Bone grafting the piriform aperture deformity in isolated cleft lip patients: indication, technique, and results

PURPOSE: This study was undertaken to determine the effect of a bone graft in the piriform aperture on the nasal deformity and orthodontic treatment of the cleft side teeth in isolated cleft lip patients. PATIENTS AND METHODS: All primary cleft lip repair was done 3 months after birth. Nine patients, four female and five male, with a mean age of 12.5 years (range, 8.2 to 24.8 years) and with a repaired cleft lip, were bone grafted between 1992 and 1996. The mean postoperative period was 2 years (range, 1 to 4 years). An iliac crest bone graft was placed in the piriform aperture deformity on the side of the cleft lip. The improvement in the nasal symmetry and angulation of the cleft side teeth were evaluated. The eight growing cleft lip patients (mean age, 11 years; range, 9 to 13 years) were compared with a control group of eight healthy growing children (mean age, 11 years; range, 9 to 13 years). The improvement of nasal symmetry was measured by the formula of the lobule portion of the columella index preoperatively and postoperatively. RESULTS: The mean lobule portion of the columella index preoperatively was 41.8% (SD, 4.4%; SE of Mean, 1.5%) and postoperatively was 44.2% (SD, 4.9%; SE of Mean, 1.6%) (P > .006, t-test for paired samples). The angulation of the cleft side teeth was improved by orthodontic treatment. CONCLUSION: Bone grafting the piriform aperture deformity results in a stable result and improves nasal symmetry and the angulation of the cleft side teeth.     

A model for the cleft lip nasal deformity

The underlying pathology of the cleft lip nasal deformity has yet to be fully realized, and cleft lip rhinoplasty continues to challenge the reconstructive surgeon. A new model is proposed, which is composed of elements that represent known anatomical structures of the nose. These structures are considered elemental to the mechanism of the primary cleft lip nasal deformity. The lobule is reduced to four arches. Five points on the skull provide foundations for these arches, which react interdependently to extrinsic forces and positional change. When certain changes are imposed on the model, predictable alterations in the configuration of the model imitate the observed deformities in the spectrum of the cleft lip nasal deformity, unilateral and bilateral, mild through severe. The model is described with illustrations, anatomic dissection, physical models, and selected clinical cases. A better understanding of the mechanisms of the cleft nasal deformities can be obtained through analysis of the model.     

Nasal sill augmentation in adult incomplete cleft lip nose deformity using superiorly based turn over orbicularis oris muscle flap: an anatomic approach

Adult incomplete cleft lip nose deformity is not uncommon in India. Poverty, ignorance, and parental neglect account for its late presentation. Besides the classical features of cleft lip nose deformity, the constant findings observed in this patient population have been a widened and depressed nasal sill. This is attributable to the sparse, hypoplastic, and abnormally orientated orbicularis oris muscle in the region of the sill. Failure to restore the nasal sill symmetry by suitably augmenting the sill frequently leads to unsatisfactory and asymmetric results. However, in the literature, satisfactory restoration of the nasal sill has not been given the importance it deserves while performing cleft lip rhinoplasty. We present a method of augmenting the depressed nasal sill in cases of adult incomplete nose deformity using a superiorly based orbicularis oris muscle flap, which is harvested from the soft tissues between the apex of the cleft and the nostril sill. Following de-epithelialization of the overlying skin, the exposed muscle is raised as a superiorly based flap after dissecting it from the underlying mucosa. It is folded, turned over, and tucked into the nasal sill base and anchored to the anterior nasal spine to give the desired augmentation. Satisfactory results have been obtained in 18 cases of nasal deformity associated with incomplete cleft lip. In our opinion, this technique offers a simple and effective method of augmenting the depressed sill by utilizing locally available tissues and without the need for procuring autologous tissue from distant sites.     

Two patients with multiple facial clefts including cleft lip and palate

Report of 2 patients with cleft lip and palate and multiple facial clefts are described using the anatomical classification of Tessier. The first patient was severely polymalformed, with heart, vertebral, and facial malformations. He was examined clinically and with an experimental three-dimensional computer reconstruction that identified an association of a classic cleft lip and palate with cleft nos. 4 and 11 on the right side and cleft nos. 3 and 11 on the left. The second patient, a partial form, with cleft lip and palate and cleft nos. 3 and 11 on the right side, also presented with bilateral cleft no. 7, preauricular tags, and an important microgenia. This second patient was operated for the cleft lip using the principles of Millard and Onizuka with a supplementary Z plasty. We comment on the difficulties of delimitation and treatment when the clefts are very close together and the difference in "quality" of the tissues compared with classic cleft lip and palate.     

Main results of researches in the area "Diabetes mellitus"

Perhaps no conditions other than cleft lip and palate and oral cancer assemble teams of dentists and physicians intensely focused on treatment and rehabilitation. The oral and maxillofacial surgeon's role is often pivotal especially in the 20-year term of care for the child born with a cleft lip and palate deformity (CLPD). Issues of basic orofacial functions of mastication, respiration and communication overlay human considerations of self-esteem and image. From the moment of birth the child with a CLPD is special and challenged. Early issues concern parent and family acceptance and insuring basic life functions. While not generally a part of the immediate surgical unit, the OMFS often provides surgical consultation, educational and emotional support for the family. A clear picture must be painted of the treatment that will unfold over the next two decades. Realistic optimism is the watchword. Indeed, today there is every reason to anticipate an outcome that will result in a balanced, functional and esthetic face.     

Suppression of heat-induced HSF activation by CDDP in human glioblastoma cells

To confirm whether or not the alar cartilage of the unilateral cleft lip nose is primarily hypoplastic as compared with the noncleft side, 35 unilateral cleft lip nasal patients who had no previous nasal surgery underwent direct measurement of the lateral crus of alar cartilage on both sides during their nasal tip plasties. Both lower lateral cartilages were dissected freely, and the thickness was measured at the intercrural, middle, and distal portions. The width was measured at the widest portion, and the length was measured from the intercrural point to the distal end. Two-mm-punch biopsies were obtained from each cartilage for histologic study. The lateral crus of the cleft side was no smaller than that of the noncleft side. Histologically, no difference was ascertained. In conclusion, we think the lateral crus of the alar cartilage of the cleft side is not hypoplastic. Therefore, external factors such as soft-tissue defect or external abnormal vector force are more attributable than intrinsic factors to the development of cleft lip nasal deformity.     

Consent: between legality and legitimacy or between "formal" and "informed" consent

OBJECTIVE: The purpose of this study was to examine the conversational skills of preschool and school-age children with cleft lip and palate. DESIGN: The children were audio- and videotaped during interactions with an unfamiliar adult. In addition, standardized measures of speech and language were administered, and ratings of resonance were obtained. Comparisons were made between the children with cleft lip and palate and their same-age peers on measures of conversational participation and a standardized test of pragmatic skills. PARTICIPANTS: Participants were 20 children with unilateral cleft lip and palate (10 preschoolers and 10 school-age children) recruited from the Craniofacial Team at Rainbow Babies and Children's Hospital, Cleveland (OH) and 20 noncleft peers matched for gender, age, and socioeconomic status. MAIN OUTCOME MEASURES: Separate comparisons were made for the preschool children with cleft lip and palate and their noncleft peers, and the school-age children with cleft lip and palate and their noncleft peers on eight measures of conversational assertiveness/responsiveness and the standardized tests of pragmatics. Next, each child with cleft lip and palate was classified for level of conversational participation. RESULTS: Paired t tests revealed no significant differences between the preschool and school-age children with cleft lip and palate and their noncleft peers in level of conversational participation. However, individual child comparisons revealed less assertive profiles of conversational participation for 50% of the preschool and 20% of the school-age children with cleft lip and palate. CONCLUSIONS: Children with cleft lip and palate may show a less assertive style of conversational participation, at least during the preschool years. Therefore, craniofacial team evaluations should include examination of conversational competency, particularly for children who are demonstrating difficulty with other aspects of speech, language, or social development.     

Plasma integrated concentration of growth hormone after recombinant human growth hormone injection. Implications for determining an optimal dose

The length of the cervical spine in a series of 206 adult males with cleft lip and/or palate and 50 normal controls was measured. The patients were divided into five subgroups according to the type and extent of the cleft. The shortening of the spine was most marked in bilateral cleft lip and palate patients (complete), less marked in unilateral cleft lip and palate patients, and was slight in isolated cleft palate patients. Complete isolated cleft palate and cleft lip was not associated with a shortening of the spine. A shortening of the cervical spine in less extensive types of isolated cleft palate was suggestive of the participation of the spine in their development, while in cleft lip and palate a simultaneous exposure to a teratogenic agent or any other developmental error during early stages of embryogenesis could explain the concomitant occurrence of spine anomalies. Patients with cleft lip and palate associated with a short spine also had a shorter mandibular ramus, which could be suggestive of simultaneous damage to both structures during morphogenesis. This relationship was not demonstrated in isolated cleft palate that developed in later stages of embryogenesis. In these cases a short spine itself could not have impaired the growth potential of the mandible, yet it could have mechanically induced the development of cleft palate. These observations are in agreement with the present state of knowledge on the development of orofacial clefts as shown in experimental animals.     

Repair of unilateral cleft lip: a comparison of five techniques

Repair of unilateral cleft lip is a challenging procedure with no single technique satisfactory for all types of unilateral cleft deformity. This study compares retrospectively five techniques of unilateral cleft lip repair in 72 children (45 boys, 27 girls). Twenty-two children had a Millard rotation-advancement repair, 5 children had a Davies Z-plasty, 22 had a modified Z-plasty, 10 had a Tennison-Randall triangular flap repair, and 13 had a Nakajima-Yoshimura straight-line repair. Assessment was performed clinically by a plastic surgeon not involved in the original surgery. Repairs were assessed objectively by measurement of the vertical length of both the repaired and normal sides of the lip with calipers. Subjective criteria used to evaluate the repair were the symmetry of Cupid's bow, the quality of scar, the alignment of white roll, the evenness of the vermilion, and the lip pout. The mean follow-up period was 5.4 years (range, 9 months-29 years). Sixty-five of the 72 repairs measured (90%) were within two standard deviations (SDs) of normal and thus were considered to be of "acceptable" length. Seven repairs were unacceptably short (>2 SDs) on measurement, six of which included a rotation-advancement repair for a complete cleft lip. Subjective results paralleled the objective results. The outcome following repair of unilateral cleft lip was similar for all five surgical methods assessed except for complete cleft lips repaired by the rotation-advancement technique, which tended to result in an unacceptably short lip as measured on the repaired side.     

Individual housing influences certain biochemical parameters in the rat

OBJECTIVE: A modified Abbe flap of the lambda figure type, designed by the author and used before or after secondary cleft lip repair in 146 consecutive cases since 1990 is described. DESIGN: This series consisted of 71 cases with unilateral deformity and 75 cases with bilateral deformity at adolescent or adult ages. The technical details of this method and representative cases with the results are shown. The philtrum is created by incising the two branches of the lambda flap obliquely at 45 degrees to the skin surface in the lower lip, then matching them in the central recipient bed of the deficient upper lip. RESULTS AND CONCLUSIONS: The resultant upper lip is not only full and slack, but also attractive with an acute cubic contour of the philtrum. Furthermore, the residual scar at the donor site is concealed in the mentolabial fold.     

Facial growth and the need for orthognathic surgery after cleft palate repair: literature review and report of 28 cases

PURPOSE: Controversy still exists regarding the optimal timing and surgical technique for primary cleft lip and palate (CLP) repair, and treatment protocols vary considerably. This study reviews the literature on timing and technique for primary repair and reports on the outcome for a consecutive group of patients treated by a single surgical protocol at the Sunnyview Cleft Palate Clinic. PATIENTS AND METHODS: Twenty-eight patients treated by a standardized clinical protocol from infancy through adolescence were evaluated with respect to the need for orthognathic surgery to correct jaw size discrepancy. For each patient, data was collected regarding type of cleft deformity, total number of surgical procedures from infancy, surgeon performing the primary repair, and the need or indication for orthognathic surgery. RESULTS: Twenty-five percent of patients treated by this protocol required orthognathic surgery because of anteroposterior jaw size discrepancy. The number of prior operations was not a significant factor. The need for orthognathic surgery was seen in all types of CLP deformity. Different primary surgeons varied considerably in the percentage of their patients who ultimately required orthognathic surgery. CONCLUSION: The results of this study parallel other larger cohort studies with respect to the percentage of patients requiring orthognathic surgery. The number of prior operations does not significantly affect the later need for orthognathic surgery.     

Presurgical columellar elongation and primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair

We present a new combined approach to primary bilateral cleft lip, nose, and alveolus repair using presurgical nasoalveolar molding combined with a one-stage lip, nose, and alveolus repair. Presurgical alveolar molding is used to bring the protruding premaxilla back into proper alignment with the lateral segments in the maxillary arch. Presurgical nasal molding produces tissue expansion of the short columella and nasal lining. A coordinated surgical approach involves a one-stage repair of the lip, nose, and alveolus. The nasal repair uses a retrograde approach in which the prolabial flap and columella are reflected over the nasal dorsum by continuing the dissection behind the prolabium up the membranous septum and over the septal angle. Tissues are dissected out from between the tip cartilages, and the domes are sutured together in the midline. This method joins a new class of bilateral cleft repairs that place the primary emphasis on correction of the deformity of the nasal tip cartilages.     

Bone grafting at the stage of mixed and permanent dentition in patients with clefts of the lip and primary palate

Secondary bone grafting of a residual alveolar cleft has become a well established procedure. However, little attention has been paid to the benefits of these bone grafts in patients with clefts of the lip and alveolus only. This retrospective and comparative study includes 21 patients who had received a secondary or a late secondary bone grafting procedure from tibia and whose mean clinical and radiographic follow-up after the bone graft was 5.5 years. Eighteen patients treated without bone grafting served as controls. Length and width of cleft, presence or absence of permanent lateral incisor, size of nasal floor bony defect, and interdental alveolar bony height in the cleft area were investigated. The results showed that bone grafting was indicated particularly in wide clefts with missing lateral incisors. Eruption of a tooth close to the cleft was facilitated and the bony support for teeth neighboring the cleft was improved. In some cases, additional support of the alar base of the nose was achieved and closure of an oronasal fistula facilitated. A further advantage of bone grafting of clefts of the primary palate was that it might make it possible to insert a titanium implant carrying an artificial tooth in the cleft area.     

Developing the process of nursing for intractable diseases: its outcome and future issues

OBJECTIVE: Kallmann's syndrome is characterized by the association of hypogonadotropic hypogonadism and anosmia or hyposmia. The principal endocrine defect of hypogonadotropic hypogonadism is a failure to secrete luteinizing hormone-releasing hormone (LHRH), resulting in underdevelopment of the pituitary gonadotropes and an inability to synthesize and release luteinizing hormone and follicle-stimulating hormone. The purpose of the present investigation was to describe the dentition and the craniofacial morphology in patients diagnosed with Kallmann's syndrome. DESIGN: The sample consisted of 11 patients, 2 of whom also had bilateral cleft lip and palate. Radiographic investigations, including cephalometry, were performed. Comparisons were made to normal individuals and to cleft lip individuals without Kallmann's syndrome. RESULTS: Dentition: tooth agenesis occurred more frequently in patients with Kallmann's syndrome. Craniofacial morphology: Increased mandibular inclination and mandibular angulation were seen in Kallmann patients. When clefting also occurred, extreme retrognathism of both maxilla and mandible was seen, a deviation which seemingly worsened during growth. The anterior cranial base and the sphenoid bone showed an altered morphology in one of the patients with Kallman's syndrome. CONCLUSIONS: An early diagnosis of Kallmann's syndrome is very important because the prognosis for endocrine treatment thereby improves, and therefore, it is recommended that the sense of smell be evaluated in patients with the craniofacial morphology described.     

Measurement using a non-contact 3-D measurement system and histopathologic study of surface of skin scar formation after cheiloplasty

As to postoperative scar formation of maxillofacial lesions, a number of authors have reported on the clinical classification and light or electron microscopic observations of hypertrophic scars. However, there has been no quantitative study to evaluate the surface of the postoperative scar and its relevance to changes in histopathology. The purpose of this study was to assess postoperative scar formation on patients with cleft lip quantitatively by using a non-contact 3-D measurement system and to compare the findings with the histopathologic changes. Thirty-six specimens were obtained from patients when they underwent corrective surgery of the lip. The depth of the scar was measured by using a non-contact 3-D measurement system. The results were compared with morphological findings of fibroblasts and collagen fibers of the scar tissues under a light microscope. The results were following as follows: 1. The depth of the CLP group was 181.4 +/- 78.4 microns, significantly higher than 55.7 +/- 24.8 microns of the non-cleft group (p < 0.05). 2. Histologically, the scar, which formed a diffuse mass of irregularly arranged thick collagen fibers, showed a higher value in the depth of the scar than the one which formed a regular pattern. 3. The scar with mature spindle fibroblasts showed a higher value in the depth of the scar than the one with immature round fibroblasts. In conclusion, it was suggested that a non-contact 3-D measurement system is useful for measuring the depth of the scar surface, and the histologic changes of the scar influence the depth.     

Rigid external distraction: its application in cleft maxillary deformities

Patients with severe maxillary hypoplasia secondary to congenital facial clefting present numerous challenging problems for the reconstructive surgeon. Traditional surgical/orthodontic approaches for these patients often fall short of expectations, especially for achieving normal facial aesthetics and proportions. The purpose of this paper is to present our clinical experience and cephalometric results with the use of rigid external distraction for the treatment of patients with severe maxillary deficiency. Eighteen consecutive orofacial cleft patients with severe maxillary hypoplasia were treated with maxillary distraction osteogenesis. Criteria for patient selection included severe maxillary hypoplasia with negative overjet of 8 mm or greater, patients with normal mandibular morphology, and patients with full primary dentition or older. There were 10 unilateral cleft lip and palate patients, 6 bilateral cleft lip and palate patients, and 2 patients with severe congenital facial clefting. A maxillary splint was prepared for each patient, and all patients underwent a high Le Fort I maxillary osteotomy. All surgery was performed on either an outpatient or a 23-hour admission basis. No patient required blood transfusions or intermaxillary fixation. Two types of mechanical distraction were utilized in this series. In group 1 (n = 14), the patients underwent rigid external distraction with an external distraction device. In group 2 (n = 4), patients underwent face mask distraction with elastics. There was no surgical morbidity in any of the patients. For the patients in the rigid external distraction group, the mean effective horizontal advancement of the maxilla was 11.7 mm. All of these patients had correction of their negative overjet. For patients in the face mask distraction group, the results were disappointing. The mean effective advancement of the maxilla in this group was only 5.2 mm. In all face mask distraction patients, the initial maxillary hypoplasia was undercorrected. Maxillary distraction osteogenesis with rigid external distraction permits full correction of the midfacial deficiency, including both the skeletal and soft-tissue deficiencies. Rigid external distraction in patients with severe maxillary hypoplasia allows full correction of the deformity through treatment of the affected region only. It offers the distinct advantage of correcting these severe deformities through a minimal procedure. Rigid external distraction has dramatically improved our treatment results for patients with severe cleft maxillary hypoplasia.     

Complementary surgical/interventional techniques for nonresective management of "inoperable" aneurysms: a second look

A review of the studies of the caries prevalence and periodontal health of patients with cleft lip and palate (CLP) revealed that only five investigations of caries prevalence in CLP patients included children. One reported that CLP children did not have a higher caries prevalence in the permanent dentition, whereas more recent studies have reported a higher caries prevalence in both the primary and permanent dentitions of CLP children than in those of noncleft children. However, there is wide variation in the teeth examined and the method of presenting data on caries prevalence. Six papers have reported on the periodontal health of adult CLP patients, and only one has done so on that of children. The adult CLP patients had poorer oral hygiene and more gingivitis, but there is no conclusive evidence that they have a higher risk of developing periodontal disease. No data on the oral hygiene of CLP children were available, but it has been emphasized that they have significantly more gingivitis than noncleft children, especially in the maxillary anterior teeth.     

Effect of lip adhesion on labial height in two-stage repair of unilateral complete cleft lip

A lip-adhesion procedure before definitive repair of unilateral complete cleft lip has been widely used but rarely analyzed over the past 25 years. This report is a quantitative prospective assessment of one possible benefit of lip adhesion, an increased vertical height of the cleft labial elements. Lip adhesion was performed on 43 consecutive infants with unilateral complete cleft of the primary palate. Markings for rotation-advancement repair were placed before lip adhesion and again at the time of the complete nasolabial correction. Using a standardized caliper, anthropometric measurements of the vertical height of the medial and lateral lip elements were made from these markings. The relative increase in vertical height of the medial and lateral labial segments during the mean interoperative interval of 3.2 months was calculated. Analysis of these measurements revealed a small disproportionate increase in vertical lip height of the cleft side compared with the normal side after lip adhesion. Discrepancy of the lateral lip height between the cleft and noncleft sides decreased from 3.0 to 2.7 mm (10 percent, p = 0.05), and the prolabial or medial height discrepancy decreased from 3.4 to 2.8 mm (17 percent, p < 0.01). Subgroup analysis of infants whose adhesion was done either at a young age, without premaxillary orthopedics, or with an intact secondary palate, revealed no statistically significant improvement in the labial height measures. It is arguable whether the small relative increase in height of the medial and lateral cleft elements justifies lip adhesion before definitive repair of unilateral complete cleft lip.     

Maxillary distraction: aesthetic and functional benefits in cleft lip-palate and prognathic patients during mixed dentition

In the last few years, distraction techniques have been used successfully to correct the hypoplastic human mandible. In patients with cleft lip and palate, normal growth of the maxilla may be impaired by early cleft repair, and many of them do not respond to orthodontic procedures alone. Maxillary distraction is an alternative technique to correct maxillary hypoplasia during mixed dentition. In the last 3 years, the procedure was performed in 38 patients aged between 6 and 12 years; 18 patients had unilateral cleft lip and palate, 9 patients had bilateral cleft lip and palate, 7 patients had unilateral cleft palate, 2 patients had prognathism, and 2 patients had nasomaxillary dysplasia. Photographs, posteroanterior and lateral cephalograms, and dental models are obtained preoperatively (as well as an orthopantomogram) to locate the tooth buds. A subperiosteal dissection is performed exposing the anterior and lateral aspects of the maxilla, and an incomplete horizontal osteotomy is done above the tooth buds. Using a facial mask and an intraoral fixed appliance system as an anchorage, we initiate on the fifth postoperative day the application of distraction forces. Maxillary advancement between 4 and 12 mm is achieved during 3 to 4 weeks, and a satisfactory class I or II molar relationship is also obtained. A combination of forward and downward distraction forces can be used to achieve simultaneous advancement and elongation of the hypoplasic maxilla. The aesthetic results are excellent, and the nasolabial angle is increased, including a more anterior projection of the upper lip. Nasal breathing is improved as well as the air flow and patency of the nasal airway. Velopharyngeal function remains unchanged after the procedure. The follow-up in this series varied from 6 months to 3 years. No relapses have been observed.     

The importance of accurate repair of the orbicularis oris muscle in the correction of unilateral cleft lip

Most of the attempts and efforts in cleft lip repair have been directed toward the skin incision. The importance of the orbicularis oris muscle repair has been emphasized in recent years. The well-designed skin incision with simple repair of the orbicularis oris muscle has produced a considerable improvement in the appearance of the upper lip; however, the repaired upper lip seems to change its shape abnormally in motion and has a tendency to be distorted with age if the orbicularis oris muscle is not repaired precisely and accurately. Following the dissection of the normal upper lip and unilateral cleft lip in cadavers, we could find two different components in the orbicularis oris muscle, a superficial and a deep component. One is a retractor and the other is a constrictor of the lip. They have antagonistic actions to each other during lip movement. We also can identify these two different components of the muscle in the cleft lip patient during operation. We thought inaccurate and mixed connection between these two different functional components could make the repaired lip distorted and unbalanced, which would get worse during growth. By identification and separate repair of the two different muscular components of the orbicularis oris muscle (i.e., repair of the superficial and deep components on the lateral side with the corresponding components on the medial side), better results in the dynamic and three-dimensional configuration of the upper lip can be achieved, and unfavorable distortion can be avoided as the patients grow.(ABSTRACT TRUNCATED AT 250 WORDS)