaw WC, et al. Assessment of dental arch relationships in Japanese patients with unilateral cleft lip and palate. Cleft Palate Craniofac J. 2006;43(1):96-102.\u003c/li\u003e\n\u003cli\u003eAsher-Mcdade C, Brattstr\u0026ouml;m V, Dahl E, Mcwilliam J, M\u0026oslash;lsted K, Plint DA, et al. A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 4. Assessment of nasolabial appearance. Cleft Palate Craniofac J. 1992;29(5):409-12.\u003c/li\u003e\n\u003cli\u003eLove R, Walters M, Southall P, Singer S, Gillett D. Dental arch relationship outcomes in children with complete unilateral cleft lip and palate treated at Princess Margaret Hospital for Children, Perth, Western Australia. Cleft Palate Craniofac J. 2012;49(4):456-62.\u003c/li\u003e\n\u003cli\u003eChawla O, Deacon SA, Atack NE, Ireland AJ, Sandy JR. The 5-year-olds\u0026apos; Index: determining the optimal format for rating dental arch relationships in unilateral cleft lip and palate. Eur J Orthod. 2012;34(6):768-72.\u003c/li\u003e\n\u003cli\u003eKato J, Mikoya T, Ito Y, Sato Y, Uematsu S, Kodama Y, et al. Dental arch relationship outcomes following 2-stage palatoplasty for Japanese patients With complete unilateral cleft Lip and palate: a 3-center study. Cleft Palate Craniofac J. 2022;59(3):355-64.\u003c/li\u003e\n\u003cli\u003eJones T, Leary S, Atack N, Chawla O, Ness A, Ireland T, et al. Are photographs a suitable alternative to dental study casts when assessing primary surgical outcome in children born with unilateral cleft lip and palate? Eur J Orthod. 2016;38(4):341-4.\u003c/li\u003e\n\u003cli\u003eHaque S, Alam MK, Khamis MF. The effect of various factors on the dental arch relationship in non-syndromic unilateral cleft lip and palate children assessed by new approach: A retrospective study. BMC Pediatr. 2017;17:1-8.\u003c/li\u003e\n\u003cli\u003eAltalibi M, Saltaji H, Edwards R, Major PW, Flores-Mir C. Indices to assess malocclusions in patients with cleft lip and palate. Eur J Orthod. 2013;35(6):772-82.\u003c/li\u003e\n\u003cli\u003eMikoya T, Shibukawa T, Susami T, Sato Y, Tengan T, Katashima H, et al. Dental arch relationship outcomes in one-and two-stage palatoplasty for Japanese patients with complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2015;52(3):277-86.\u003c/li\u003e\n\u003cli\u003eNadjmi N, Van Erum R, De Bodt M, Bronkhorst E. Two-stage palatoplasty using a modified Furlow procedure. Int J Oral Maxillofac Surg. 2013;42(5):551-8.\u003c/li\u003e\n\u003cli\u003eMeng T, Shi B, Huang X, Zheng Q, Wang Y, Wu M, et al. Roles of different areas of palatine bone denudation on growth and development of the maxilla and dental arch: an experimental study. J Craniofac Surg. 2007;18(2):391-8.\u003c/li\u003e\n\u003cli\u003eKamal lashin M, Kadry W, al-Byale RR, Beheiri G. A novel technique predicting velopharyngeal insufficiency risk in newborns following primary cleft repair. A randomized clinical trial comparing buccinator flap and Bardach two-flap palatoplasty. Journal of Cranio-Maxillofacial Surgery. 2024;52(2):188-95.\u003c/li\u003e\n\u003cli\u003eGrant III JH, Braswell AC, Soto E. Pros and cons of the Sommerlad and Furlow palate repair techniques. Frontiers of Oral and Maxillofacial Medicine. 2023;6.\u003c/li\u003e\n\u003cli\u003eHeli\u0026ouml;vaara A, Skaare P, K\u0026uuml;seler A, Shaw W, M\u0026oslash;lsted K, Karsten A, et al. Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate. Dental arch relationships in 8 year-olds. Eur J Orthod. 2020;42(1):1-7.\u003c/li\u003e\n\u003cli\u003eKahraman A, Yuce S, Kocak OF, Canbaz Y, Guner SI, Atik B, et al. Comparison of the fistula risk associated with rotation palatoplasty and conventional palatoplasty for cleft palate repair. J Craniofac Surg. 2014;25(5):1728-33.\u003c/li\u003e\n\u003cli\u003eLu Y, Shi B, Zheng Q, Hu Q, Wang Z. Incidence of palatal fistula after palatoplasty with levator veli palatini retropositioning according to Sommerlad. Br J Oral Maxillofac Surg. 2010;48(8):637-40.\u003c/li\u003e\n\u003cli\u003eMahajan R, Tambotra A, Ghildiyal H, Singh M, Thussu T, Bhamre A, et al. Comparison of Furlow\u0026apos;s Double Opposing Z-plasty and Straight-Line Intravelar Veloplasty as Methods of Cleft Palate Repair. Cureus. 2024;16(1):e52897.\u003c/li\u003e\n\u003cli\u003eFurlow Jr LT. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78(6):724-38.\u003c/li\u003e\n\u003cli\u003eEstacio Salazar AR, Kodama Y, Yuki R, Ominato R, Nagai T, Watanabe M, et al. Occlusal Evaluation Using Modified Huddart and Bodenham Scoring System Following 2-Stage Palatoplasty With Hotz Plate: A Comparison Among 3 Different Surgical Protocols. Cleft Palate Craniofac J. 2023;60(9):1061-70.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cleft Lip, Cleft Palate, Dental Arch, Plastic Surgery Procedures, Treatment Outcome","lastPublishedDoi":"10.21203/rs.3.rs-6420449/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6420449/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnilateral cleft lip and palate (UCLP) is a congenital defect affecting speech, appearance, and maxillofacial growth, often requiring surgical interventions. Comparative studies are needed to evaluate the outcomes of different palatoplasty techniques for improved treatment planning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo compare the outcomes of Nadjmi's modified Furlow palatoplasty and pushback palatoplasty techniques in UCLP patients utilizing the Modified Huddart index, EUROCRAN Yardstick, and the 5-year-old index.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eForty non-syndromic UCLP patients from Shiraz Cleft Lip and Palate Clinic were included: 19 underwent Nadjmi’s modified Furlow palatoplasty, and 21 pushback palatoplasty. Study models were rated by three orthodontists using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices. The data was analyzed using a general linear model, with \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05 designated as the significance level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the 5-year-old index and EUROCRAN dental arch relationships, there was a significant difference (\u003cem\u003ep\u003c/em\u003e = 0.003) between the two groups. However, palatal morphology was not significantly different between the two techniques (\u003cem\u003ep\u003c/em\u003e = 0.838). Mean mHB scores were − 2.45 for Nadjmi’s modified Furlow and − 8.76 for the pushback palatoplasty group (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Moreover, the oronasal fistula rate was 15% in Nadjmi’s modified Furlow and 47% in the pushback palatoplasty group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNadjmi’s modified Furlow palatoplasty offers superior outcomes in maxillary growth and dental arch relationships, with fewer complications. However, based on the EUROCRAN index, palatal morphology outcomes were similar for both techniques. Moreover, further longitudinal studies are needed to confirm the results of the present study.\u003c/p\u003e","manuscriptTitle":"Comparison of Treatment Outcomes of Two Palatal Repair Methods Using the Modified Huddart Scoring System, EUROCRAN Yardstick, and the 5-Year-Old Indices","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 10:38:47","doi":"10.21203/rs.3.rs-6420449/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-23T16:10:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-19T04:53:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-10T10:42:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59757824123365905475775196410340145295","date":"2025-05-29T05:54:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38486131153611927387160368447912922006","date":"2025-05-24T01:08:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-22T12:07:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317394261596067730646955534480040395488","date":"2025-05-22T10:40:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92730180631320365970561411267314112950","date":"2025-05-14T18:21:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-14T17:37:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-22T05:12:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-16T15:41:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-16T15:40:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-04-10T13:04:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73e88953-f528-4b85-ae86-f0650fb89831","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-30T15:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 10:38:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6420449","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6420449","identity":"rs-6420449","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}