Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16-19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16-19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16-19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

Long-term influence of infant periosteoplasty on facial growth and occlusion in patients with bilateral cleft lip and palate

Abstract

This retrospective, long-term study evaluated the influence of two different treatment protocols, one including infant periosteoplasty, on facial growth and occlusion in patients with complete bilateral cleft lip and palate (BCLP). Thirty-five patients with records of 5-, 8- and 16–19-year-olds were included. Sixteen of these received infant periosteoplasty (BCLP-pp) to the cleft alveolus in conjunction with lip repair and a one-stage closure of the palate. The remaining 19 patients with a two-stage closure of the palate did not have an infant periosteoplasty (BCLP-np). The bone formation induced by periosteoplasty in the BCLP-np group was insufficient and both groups had secondary bone grafting to the alveolar clefts before the eruption of the lateral incisor or the canine. Facial growth was evaluated with cephalometry at the recorded ages and dental arch relationships with the Huddart and Bodenham crossbite scores at the age of 16–19 years. Until 19 years a significant retrusion of the maxillary position (SNA) was observed in both groups. At 16–19 years of age there was no significant difference of maxillary protrusion (SNA), intermaxillary position (ANB), maxillary length (ss-pm) or vertical skeletal relationships (ML/NSL, Ml/NL) between the two groups. However, a significant difference of the crossbite scores was found. The BCLP-pp group did not show more facial growth problems but more malocclusion and the insufficient bone formation of the alveolar clefts after infant periosteoplasty required a secondary bone grafting.     

改良颊侧多曲簧矫治器纠正早期安氏Ⅲ类错伴下颌偏斜

目的:通过头颅定位后前位片测量,探讨改良颊侧多曲簧活动矫治器纠正早期安氏Ⅲ类错且伴下颌功能性偏斜,改善早期功能性下颌偏斜。方法:混合牙列早期安氏Ⅲ类错且伴有下颌功能性偏斜患者20例,采用改良颊侧多曲簧活动矫治器的方法,矫治前后头颅定位后前位片P-A测量分析,用统计软件处理数据。结果:改良颊侧多曲簧活动矫治器矫正早期安氏Ⅲ类错且伴有下颌功能性偏斜后,下颌骨两侧结构不对称性有明显改善,下颌骨两侧综合长度差亦减小(P<0.01),两侧下颌体长度差明显减小(P<0.01)。结论:由于早期安氏Ⅲ类错且伴有单侧后牙反,导致的功能性下颌偏斜,采用改良颊侧多曲簧活动矫治器,可以使下颌骨的不对称得到一定的改善,是早期纠正下颌功能性偏斜的有效手段。     

Dentofacial relations in young adults with unilateral complete cleft lip and palate. A follow-up study

A retrospective study was made on 30 patients born between 1958 and 1969 with unilateral complete cleft lip and palate (C-UCLP) and operated on at the Department of Plastic Surgery, University Hospital, Ume?, Sweden. All patients were operated on by the same surgeon. The results are based on data from records at 5, 10, 16 and 20 years of age. The facial morphology of the cleft children at 5 years of age was rather close to that of the normal children. During growth the faces became retrognathic, more visibly so in the maxilla resulting in straight or concave profiles. This was more evident among the boys. There were no differences regarding maxillary growth between children bone grafted at 10 to 16 years of age and those bone grafted after 16 years of age or not at all. Although surgical procedures and orthodontic treatment varied, 70% had less than 3 teeth in crossbite relationships at 20 years of age. An important factor to take into consideration is the fact that in addition to the influence that the cleft morphology and treatment have on the dentofacial growth, other dentofacial growth patterns also exist among the cleft patients. Generally the groups of patients reported are rather small and therefore conditions like these can have a strong influence on the results.     

Challenges in maxillofacial reconstruction on secondary cleft deformities

Cleft surgery demands much on the meticulous surgical skills and aesthetic sense in relation to craniofacial growth and functions. With the understanding of genetic interplay and peer review on the surgical outcome, cleft surgeons have made great strides in treatment concept during the past decades. It is inevitable that secondary cleft deformities may rely on the cumulative effects of functional and morphological abnormalities from the stage of primary repair. Problems could range from uncorrected defects, complicated healing from initial repair, to some exaggerated developmental facial disharmonies as the patients attain adolescent or adult age. For this reason, the Cleft Palate Team is posed an immense challenge in treating the residual cleft deformities. Some of the challenges include large oronasal fistula, severe maxillary or midfacial retrusion, and pursuit of aesthetics on lip nose complex correction. These problems demand sophisticated surgical skills and sound understanding of craniofacial bio‐physiology. The sequential treatment strategy of secondary cleft reconstruction as practiced in the United Christian Hospital is considered as the foundation in the management of those challenging maxillofacial complexities. The purpose of the present paper is to share our sequential protocol practiced in the United Christian Hospital as a foundation to accomplish those maxillofacial complexities. Treated clinical cases demonstrate the innovative application of distraction osteogenesis on severe cleft skeletal correction, the use of tongue flap for repair of large oronasal defect, and corrective radical rhinoplasty with fascial graft augmentation. The last section of the present report is concentrated on the practical application of Nasal Symmetry Index for assessing result of cleft rhinoplasty.      

Craniofacial and occlusal characteristics in unilateral cleft lip and palate patients from four Scandinavian centres.

Craniofacial morphology and dental occlusion were studied at early school age in 15 consecutive patients with unilateral cleft lip and palate from each of four Scandinavian cleft centres. Treatment differed mainly in the techniques of palatal repair. Push-back closure of the palate particularly impaired maxillary development, which resulted in an increased incidence of crossbite and reduced intercanine distance when compared with patients who had been operated on by the von Langenbeck method or in whom the anterior palate had not yet been closed.     

The comparative study of craniofacial structural characteristic of individuals with different types of cleft palate

To compare craniofacial structural characteristic of individuals with different types of cleft palate and to lay a foundation for better treatment protocol for patients with cleft palate, we chose a sample consisting of 12 patients with Treacher Collin syndrome, 15 patients with Pierre Robin sequence, 40 patients with unilateral complete cleft lip and palate, and 40 patients with isolated cleft palate who met certain criteria. Lateral cephalometric radiographs were obtained from each subject. A total of 22 variables, comprising 11 angular, 9 linear, and 2 ratio measurements, were studied. The z-scores were analyzed during paired Student t test. The data showed us that there seems to be no difference in craniofacial structures between patients with isolated cleft palate and normal persons. Patients with unilateral complete cleft lip and palate who had only cleft lip repaired exhibit such characteristics as midface retrusion, relatively excessive lower facial height, and more obtuse gonial angle. The cranial base areas of individuals with Treacher Collin syndrome and Pierre Robin sequence are similar to those of normal persons. Mandibular hypoplasia in both vertical and horizontal dimensions and maxillary retrusion can be found in patients with Treacher Collin syndrome, while only mandibular hypoplasia in the horizontal dimension can be found in patients with Pierre Robin sequence. The developmental deficiency of craniofacial structures seems to be a separate deformity, not the direct outcome of cleft palate defect.     

唇腭裂上颌复合体不同类型截骨块的抗力中心

目的 探讨唇腭裂上颌复合体不同类型截骨块的抗力中心,以便为临床牵引截骨提供理论指导.方法 采用螺旋CT扫描与三维有限元方法相结合,建立唇腭裂上颌复合体LeFort Ⅰ、Ⅱ、Ⅲ型截骨骨块及相应软组织有限元模型,分别在5个不同垂直高度加载水平向力和4个不同水平距离加载垂直向力,力值均为9.8 N,根据骨块不同观察点位移情况确定不同截骨块的抗力中心.结果 唇腭裂上颌复合体LeFort Ⅱ型截骨骨块的抗力中心前后位置在尖牙与第1双尖牙后缘之间,高度为鼻底与梨状孔中点间.LeFort Ⅲ型截骨骨块的抗力中心前后位置在第1双尖牙后缘与第1磨牙后缘之间,高度为梨状孔中点与鼻前点间.结论 唇腭裂上颌复合体不同截骨块抗力中心的确定,为唇腭裂颅面复合体牵引成骨生物力学研究奠定了基础.     

Tissue engineering solutions for cleft palates.

PURPOSE: Clefts of the lip and palate are the most prevalent congenital craniofacial birth defect in humans. The developing field of tissue engineering is considered for the management of clefts of the lip and palate. MATERIALS AND METHODS: A review of the literature was carried out by using electronic databases (such as PubMed and ISI Web of Science) to search topics including "cleft palate," "tissue engineering," "bone engineering," "palate engineering," and "alveolar bone grafting." To reflect current practice and research, these searches were limited primarily to articles published after the year 2000. RESULTS: Current approaches for the treatment of clefts of the lip and palate include surgery and bone grafts; however, there are limitations associated with these therapies. Tissue engineering strategies, particularly alveolar bone engineering and soft tissue engineering, may provide clinicians with new alternatives. The application of these emerging technologies to a pediatric population must be well considered. CONCLUSIONS: A tissue engineering approach may be a useful alternative for the treatment of cleft palates as it mitigates the concerns of donor site morbidity as well as provides additional options including scaffold implantation and growth factor delivery.     

Postoperative Evaluation of Palatoplasty Using the Modified Kaplan Method

Purpose Bilateral buccal mucosal flaps were used for a pushback operation of the nasal mucosa as well as the oral mucosa.Methods Two flaps from the buccal mucosal areas were inserted into the nasal mucosal raw surface at the hard and soft palatal border to achieve nasal mucosal pushback. Forty-four children with cleft palates were retrospectively studied to investigate the velopharyngeal function, articulation, and craniofacial morphology following primary palatoplasty using the modified Kaplan method.Results 72.7% showed good velopharyngeal function. Articulation disorders were found in 26 of the 44 subjects (59.1%). A craniofacial morphological analysis revealed no major changes in the SNA (sella–nasion point A angle) and SNB (sella–nasion point B angle) and no cases of a marked loss of maxillary mandibular balance. In addition, no significant differences were observed in the maxillary length and width.Conclusion The results of these palatoplasties by the modified Kaplan method indicated that the use of bilateral buccal mucosal flaps for the pushback of the nasal mucosa was effective in preventing the contraction of the maxillary and mandibular corpal lengths.     

先天性颅面裂隙畸形的诊断和分类

目的 对先天性颅面裂隙畸形进行分类和诊断，有利于区分畸形的部位和程度，为手术修复提供指导。方法 用Tessier颅面裂分类的基本方法，对81例先天性颅面裂隙畸形进行分析，再根据畸形发生的部位、性状、CT扫描等临床检查结果，按照受累的范围，选用S(皮肤)、T(皮下组织)、O(颅面骨)等字母组合表示畸形部位和性状，选用阿拉伯数字的大小表示畸形的严重程度，作为Tessier分类的补充。结果 以STO分类法分析81例病例，眶下方畸形以Ⅲ、Ⅳ号裂多见(24．70％)，眶上方畸形以IX、X号裂多见(38．27％)，各种组织的受累程度并未表现出一定的规律性。结论STO分类法是Tessier分类法的补充，可为颅面裂隙畸形的修复提供依据。     

Periodontal tissue changes after the correction of reverse over-jet

Frequently, the incisor crossbite is the result of the abnormal retroclination of the anterior teeth of the maxilla. The occlusal trauma due to this condition and crowding can affect the periodontal health of the anterior teeth. We took in our study a sample of children with incisor crossbite who have undergone orthodontic treatment with proclination of the maxillary incisors in order to correct the reverse overjet. All subjects were monitored for oral hygiene during the correction of the incisor crossbite. When found that the orthodontic movements for the correction of the incisor crooss-bite produced an increased and transcent periodontal inflammation in the maxillary incisor's area, but with a good oral hygiene, these kind of orthodontic movements seemed to be harmless for the periodontal status of this patients.     

General body growth in children with clefts of the lip, palate, and craniofacial structure

This paper discusses general body growth in children with craniofacial clefts. Body growth is important in such patients because morphology reflects the cumulation of metabolism over time. The same hormones that direct general body growth also govern the ontogeny of the head and face. Body growth varies in children with different types of clefts. We found no average differences from US norms for those with isolated clefts of the lip alone or those with bilateral clefts of the lip and palate. Children with unilateral clefts of the lip and palate and with isolated cleft palate were significantly shorter than their unaffected peers. Males with these defects were also thinner than normal based on average standard deviation scores for body mass indices. Both unilateral and bilateral clefts of the lip and palate predominated in males, while isolated cleft lip was more frequent in females. Our results indicate that congenital metabolic variation contributes to the development of orofacial clefting and influences postnatal development in certain types of cleft. Accordingly, cleft type is important to growth prognosis, and growth status is relevant to optimization of therapy in orofacial cleft patients.     

改良固定反式TBA联合前牵引矫治前牙反的比较性研究

目的:应用改良固定反式双阻板矫治器(Twin-blockappliance,TBA)联合前牵治疗AngleIII类骨性前牙反,综合评价其临床应用效果。方法:矫治骨性前牙反牙合15例,对治疗前后临床表现及X线硬组织测量进行分析,并与单纯反式TBA组及前牵组进行比较。结果:经过3￣5个月的治疗,患者侧貌外型明显改善,反覆盖、覆纠正。结论:反式TBA联合前牵引是矫治前牙反牙合的理想装置,对上下颌骨影响均较大。     

Facial growth of adults with unoperated clefts

Studies of adult patients with unoperated complete unilateral cleft lip and palate indicate that there is normal potential for maxillary growth. The maxilla in the unoperated patient is normally positioned or protruded. The protrusion of maxilla in the unoperated adult cleft patient is limited to the non-cleft side, contributing to hemifacial maxillary prognathism. Surgical scar tissue is known to interfere with the growth of the midface. Palatal surgery has more significant influence on the growth of the mid-face than the lip surgery; therefore, it is important to reduce the effect of surgery by delaying the timing of palatal surgery or changing the location of the surgical scar from the sutural areas. Delaying palatal surgery until the maxillary growth is complete is desirable but could lead to poor speech development. Therefore, it is essential to perform the palatal surgery before speech development. The other variables that affect the midface are the development genetic make-up of the cleft child, the amount of tissue deficiency, timing of surgery, surgical technique, and the skill of the surgeon. Surgeries continue to have some inhibitory effect on maxillary growth, but it is essential to recognize and perform those surgical procedures that have the least effect on growth of the maxilla. This will help minimize extensive orthodontic treatment and eliminate major secondary orthognathic surgery for correction of the abnormal growth of the maxilla.     

Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review

Rehabilitation of cleft lip and palate (CLP) patients is a challenge for all the concerned members of the cleft team, and various treatment modalities have been attempted to obtain aesthetic results. Presurgical infant orthopaedics (PSIO) was introduced to reshape alveolar and nasal segments prior to surgical repair of cleft lip. However, literature reports lot of controversy regarding the use of PSIO in patients with CLP. Evaluation of long-term results of PSIO can provide scientific evidence on the efficacy and usefulness of PSIO in CLP patients. The aim was to assess the scientific evidence on the efficiency of PSIO appliances in patients with CLP and to critically analyse the current status of PSIO. A PubMed search was performed using the terms PSIO, presurgical nasoalveolar moulding and its long-term results and related articles were selected for the review. The documented studies report no beneficial effect of PSIO on maxillary arch dimensions, facial aesthetics and in the subsequent development of dentition and occlusion in CLP patients. Nasal moulding seems to be more beneficial and effective in unilateral cleft lip and palate patients with better long-term results.KEY WORDS: Bilateral cleft lip and palate, long-term results, nasoalveolar moulding, presurgical infant orthopaedics, unilateral cleft lip and palate     

Foetal surgery and cleft lip and palate: current status and new perspectives.

Now-a-days, high-resolution ultrasound allows an accurate and relatively early diagnosis of congenital malformations. In a limited number of such conditions foetal surgery may be lifesaving. However, premature labour has been the major drawback for open foetal surgery. Recently, improvement of video-endoscopic technology has boosted the development of operative techniques for feto-endoscopic surgery, which has been demonstrated to be less invasive than the open approach. Main clinical application of fetoscopic procedures today is the treatment of feto-foetal transfusion syndrome. Although still in development, feto-endoscopic surgery seems to offer new hope for surgical foetal therapy not only in cases of life threatening conditions. Experimental intrauterine correction of cleft lip and palate (CLP) has been lately performed using the feto-endoscopic approach. This procedure offers two major advantages: first, scarless foetal wound healing and bone healing without callus formation, which would also allow a better/normal maxillary growth, and second, significant decrease of foetal and maternal morbidity. Herein, we report the current status of experimental and clinical foetal surgery and propose possible directions for continuing research to make intrauterine procedures safer. Furthermore, we discuss current knowledge and new perspectives of experimental foetal cleft lip and palate repair, which in the future may lead to such excellent results in the operative treatment of clefts, that less or no secondary corrections and therapies, such as orthodontic, dental, logopedic, etc. would be needed. Only if these conditions can be fulfilled, will we be able to improve substantially our therapy for the human foetus with a cleft lip and palate. In spite of all efforts, however, it must be considered that it may not ever be possible to find the optimal treatment method for this or other craniofacial malformations.     

New orthodontic and orthopaedic managements on the premaxillary deformities in patients with bilateral cleft before alveolar bone grafting

At the age of mixed dentition, a downward or laterally displaced premaxilla with a wide alveolar cleft in patients with bilateral cleft lip and palate remains a dilemma both for orthodontists and surgeons. These premaxillary deformities not only make the alveolar bone grafting difficult but also aesthetically and functionally unacceptable. The purpose of the present article is to introduce three new orthodontic and orthopaedic techniques for solving these premaxillary deformities and facilitating alveolar bone graft through a non‐surgical approach. These techniques are the premaxillary orthopaedic intrusion for correcting a downward displaced premaxilla, the premaxillary orthopaedic repositioning for correcting a laterally displaced premaxilla, and maxillary orthopaedic protraction by alternate rapid maxillary expansions and constrictions for minimizing a wide alveolar cleft. They were evaluated clinically and cephalometrically for their treatment effects. The results revealed that the premaxillary and cleft deformities were corrected in a short period of time and therefore the alveolar bone grafting could be carried out without difficulty in all of the patients who received the treatment. The treatment effects were mostly orthopaedic and partly orthodontic. No growth disturbance on the maxilla was observed throughout the treatment. These new orthodontic and orthopaedic techniques are very effective for solving the difficult‐to‐treat premaxillary deformities and facilitating the alveolar bone grafting in the patients with bilateral cleft.      

33例颅面裂Tessier分类诊断与治疗体会

目的介绍颅面裂的Tessier分类诊断与手术治疗体会。方法按Tessier分类法对33例颅面裂患者进行分类，并根据畸形类型及轻重程度制定手术方案；共施术29例，手术方法包括单纯眶内侧壁截骨与鼻翼软骨修整、局部皮瓣转移、内眦固定、真皮移植、骨移植、组织代用品置入、吻合血管的游离组织瓣移植等。结果33例中属0号颅面裂1例、0—14号颅面裂3例、1号颅面裂1例、2-12号颅面裂2例、3号颅面裂3例、4号颅面裂1例、5／6号复合颅面裂1例、7号颅面裂18例、6／7／8号复合颅面裂2例、11号颅面裂1例；29例接受手术的患者，术后面部形态明显改善，无并发症发生。结论①Tessier颅面裂分类法有助于发现与主诉体征相伴的其它颅面畸形，对作出全面正确的诊断及制定手术方案具有重要的指导作用。②在Tessier颅面裂中以7号颅面裂较为常见。③Tessier颅面裂有不同的类型，且每一类型的颅面裂又有不同的严重程度，而且不同类型及不同严重程度的颅面裂又可见于同一患者，需根据患者具体情况制定个性化的手术方案。