Invited Discussion: Early Cleft Lip Repair in Children With Unilateral Complete Cleft Lip and Palate: A Case Against Primary Alveolar Repair

Changes in maxillary alveolar morphology with nasoalveolar molding

AIM

To evaluate the changes in maxillary alveolar morphology in unilateral cleft lip palate infants treated with nasoalveolar molding (NAM).

SETTING AND DESIGN

Study was carried out in the orthodontic department associated with a operating cleft unit in a rural region of central India. Ten UCLP (unilateral cleft lip palate) infants less than 6 weeks of age were treated with NAM prior to surgical repair.

MATERIALS AND METHODS

Pre NAM and Post NAMstudy models of the UCLP infants were analyzed. Critical linear dimensions including inter- canine width, inter-tuberosity width, arch length and midline deviation were recorded at the different stages using a digital vernier caliper and compared. Statistical analysis were performed using SPSS 13.00 statistical software.

RESULTS

Results from this study showed that the width of the alveolar cleft showed a significant decrease with NAM. The arch length and width of the arch in the anterior region also showed a reduction with NAM. The intertuberosity width showed a statistically significant increase during treatment. The arch perimeter showed a significant increase with NAM.

CONCLUSION

NAM was effective in reducing the severity of the initial cleft deformity mainly at the anterior portion of the maxillary arch.

Early secondary gingivo-alveolo-plasty in the treatment of unilateral cleft lip and palate patients: 20 years experience

Since 1988, the Milano surgical protocol has included lip, nose and soft palate repair at 6-9 months of age and closure of the hard palate at 18-36 months together with an Early Secondary Gingivo-Alveolo-Plasty (ESGAP). Prior to 1988 the alveolar cleft was repaired in a third step by bone grafting at 9-11 years of age. The goal of this study was to evaluate the long-term maxillary growth in unilateral cleft lip and palate (UCLP) patients who have undergone ESGAP. Alveolar ossification after ESGAP was also studied in the permanent dentition. Growth assessment was carried out comparing lateral X-ray cephalograms of a UCLP ESGAP sample (15 consecutive patients with a mean age of 18.2 +/-1.2 years) and of the UCLP bone graft sample (10 consecutive patients with a mean age of 18.7 +/-1.1 years) and a sample from the Oslo cleft lip and palate (CLP) centre sample (15 patients with a mean age of 18.1 +/-0.8 years). Alveolar ossification in the sample which had undergone ESGAP was evaluated through a sample of panoramic X-rays of UCLP in the permanent dentition. Alveolar bridging was assessed using a modified Bergland's scoring system. From the results it seems that ESGAP allows for an excellent alveolar ossification, but patients show an inhibition of maxillary growth compared with the secondary bone graft group and with the Oslo group. Although ESGAP allows for early repair of the alveolus together with palate repair, thus eliminating in all patients the need for secondary bone grafting, it seems to have an inhibiting influence on maxillary growth which increases the need for Le Fort I osteotomies. It is however fair to recall, that, even with an adjunctive Le Fort I osteotomy, ESGAP enables the total number of operations to be reduced to three, instead of most European protocols (4-5 procedures).

Comparison of growth results in patients with unilateral cleft lip and palate after early secondary gingivoalveoloplasty and secondary bone grafting: 20 years follow up

The Milan surgical protocol from 1988 has included repair of lip, nose, and soft palate at 6-9 months of age, and closure of the hard palate and alveolus with an early secondary gingivoalveoloplasty at 18-36 months. The goal of this study was to evaluate the long-term maxillary growth in patients with unilateral cleft lip and palate (UCLP) who had had the early secondary gingivoalveoloplasty, compared with the growth in a sample treated before 1988, by the same surgeon, with a surgical protocol that differed only by the method and the timing of alveolar closure. In the second group they were repaired by secondary bone grafting. The samples consisted of lateral cephalograms of the UCLP early secondary gingivoalveoloplasty sample (15 patients with a mean age of 18 (1.2) years) and of the UCLP bone graft sample (10 patients with a mean age of 19 (1.1) years). The early secondary gingivoalveoloplasty patients showed that maxillary growth was inhibited compared with the secondary bone graft group. Although the early secondary gingivoalveoloplasty allowed for early repair of the alveolus together with palatal repair, eliminating the need for secondary bone grafting, it seemed to have an inhibiting influence on maxillary growth that increased the need for Le Fort I osteotomies. Even with a Le Fort I osteotomy, the early secondary gingivoalveoloplasty allows the total number of operations to be kept down to three, as in most European protocols.