Long-term effects of premaxillary setback on facial skeletal profile in complete bilateral cleft lip and palate

The purpose of this study was to analyze the long-term effects of premaxillary setback in the surgical treatment of complete bilateral cleft lip and palate (C-BCLP). Roentgencephalograms at adolescence or early adulthood were available for 13 of our longitudinal C-BCLP patients who were treated with premaxillary setback and followed up with serial films since infancy. Six individuals had been subjected to early premaxillary setback to facilitate lip repair. Seven of the patients had had their premaxillae setback at a later age to correct a severe midfacial protrusion in the preschool years. Fourteen other C-BCLP patients, followed up and treated similarly except for the premaxillary setback, served as controls. The average long-term outcome of the setback surgery in both the early and late subgroups was retrusion of the midface and a slightly concave facial skeletal profile.     

Unusual clinical presentation of a severely protruding premaxilla in patient with bilateral clefts

Prominent premaxilla is one of the problems encountered when dealing with bilateral complete cleft lip and palate patients. Secondary alveolar bone grafting with these patients would achieve filling of the osseous defect, supports the alar base, eliminate the oro-nasal fistula and enhance the maxillary instability. This article describes the management of a bilateral cleft lip and palate patient with an extremely protruding premaxilla done in one stage surgery. To our knowledge, this is the first report of such degree of severity in the English literature.     

A rapid solution to align the severely malpositioned premaxilla in bilateral cleft lip and palate patients.

OBJECTIVE: To describe a laboratory modification of the maxillary cast to make an improved nasoalveolar molding plate used in presurgical orthopedics for infants with bilateral cleft lip and palate. CONCLUSIONS: Modifying the nasoalveolar molding plate may reduce the presurgical treatment time for the bilateral cleft lip and palate patient.     

Secondary correction of premaxilla in bilateral cleft lip and palate with lag-screw fixation

It is not unusual for the protruding premaxilla to attain an undesirable position after cleft lip repair. Such a premaxilla may lead to considerable problems in facial aesthetics, or oral functions, or both in early childhood. These abnormal premaxillas may produce difficulties in bone grafting and orthodontic treatment in late childhood. In such cases, surgical correction of the premaxilla in childhood is justified. From 2013 to 2018, 11 children, aged 2 to 11 years, had a secondary ostectomy of their premaxilla. A new stabilisation method (developed by us) was used to provide rigid fixation to the premaxilla. The follow up period ranged from 1 - 6 years. The results were satisfactory in all except for a few minor issues in three patients. There was significant improvement in their appearance, oral functions, and most importantly in their quality of life. The need for secondary osteotomy of the premaxilla should always be weighed against its potential complications. The fixation technique described by us, though, provides rigid fixation, but may potentially be associated with a few complications if not practised carefully.     

Management of the prominent premaxilla in bilateral cleft lip and palate.

DESIGN AND OBJECTIVE: This study was designed to present our philosophy in managing the prominent premaxilla in patients with bilateral cleft lip and palate. Indications, contraindications, and the pre- and postoperative orthodontic role are defined. SETTING: Tertiary care, cleft palate and craniofacial center-academic institution. PATIENTS: Under review were four cases of bilateral cleft lip and palate presenting with prominent premaxilla and operated on by a single surgeon between 1996 and 2004. CONCLUSION: With appropriate patient selection, bilateral alveolar bone grafting with premaxillary repositioning is a safe procedure and can produce good aesthetic and functional results.     

Secondary management of the premaxilla in bilateral cleft lip and palate patients

Bilateral clefts of the palate pose difficult and unique problems in surgical rehabilitation. The premaxilla traditionally has been a controversial subject with a historic lack of uniformity in treatment protocol. Based on a review of facial growth and the evolution of premaxillary cleft surgery, principles of management and secondary reconstruction of the premaxilla are discussed. Timely surgical intervention combining osteotomies and bone grafting in conjunction with closure of soft tissue defects is shown to result in satisfactory functional and aesthetic results.     

Repair of bilateral complete cleft lip and nasal deformity--state of the art.

OBJECTIVE: Dissatisfaction with the stigmata of repaired bilateral cleft lip has stimulated surgeons to change conventional operative strategies. The old staged labial repairs, one side and later the other, have been replaced by simultaneous closure. For nasal correction, most surgeons no longer believe that the columella is deficient, and thus there is no need to recruit tissue from the lip or nostril sills as a secondary procedure. The columella is concealed in the nose. The new strategy is to construct the columella and nasal tip by anatomic positioning of the alar cartilages and sculpting the investing skin. Furthermore, nasal correction is done at the time of bilateral labial repair and, whenever possible, the alveolar clefts are closed as well. The goal is primary repair of the primary palate. CONCLUSION: Although the principles of synchronous repair of the bilateral complete cleft lip and nasal deformity are established, the techniques continue to evolve. Bilateral nasolabial repair requires continual study of three-dimensional form and fourth-dimensional changes that are normal and altered by the deformity. Every surgeon who lifts a knife to care for these children has an obligation to periodically assess outcome.     

Repositioning of premaxilla in bilateral cleft lip and palate using a "J-hook headgear"

The purpose of this clinical approach is to present the successful treatment of the severely protruded and extruded premaxilla with high-pull J-hook headgear. Two patients with bilateral cleft lip and palate deformity and a protruding and extruding premaxilla causing a deep bite were treated with high-pull J-hook headgear and fixed orthodontic appliances. The lateral cephalometric measurements before and after orthodontic treatment were evaluated with Ricketts analysis. The premaxillae of the two patients were repositioned, correcting the deep overbite and overjet and a well-functioning occlusion was attained. The repositioning of an inferiorly positioned and protruded premaxilla with J-hook headgear is an alternative treatment approach compared to other treatment modalities.     

Craniofacial morphology in children with complete bilateral cleft lip and palate: does infantile size of the premaxilla predetermine outcome?

OBJECTIVE: To evaluate the possible association between the size of the premaxilla in infants and craniofacial morphology in children with complete bilateral cleft lip and palate (CBCLP) and identify the characteristics of craniofacial morphology in children with CBCLP with median facial dysplasia (MFD). DESIGN: Retrospective study. SETTING: A university hospital craniofacial center. SUBJECTS: Thirty-four patients with nonsyndromic CBCLP, 24 boys and 10 girls, had large premaxilla (LP group). Thirty-six patients with nonsyndromic CBCLP, 16 boys and 20 girls, had small premaxilla (SP group). Thirteen CBCLP patients with MFD, five boys and eight girls (MFD group). MAIN OUTCOME MEASURES: Infant maxillary dental cast at the age of 1 year was used to measure the size of the premaxilla. Cephalometric analysis was used to determine craniofacial morphology in children at the age of 5 years. RESULTS: The size of the premaxilla in infants with CBCLP varied greatly. The LP group tended to have a longer maxilla and a more protruded maxilla, producing a better interjaw relation. The opposite phenomena were observed in the MFD group; the SP group yielded results between those of the LP and the MFD groups. CONCLUSION: The size of the premaxilla in infants with CBCLP can be used to predetermine subsequent craniofacial morphology at the age of 5 years. Children with nonsyndromic CBCLP had craniofacial characteristics that differed significantly from those of children with CBCLP with median facial dysplasia.     

An intraoral appliance for management of the protrusive premaxilla in bilateral cleft lip

Management of the protruding premaxilla and prolabium in bilateral cleft lip and palate can be a confounding problem. This report introduces an intraoral traction appliance that has been successfully used to move the premaxilla and prolabium to a more favorable position for surgical repair of the bilateral cleft lip. The appliance consists of a palatal baseplate for anchorage and a latex rubber traction strip looped over the prolabium to retract the premaxillary segment. The results in five cases are presented and compared to two cases where no presurgical management was performed and lip repair had been delayed for medical reasons. Advantages and disadvantages of the appliance are discussed.     

Dental maturity in children with a complete bilateral cleft lip and palate.

OBJECTIVE: Dental age in children with a bilateral cleft lip and palate (BCLP) was assessed and compared with children without cleft. DESIGN: Dental age was estimated for 74 children with a complete BCLP (54 boys and 20 girls) from 364 orthopantomograms. Nonlinear regression curves were made between 5 and 14 years of age for boys and girls separately. A comparison was made with a sample of Dutch children (91 girls and 90 boys) without oral clefts for three different age groups, namely 5, 9.5, and 14 years of age. SETTING: Data collection was carried out at the Cleft Palate Center, University Medical Center Nijmegen (The Netherlands). A sample from the Nijmegen Growth Study was used as a normative sample. RESULTS: At 5 years of age, boys with a BCLP were significantly delayed in dental age compared to boys without cleft. After that age, no significant differences in dental age were found. For girls with a BCLP, no difference in dental age with the girls without cleft could be found. CONCLUSION: Dental age in BCLP showed a tendency to be delayed at 5 years of age. At the ages of 9.5 and 14 years of age, no differences were found. Further investigation on the development of individual teeth is suggested to gain more insight into the origin of this delay.     

Growth characteristics of the premaxilla and orthodontic treatment principles in bilateral cleft lip and palate

Sixty-three individuals with complete bilateral cleft lip and palate (BCLP) were studied. In 51 of these subjects no surgical set-back or early bone grafting procedures were done. In the other 12 subjects early surgical procedures to reduce the prominence of the premaxilla had been done. In the larger group the premaxilla was, on the average, protrusive until age 12, after which it gradually became more retrusive. By the end of the growth period the premaxilla was not excessively protrusive in any of these subjects. It was concluded that it is advantageous for the premaxilla in individuals with BCLP to be protrusive during most of the growth period, since the premaxilla grows forward at a slower rate than the mandible. In the 12 subjects with premaxillary surgery, midface retrusion was demonstrated at an early age. The forward growth of the premaxilla in these individuals was slower than in the BCLP without premaxillary surgery and all 12 subjects developed rather severe midface retrusion. Orthodontic treatment principles for four different stages of craniofacial and dental development have been outlined.     

Postoperative lip and nose forms following primary bilateral cleft lip repair selecting one/two stage surgery in comparison to those of healthy children

PurposeTo analyze the short-term outcomes for the lip and nasal forms after primary treatment following our surgical strategy for bilateral cleft lip with/without palate (BCL ± P) repair selecting one- or two-stage surgery at Kagoshima University Hospital.Patients and methodsTwenty-one patients with BCL ± P were treated and followed up over 1 year (1–6 years). Patients underwent primary lip repair by one- or two-stage surgery depending on the prolabium height, medial-upward advancement of nasolabial components, and vestibular expansion using two cleft margin flaps. The postoperative lip and nasal forms were longitudinally measured using serial color photographs and were compared to those of 18 age- and sex-matched healthy Japanese children.ResultsPostoperative lip form showed the upper lip height and vermilion mucosal height were significantly increased compared with the preoperative values. The vermilion/cutaneous lip height ratio was improved to the same level as that of controls at 3 years of age. Symmetry of lip and nasal forms was successfully achieved postoperatively, but the nasal height was still smaller than that of controls.ConclusionsOur surgical management strategy for BCL ± P will provide well-balanced and symmetrical lip and nasal forms, except for the nasal height, without damaging an infant's prolabium.     

Examination of dental casts in newborns with bilateral complete cleft lip and palate

This study reports measurements of dental casts in patients up to 6 months of age with bilateral complete cleft lip and palate (BCLP). 25 mouth casts of newborns with BCLP were selected from the hospital archive. They were measured independently by two examiners who assigned numbers to each measurement, referring to the expected reproducibility. The investigators also classified each dental cast according to an established score. The absolute values of all measured distances (P-P′, L-C1-C2-T, L′-C1′-C2′-T′, P-L, P′-L′, L-L′, C1-C1′, C2-C2′, Q1-Q1′, Q2-Q2′, T-T′, I-Q1Q1′, I-Q2Q2′, I-TT′) are reported. Inter-observer reproducibility was acceptable with total measurement errors ranging from 0.5 to 1.4 mm. Most reliability scores, ranging from 1 (very high) to 5 (very low), showed a mean between 2 and 3 (min 2.17; max 3.16). The two examiners rated only one patient differently, according to the applied classification scheme. The absolute measurement values of the two classification systems accorded with the literature. This is the first study to measure the distances according to an established protocol in BCLP patients. The measurements between certain landmarks are more precise than others; it may be possible to use the more precise points for a longitudinal study from birth to 18 years.     

Non-surgical treatment of vertical excess of the premaxilla in growing bilateral cleft lip and palate patients

Patients with bilateral complete cleft lip and palate (BCLP) may present a vertical excess of the premaxilla in childhood. This is a severe functional and aesthetic problem, where bone grafting is more challenging. The aim of this study was to describe a simple and reproducible non-surgical orthopaedic treatment for vertical excess of the premaxilla in the deciduous/early mixed dentition phase in BCLP patients. Six growing patients with complete BCLP with a severe vertical excess of the premaxilla were included. An intrusion device associated with a bonded rapid palatal expander was applied to intrude the premaxilla. Radiographic and photographic records obtained before and at the end of the orthodontic intrusion, at short- and long-term follow-up, were available. A flattening of the occlusal plane was achieved in all patients. Normalization of the position of the maxillary incisors and gingival display in relation to the upper lip was obtained, and an improvement in anterior nasal spine position was also observed in all cases. The novel technique described might be of assistance in treating BCLP children with vertical excess of the premaxilla during the deciduous/early mixed dentition phase. This simplified, easily reproducible method may allow the burden of care of this rare but complex problem affecting BCLP patients to be reduced significantly.