Maxillary distraction and implantology

Vertical alveolar distraction can be a useful surgical technique in preprosthetic reconstructive surgery, especially after failed autogenous onlay bone grafting. The main advantage of this technique is to allow expansion of both the bone and soft tissue. Through a case of vertical alveolar reconstruction by distraction osteogenesis and implant rehabilitation in a patient who had undergone two previously unsuccessful interposition bone graft procedures, this report illustrate the advantages of alveolar ridge augmentation by distraction osteogenesis.     

Maxillary sinus development and sinusitis in patients with cleft lip and palate

OBJECTIVE: Sinusitis is frequently associated with cleft lip and palate. The present study was performed in an attempt to investigate maxillary sinus development in relation to the occurrence of sinusitis in cleft patients. METHODS: Forty-seven consecutive patients with cleft lip and alveolus with or without cleft palate underwent computed tomographic scans of the maxilla. The cross-sectional area of the maxillary sinus at the level of the zygomatic arch was measured, and the soft tissue density shadow of the sinus was scored on a 4-point scale. RESULTS: The cross-sectional area of the sinus was significantly smaller in the child group (10 years or less) than in the adolescent group (11-20 years, P<0.001) and the adult group (over 20 years, P<0.02). The cross-sectional area significantly increased with age in the child group (r=0.552, P<0.001). The growth rate became slower in the adolescent group. The cross-sectional area then gradually decreased with age in the adult group (r=-0.64, P<0.05). Sinusitis was observed in 15 patients (32%) and in 20 sinuses (21%). Severe sinusitis was more common in the child group than in the patients over 10 years of age (P<0.05). CONCLUSION: These results indicate that maxillary sinusitis associated with cleft lip and palate occurs preferably in the developing sinuses of children.     

Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. In this article the authors analyze the impact of primary surgery on the maxillary growth failure and discuss on how to prevent this complication.     

Maxillary sequels in labial-alveolar-velopalatine clefts. Role of distraction osteogenesis

A high rate of cleft patients present with maxillary hypoplasia. Most of the growth defects concern the anteroposterior axis of the maxilla. Before bone lengthening by distraction osteogenesis, orthognathic surgery was the only alternative treatment for maxillary hypoplasia. Several studies showed the lack of stability after conventional surgery. In this article reviewing the literature concerning all bone lengthening procedures, the authors discuss published data on maxillary distraction osteogenesis by external and internal devices. Indications of distraction in growing children as an interceptive step are discussed.     

Maxillary growth in patients with complete cleft lip and palate, operated on around 4-6 months of age

Background

The controversy about timing of cleft palate repair has been focused on early closure for improved speech versus delayed repair for enhancing maxillary growth. Early palatal repair enhances phonological development decreasing the frequency of articulation disorders associated with velopharyngeal insufficiency (VPI). In contrast, it has been described that early surgery adversely affects maxillary growth.

Objective

The purpose of this paper is to study maxillary growth in a group of cleft palate patients operated on around 4-6 months of age, and receiving further orthodontic treatment.

Materials and methods

A group of 20 cleft palate patients, who were subjected to early minimal incision palatopharyngoplasty around 4-6 months of age, were followed for a minimum of 10 years (range: 10-14 years). All patients received the same orthodontic management, starting at 4 years of age. None of the patients had orthognatic surgery or alveolar bone grafting. After orthodontic treatment, their cephalometric data were compared with a group of subjects without cleft lip and palate, matched by gender and who were within the age range of the cleft palate group.

Results

SNA, SNB, ANB, and WITS cephalometric measures were compared. A non-significant difference was found in all measurements between the two groups.

Conclusion

Early cleft palate repair enhances phonological development. Although maxillary growth is affected in cleft palate patients, appropriate orthodontic treatment can achieve normal maxillary growth as measured during adolescence.     

Maxillary removal and reinsertion in pediatric patients.

OBJECTIVE: To examine outcomes after the maxillary removal and reinsertion (MRR) approach for the treatment of anterior cranial base tumors in pediatric patients. DESIGN: Eligible patients were identified by medical record review. Consenting patients were studied via rhinoscopy, fiberoptic endoscopy, standard facial photographs, and cephalometric radiographs. SETTING: A tertiary care otolaryngology clinic. PATIENTS: Inclusion criteria were age younger than 16 years at time of initial procedure and a follow-up period of at least 6 months. Nine patients were eligible, and 5 enrolled. All were male patients (mean age, 13.8 years; age range, 11-15 years) treated for juvenile nasopharyngeal angiofibroma. MAIN OUTCOME MEASURES: History and examination were performed to evaluate occlusion, vision, facial growth, and tumor status. Cephalograms were used to calculate 3 standard cephalometric measurements: sella to A point, basion to A point, and condylion to A point. Cephalograms were examined for plate migration and bony resorption. RESULTS AND CONCLUSIONS: No major long-term complications were identified in the patients after MRR. Cephalometric analysis revealed minor abnormalities in 2 children, but no plate migration or bony resorption was identified in the removed and reinserted maxillae. No abnormal development patterns were detected on physical examination or when cephalometric measurements were compared with age- and race-matched normative data. Although further study is warranted, MRR seems safe and effective for treatment of pediatric patients with anterior cranial base tumors.     

Late ear sequelae in cleft palate patients

This retrospective study looks at the incidence and nature of ear disease in 50 adolescent patients who had cleft palates repaired in infancy. Half of these patients had a history of grommet insertion. We found that most patients had normal hearing (81%) and middle-ear pressures (86%), although about half had tympanic membrane abnormalities. Grommet insertion did not result in better long-term hearing in this study but was strongly associated with tympanosclerosis. Cleft type did not influence the degree of ear disease although more patients with complete clefts had a history of repeated grommet insertion. Otitis media with effusion is almost universal in cleft palate infants and may influence later language, speech and educational development. At the time of palatal repair grommets should be inserted to improve hearing in these infants.     

Surgery for speech in cleft palate patients

INTRODUCTION: Superiorly based pharyngeal flaps and sphincter pharyngoplasties are the two main possibilities for the surgical treatment of hypernasality in velopharyngeal dysfunction. Videonaspharyngoscopy and multi-view videofluoroscopy can provide anatomical and physiological data for planning these surgical procedures for correcting hypernasality. AIM: This study was undertaken to assess the planning and outcome of pharyngeal flaps and sphincter pharyngoplasties for correcting velopharyngeal insufficiency. The surgical techniques were customized according to the findings of videonasopharyngoscopy and multiview videofluoroscopy. MATERIALS AND METHODS: Seventy patients with repaired palate clefts and residual velopharyngeal dysfunction were studied. The patients were randomly divided into two groups. The first group received a pharyngeal flap. The second group received a sphincter pharyngoplasty. Both procedures were individually customized according to the findings of videonasopharyngoscopy and multi-view videofluoroscopy. RESULTS: There was a non-significant difference (P >0.05) between the mean size of preoperative velopharyngeal closure gap between the two groups of patients (mean=27.5%; S.D.=7.7% versus mean=28.3%; S.D.=5.9%). Postoperatively, velopharyngeal dysfunction was completely corrected in 89% of the cases from group 1, and in 85% of the cases from group 2. There was a non-significant difference (P >0.05) between the success rate for correcting VPI in both groups of patients. CONCLUSIONS: Pharyngeal flap and sphincter pharyngoplasty seem to be safe and reliable procedures for treating residual velopharyngeal dysfunction. Although not all the patients studied for this paper achieved complete closure after the surgical procedures, all of them showed a reduction of the size of the velopharyngeal closure defect. The planning of the surgical procedure, in order to match the postoperative structure to the preoperative velopharyngeal dimensions and movements visualized through Videonasopharyngoscopy and videofluoroscopy, seems to be the most important aspect of the surgery for correcting residual velopharyngeal dysfunction.     

Tympanometric findings in cleft palate patients: influence of age and cleft type

Tympanometry was analysed according to cleft type with respect to age in 239 cleft palate patients (57 with bilateral cleft lip and palate (BCLP)), 122 with unilateral cleft lip and palate (UCLP) and 60 with isolated cleft palate (ICP). The frequency of type B tympanograms was 46.5 per cent in the BCLP group, 50.6 per cent in the UCLP group and 58.3 per cent in the ICP group. Type A tympanograms were more frequently observed in older patients (median age 11 years) in comparison to type B (median age five years; p < 0.001) and type C (median age six years; p < 0.001). The total sample showed an age-related decrease in the frequency of type B tympanograms (rs = -0.3942; p < 0.001). The frequency of type A tympanograms increased significantly with age (rs = 0.4263; p < 0.001), whereas type C was not correlated with age. In the UCLP group, the frequency of type B tympanograms decreased with age (rs = -0.4430; p < 0.001), the decrease being faster than in the BCLP group (rs = -0.3186; p = 0.001) and the ICP group (rs = -0.3378; p < 0.0001)). Type B tympanograms had the highest correlation with a hearing loss of 21-40 dB at mean hearing level at speech frequencies (MHLSF) (rs = 0.4574; p < 0.001), a lower correlation with a hearing loss of 11-20 dB (rs = 0.2184; p = 0.02) and the lowest correlation with hearing loss above 40 dB. At the ages of one to three, the frequency of type B is higher in UCLP patients than in the BCLP and ICP groups, decreasing at seven to 12, increasing again at 13 to 15, and thereafter showing a continuous decrease. In the BCLP group, the frequency of type B increased significantly at the ages of four to six and then decreased continuously from seven to 18. In ICP patients, the changes in the frequency of type B with age are not significant until the age of 15; at the age of seven, it is higher than in the BCLP and ICP groups. The type C tympanogram is not typically found in cleft palate patients and its frequency is not correlated with age. It can be presumed that each type of cleft lip and palate, due to its characteristic conditions in the epipharynx, will favour a different mode of pathophysiological development of middle-ear disease.     

Socioeconomic adjustment in young cleft lip-palate patients

INTRODUCTION: The aim of our study was to evaluate socioeconomic adjustment of young adults after treatment for cleft lip and palate. MATERIALS AND METHODS: A retrospective study was made including patients born from 1975 to 1986 and followed-up in our department. The investigation was based on response to a questionnaire that partly replicated a national survey of social and economic life in the population (standard of living survey Burgundy, Insee France 1999). The control group was constituted by individuals taken from a regional probability sample of households. This report covered education, employment, and marriage. RESULTS: 41 patients were enrolled in this retrospective study and compared to 972 young adults. There was a significant delay in the independence process, regarding housing and marriage. Patients remained in normal limits concerning employment. However the patients' education history showed a significant delay, and a higher rate of vocational courses. DISCUSSION: The independence process showed a significant delay in cleft lip-palate patients, as well as education history. Nevertheless the final socioeconomic adjustment was similar to that of the general population.     

Maxillary sinuses microbiology from patients with chronic rhinosinusitis

There isn't definitive and consistent data concerning the distribution of bacterial species in patients with Chronic Sinusitis (CS). The variability of the results from studies in CS may be due to the different techniques used as collection method, variations in culture methods, previous antibiotic use, and difficulty in distinguishing bacterial flora from pathogenic agents.Study designClinical prospective.AimTo identify the incidence of microorganisms in patients with CRS by growing bacteria from the secretion of the maxillary sinus.Patients and MethodsCross-sectional study in 62 patients that had undergone FESS for treatment of chronic sinusitis; cultures from the maxillary sinus were obtained.Results62 samples, 33 (53.2%) had no growth; 29 (45.2%) counts of aerobic bacteria; one case (1.6%) of fungus growth; we did not find anaerobic bacteria. Pseudomonas aeruginosa was the one more frequently found - 8 samples (27.6%), Staphylococcus aureus and Staphylococcus epidermidis in 4 samples each; Streptococcus pneumoniae in 3 samples (10.4%); other Gram negative agents in 17 samples (31%).ConclusionIn the present study we concluded that Pseudomonas aeruginosa, other Gram negatives bacteria and Staphylococcus spp were the representatives of the bacterial flora found in the paranasal sinuses of patients with CS.     

Hearing levels and age in cleft palate patients

Tonal audiometry was used to compare hearing levels in patients with bilateral cleft lip and palate (BCLP) (57 patients), unilateral cleft lip and palate (UCLP) (124 patients) and isolated cleft palate (ICP) (62 patients), and according to age groups. Patients with isolated cleft palate showed greater improvement in hearing level with age than patients with UCLP and BCLP; as adults they showed the lowest frequency of ears with hearing level of less than 40 dB, and the highest frequency of ears with hearing levels of 11–20 dB. Patients with BCLP had a higher frequency of ears with a hearing level of 21–40 dB during early childhood and adult age than patients with ICP. Patients with UCLP and BCLP showed a slower decrease with age in the frequency of ears with hearing loss than patients with ICP; the hearing level in patients with UCLP and BCLP improved only in groups with hearing levels of 21–40 dB, while those with hearing levels above 40 dB showed no significant improvement with age.Conservative therapeutic methods for normalization of the hearing level and middle ear state were found to be inefficient in the cleft palate population Thus, early surgical treatment (ventilation tube insertion) appears to be the therapy of choice.