Primary Premaxillary Setback and Repair of Bilateral Complete Cleft Lip: Indications, Technique, and Outcomes

A Modified 270-Degree Closure Technique to Address the Prominent or Locked-Out Premaxilla in Bilateral Cleft Palate Repair

SUMMARY

The bilateral cleft deformity with a prominent or "locked-out" premaxilla presents one of the most challenging repairs in cleft surgery. Despite its relative frequency, traditional hard palate repair techniques fail to fully address this deformity, exposing surgeons and patients to the risk of a large anterior fistula developing when flaps cannot approximate the premaxilla. This greatly increases morbidity for the patient and creates unnecessary challenges during fistula repair or alveolar cleft bone graft later in childhood. The 270-degree closure technique extends the nasal closure 270 degrees around the premaxilla, continuing the hard palate repair through the alveolar clefts. This technique has been performed on 41 patients, with a mean follow-up of 10.8 years. The repair was successful in 93% of patients, with 3 patients developing palatal fistulas, all posterior to the 270-degree closure. The 270-degree cleft palate repair around the prominent premaxilla fills a void in the literature for managing the immense challenge of this deformity. When presurgical orthopedic appliances are not a viable option, this approach can minimize the risk of large or complex fistula formation posterior to the premaxilla.

Cleft Palate

The primary function of the palate is to separate the nasal and oral cavities and facilitate the production of normal speech. The velar levator veli palatini (LVP) muscular sling is the palate speech motor. In the cleft palate, the LVP muscles are aberrantly sagittally oriented, which prevents their normal cranial, posterior, and lateral pull on the soft palate, resulting in velopharyngeal incompetence. Palatoplasty techniques enlist the same 3 principles: closure of the nasal mucosa, reorientation and repair of the LVP muscle sling, and closure of the oral mucosa. The primary outcome measures for palatoplasty are speech quality and palatal integrity.

Surgical management of severely protruding premaxilla in bilateral clefts

BACKGROUND

In the cases of severe premaxillary protrusion where nasoalveolar moulding could not be delivered, we have opted for primary osteotomy of premaxilla/vomer to achieve tensionless closure of lip. The aim of present study is to document our experience with both kinds of osteotomies; premaxillary and vomerine.

METHODS

In last seven years, 104 patients of bilateral cleft lip with severely protruding premaxilla reported to our unit. Out of these patients, 26 underwent primary osteotomy of premaxilla/vomer. Follow up period ranged from 4 to 72 months.

RESULTS

In both types of osteotomies, we did not observe any issues with vascularity of premaxilla, eruption and vitality of maxillary incisors. Manipulation of osteotomised segment and closure of lip were more convenient in premaxillary osteotomy. Healing was satisfactory in all the patients except two. Aesthetic outcome was acceptable in all except five patients of premaxillary and three cases of vomerine osteotomy.

CONCLUSION

Primary setback osteotomy of premaxilla/vomer is a safe procedure to manage bilateral cleft lip with excessive protrusion of premaxilla. Regular follow-up should be done in such cases to assess the growth of midface and if required corrective orthodontic and/or surgical treatment should be carried out.

Premaxillary Setback in the Management of Patients With Bilateral Cleft Lip: A 2 Decade Review

OBJECTIVE

This study analyzes indications and outcomes of premaxillary setback (PS) and presents an algorithm for its use in patients with bilateral cleft lip and/or palate (BCL ± P).

DESIGN

Retrospective review.

SETTING

Children's Hospital Los Angeles.

A retrospective review was conducted evaluating patients with BCL ± P undergoing lip repair from 2003-2023. Patients were categorized as undergoing repair with (BCL + PS) or without (BCL-PS) simultaneous PS. Presurgical nasoalveolar molding (NAM), indications for PS, timing of surgery, and complications were collected.

INTERVENTIONS

BCL with PS, BCL + PS.

MAIN OUTCOME MEASURES(S)

Primary outcomes included rates of postoperative complications and revision surgeries. Secondary outcome was the need for orthognathic surgery to correct midface hypoplasia in patients at least 14 years old at their most recent follow-up.

RESULTS

Of 1193 patients, 262 met inclusion criteria. One hundred forty-nine patients (56.9%) were referred for NAM. Fifty-one patients (19.5%) underwent PS during primary BCL repair. Patients who failed repositioning of the premaxilla following presurgical NAM (n = 12) were not candidates for NAM (n = 31) or presented late with a protruding premaxilla (n = 8, 12.977 ± 8.196 months) underwent PS. Median age at surgery was 4.29 months. Complications included wound dehiscence (n = 3) and abscess formation (n = 2). No premaxillary necrosis occurred. Overall revision rates were 9.9%. Of 41 patients over 14 years old, 53.6% needed orthognathic surgery. BCL + PS had comparable rates of wound dehiscence (2.0% vs 4.0%; P = .790), lip revisions (7.8% vs 10.4%; P = .770), and orthognathic surgery (50.0% vs 56.3%; P > .999).

CONCLUSION

PS is a safe and effective method to facilitate BCL repair in patients who are not candidates for NAM.

The Efficacy of Naso-Alveolar Molding on Premaxilla Pushback and Dentoalveolar Changes in Patients With Bilateral Cleft Lip and Palate

OBJECTIVE

To evaluate the extent of naso-alveolar molding (NAM) in pushing the premaxilla posteriorly in patients with bilateral cleft lip and palate (BCLP).

BACKGROUND

Naso-alveolar molding application in cleft lip and palate cases bridges the cleft gap and increases nasal tip projection. In BCLP, NAM potentially mobilizes the premaxilla posteriorly to allow tension-free primary lip closure. However, some patients with BCLP with NAM history still necessitate osteotomy during labioplasty, questioning the efficacy of NAM for BCLP management.

METHODS

This single-center retrospective study was conducted using medical records of nonsyndromic patients with BCLP. Twenty-six patients with BCLP were enrolled over a 5-year period with a history of NAM application before primary labioplasty. The changes in premaxilla width (P), anterior arch width (A), posterior arch width (R), and anteroposterior projection of the premaxilla (P'-A') were statistically analyzed at 2 time points: (1) at the start of NAM application (T1) and (2) after completion of NAM before surgery (T2).

RESULTS

The average age at NAM initiation was 46.2 ± 40.4 days, and the average duration of NAM usage was 125.14 ± 62.94 days. A and P-A showed significant differences between T1 and T2 (P < 0.0001), whereas the rest did not show significant differences in value following NAM application (P > 0.05). Naso-alveolar molding successfully pushed back the premaxilla portion about 4.68 ± 2.83 mm on average.

CONCLUSION

Naso-alveolar molding can push back the premaxillary protrusion up to 5 mm, which can serve as a cutoff point for the consideration of combined modalities. Prenatal diagnosis, counseling, and cleft education should be the benchmark in cleft centers to improve overall patient outcomes.

Single-Stage Posterior Vomerine Ostectomy and Primary Cheiloplasty in Patients with Bilateral Cleft Lip & Palate and Protuberant Premaxilla

OBJECTIVE

A protruded premaxilla has always been challenging to care for by cleft care professionals. This study aims to fortify the use of a single-stage premaxillary setback, with posterior vomerine ostectomy and primary cheiloplasty to achieve proper care for patients with bilateral cleft lip and palate (BCLP) and protruded premaxilla.

DESIGN

Longitudinal retrospective analysis.

SETTING

Twenty-three outreach programs to four countries (Ecuador, Lebanon, Peru, and El-Salvador) between 2016-2022.

PATIENTS/PARTICIPANTS

Sixty-five patients between the ages of 3 months and 6 years and 5 months, with BCLP and severely protruded premaxilla underwent premaxillary setback via posterior vomerine ostectomy and primary cheiloplasty. Patients with diagnosed syndromes and inaccessible vomer bone due to fused palates were excluded from the study.

INTERVENTIONS

Premaxillary setback with posterior vomerine ostectomy, bilateral gingivoperiosteoplasties (GPP), and primary cheiloplasty.

MAIN OUTCOME MEASURE(S)

Postoperative complications and aesthetic outcomes.

RESULTS

The mean age at surgery was 13.17 ± 14.1 months, with an average follow-up time of 26 ± 17 months. Patients underwent their procedures in Ecuador (72%), Peru (9%), Lebanon (8%) and El-Salvador (1%). The majority of patients were aged 1 year or less (66.7%) and were males (58.5%). All patients were operated on successfully and had good aesthetic outcomes. Only one patient developed partial necrosis.

CONCLUSION

Patients with BCLP and severe premaxillary protrusion have always carried immense social, psychological, and financial burdens, especially in outreach settings. Our described single-stage technique has proven to be safe and effective with good aesthetic results. Further follow-up after primary repair should be done to document and ensure proper facial growth and normal nasolabial maturation.

Premaxillary Setback in Bilateral Cleft Lip and Palate Repair

OBJECTIVE

The aim of this study is to evaluate surgical outcomes and maxillofacial growth in patients undergoing primary lip repair with or without premaxillary setback.

DESIGN

Retrospective review.

SETTING

Children's Hospital of Los Angeles, California.

PATIENTS AND PARTICIPANTS

Patients with bilateral cleft lip  ±  palate (BCLP) who underwent lip repair with or without premaxillary setback from January 1975 to September 2021.

INTERVENTIONS

No intervention was performed.

MAIN OUTCOME MEASURE(S)

Patient demographics, comorbidities, and syndromic status were obtained. Indications for premaxillary setback, incidence of midface hypoplasia, orthodontic and/or orthognathic treatments, follow-up, complications, and revisions were recorded and analyzed. Comparisons among long-term outcomes, particularly the development of midface hypoplasia were made between groups.

RESULTS

Thirty-one patients who underwent BCLP repair with premaxillary setback (BCLP  +  PS) and 31 matched control patients who underwent BCLP repair without premaxillary setback (BCLP - PS) were included. Among the 2 groups, multiple logistic regression demonstrated that when controlling for comorbidities, syndromic status, timing of lip repair, and timing of palate repair, premaxillary setback was neither significantly associated with the development of midface hypoplasia (P  =  .076) nor the timing of midface hypoplasia development (P  =  .940) in those that ultimately acquired this facial dysmorphology.

CONCLUSIONS

While a high incidence of midface hypoplasia was seen in both BCLP  ±  PS and BCLP - PS, our findings demonstrate no difference in midface hypoplasia irrespective of premaxillary setback in the setting of BCLP. Future prospective studies investigating the downstream ramifications of our suggested selection criteria for premaxillary setback are warranted.

Surgical Premaxillary Setback with Vomerine Ostectomy for Complicated Bilateral Cleft Lip

Important factors that affect the initial repair of complete bilateral cleft lip (CBCL) include not only the width of the cleft but also the distance between the premaxilla and alveolar bone. We report a case of a patient with CBCL in whom favorable morphological and aesthetical results were achieved by surgical premaxillary setback. The patient was a 5-month-old boy with CBCL, who had a severely protruding premaxilla. Despite repeated lip adhesion before lip closure surgery, wound dehiscence occurred, and therefore, we performed premaxillary setback with vomerine ostectomy. The bone was removed posterior to the vomero-premaxillary suture, and the premaxilla was indirectly stabilized by bilateral mucosal bridging. The procedure for the vomer worked well, and his premaxilla was moved back enough to undergo surgery. The premaxillary setback is thought to be a reasonable option to treat CBCL in patients with a protruding premaxilla. The subsequent long-term follow-up of the midfacial development of these patients is necessary.

Primary vomerine osteotomy with gingivoperiosteoplasty for bilateral cleft lip and palate patients with protrusion and/or torsion of the premaxilla

In patients with bilateral cleft lip and palate (BCLP) with protrusion and/or torsion of the premaxilla, achieving a favorable outcome with adequate facial and maxillary development remains challenging. In the present study, we report a retrospective cohort of patients with complete BCLP who were treated between 2017 and 2020 at a single center in Japan. We investigated the effects and complications of primary vomerine osteotomy (PVO) with gingivoperiosteoplasty (GPP) following pre-surgical orthodontics (PSO) for premaxillary protrusion and/or torsion. For patients with residual premaxillary protrusion and/or torsion after PSO, PVO, and GPP were performed. The distances and angles of the premaxilla were measured on dental casts before PSO, on the day of PVO, after PVO, and on the day of palatoplasty after cheiloplasty. We further assessed postoperative complications. From a total of 36 patients with complete BCLP after PSO, seven patients underwent PVO with GPP. Proper positioning of the premaxilla was achieved in all seven patients. The distance between the anterior edge of the premaxilla and the anterior edge of the lateral segment and the length of the premaxillary-lateral segment on both sides continued to decrease over time. Loosening of GPP sutures occurred in two cases, although no major complications such as necrosis of the premaxilla or fistula formation occurred. Vomerine osteotomy with GPP before primary cheiloplasty is a potential treatment option in BCLP when the premaxilla still protrudes despite PSO or because PSO cannot be applied.

Long-term treatment outcome of patients with complete bilateral cleft lip and palate: a retrospective cohort study

BACKGROUND

Patients with cleft lip and palate have functional and esthetic impairment and typically require multiple interventions in their life. Long-term evaluation following a treatment protocol, especially for patients with complete bilateral cleft lip and palate (BCLP), is important but was rarely reported in the literature.

PATIENTS AND METHODS

A retrospective review was conducted on all patients with complete BCLP born between 1995 and 2002 and treated at our center. Inclusion criteria were having adequate medical records and receiving continuous multidisciplinary team care at least until 20 years of age. Exclusion criteria were lack of regular follow-up and congenital syndromic abnormalities. The medical records and photos were reviewed, and facial bone development was evaluated using cephalometric analysis.

RESULTS

A total of 122 patients were included, with a mean age of 22.1 years at the final evaluation in this study. Primary one-stage cheiloplasty was performed in 91.0% of the patients, and 9.0% underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent two-flap palatoplasty at an average of 12.3 months. Surgical intervention for velopharyngeal insufficiency was required in 59.0% of patients. Revisional lip/nose surgery was performed in 31.1% during growing age and in 64.8% after skeletal maturity. Orthognathic surgery was applied in 60.7% of patients with retruded midface, of which 97.3% underwent two-jaw surgery. The average number of operations to complete the treatment was 5.9 per patient.

CONCLUSION

Patients with complete BCLP remain the most challenging group to treat among the cleft. This review revealed certain suboptimal results, and modifications have been made to the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

Effect of One-Stage Bilateral Cleft Lip, Nose, and Alveolus Repair Following Nasoalveolar Molding on the Premaxilla Position at Preadolescence: An 8-Year Retrospective Study

BACKGROUND/PURPOSE

This paper describes the changes in maxillary arch morphology in infants with bilateral cleft lip and palate (BCLP) following nasoalveolar molding (NAM) and with follow up to assess the need for secondary alveolar bone grafting (ABG) and premaxillary repositioning surgery at preadolescence.

METHODS/DESCRIPTION

Treatment records of infants with BCLP treated with NAM between 2003 and 2013 were reviewed. Patients with complete BCLP who underwent NAM and had complete sets of maxillary casts at T 0 pre-NAM (mean = 27 days), T 1 post-NAM (mean = 6 months and 5 days), and T 2 before palate surgery (mean = 11 months and 15 days) were included. The sample comprised 23 infants (18 male, 5 female). Casts were digitized and analyzed using three dimensional software. The need for secondary ABG and premaxillary repositioning surgery was assessed at preadolescent follow-up (mean = 8.3 years).

RESULTS

Cleft width was reduced on average by 4.73 mm (SD±3.15 mm) and 6.56 mm (SD±4.65) on the right and left sides, respectively. At T 1, 13 (56.52%) patients underwent bilateral gingivoperiosteoplasty (GPP), 8 (34.78%) patients unilateral GPP, and 2 patients (8.7%) did not undergo GPP. 34/46 clefts sites (73.91%) underwent GPP while 12 (26.08%) did not. At preadolescent follow-up of 19 patients, 7 patients (36.84%) did not need ABG on either side, 8 (42.10%) needed ABG on 1 side, and 4 (21.05%) needed ABG on both sides. None of the patients needed premaxillary repositioning surgery.

CONCLUSIONS

Nasoalveolar molding treatment significantly improves the position of the premaxilla before primary repair, and there is a significant reduction in the need for secondary ABG and premaxillary repositioning surgery at preadolescence.

Presurgical Orthopedic Treatment of a 3-Year-Old Child with Unoperated Complete Bilateral Cleft Lip and Palate and Protruding Premaxilla

Unoperated patients with bilateral complete cleft lip and palate (BCCLP), who do not receive orthopedic treatment in infancy and present with significant sagittal excess of the premaxilla, are among the most difficult patients to treat. Delay in primary reconstruction reduces the elastic characteristics of the tissues. The resulting rigidity of bony structures accompanied by the wide alveolar and palatal clefts associated with sagittal excess of the premaxilla pose a great challenge for both surgeon and orthodontist. There is no unique protocol for treatment of these conditions. This paper describes the use of orthopedic treatment in an unoperated 3-year-old male child with BCCLP and a protrusive premaxilla whose appearance and function were both severely affected. A modified Meazzini technique, as described in operated BCCLP patients with a downward-displaced premaxilla, was used. The device itself consists of the 2 independent components mutually connected by a 17 × 25 steel arch. The first is an active fan-type expander. The second consists of an acrylic cap covering the premaxilla and 3 brackets used for the steel arch application. They are connected by a rectangular steel 17 × 25 archwire. Reduction of the premaxillary sagittal excess of is carried out with an elastic chain. The use of this orthopedic appliance is a reliable and valuable presurgical treatment in the therapy of children with BCCLP and protrusive premaxilla whose orthopedic and surgical treatment have been delayed.

Repair of Protruding Bilateral Cleft Lip and Palate With Staged Premaxilla Setback Osteotomy, Cheiloplasty, and Palatoplasty in Trisomy 17p Patient: A Review of Syndromic Clinical Characteristic

Chromosome 17 duplication is correlated with an increased risk of developmental delay, birth defects, and intellectual disability. Here, we reported a female patient with trisomy 17 on the whole short arm with bilateral complete cleft lip and palate (BCLP). This study will review the surgical strategies to reconstruct the protruding premaxillary segment, cleft lip, and palate in trisomy 17p patient.

The patient had heterozygous pathogenic duplication of chromosomal region chr17:526-18777088 on almost the entire short arm of chromosome 17. Beside the commonly found features of trisomy 17p, the patient also presented with BCLP with a prominent premaxillary portion. Premaxillary setback surgery was first performed concomitantly with cheiloplasty. The ostectomy was performed posterior to the vomero-premaxillary suture (VPS). The premaxilla was firmly adhered to the lateral segment and the viability of philtral flap was not compromised. Two-flap palatoplasty with modified intravelar veloplasty (IVV) was performed 4 months after.

Successful positioning of the premaxilla segment, satisfactory lip aesthetics, and vital palatal flap was obtained from premaxillary setback, primary cheiloplasty, and subsequent palatoplasty in our trisomy 17p patient presenting with BLCP. Postoperative premaxillary stability and patency of the philtral and palatal flap were achieved. Longer follow-up is needed to evaluate the long-term effects of our surgical techniques on inhibition of midfacial growth. However, the benefits that the patient received from the surgery in improving feeding capacity and facial appearance early in life outweigh the cost of possible maxillary retrusion.

Repair Sequence and Management of the Premaxilla in Patients With Bilateral Cleft Lip and Palate: A Systematic Review of the Literature

BACKGROUND

Bilateral cleft lip and palate (BCLP) remains a difficult surgical problem due to the severely protruding premaxillary segment, with no consensus of optimal treatment sequence in older patients. A systematic review of the literature was performed to assess the current status of BCLP repair based on age.

METHODS

A PRISMA systematic review of the PubMed, Web of Science, and Embase databases was performed using a series of search terms related to BCLP. Studies were categorized based on the age of presentation, repair sequence, and technique.

RESULTS

The database search identified 381 articles. Of these, 72 manuscripts were ultimately included. The lip was repaired first in 1077 patients (86.0%), palate first in 161 patients (12.9%), and simultaneous lip and palate in 14 patients (1.1%). Patients less than 6 months old received lip repair first (n = 959, 98.6%), with complications of unaesthetic appearance (n = 86, 62.3%) and midface retrusion (n = 41, 34.1%) in younger patients and wound dehiscence (n = 8, 40%) in older patients. Primary lip repair was preceded by presurgical orthopedics (n = 760) or lip adhesion (n = 272) to reduce lip tension with nasoalveolar molding (n = 452, 62.9%) or the Latham device (n = 282, 37.1%). In older patients, the palate was repaired first or premaxillary setback (n = 222) was indicated in protruded premaxillae greater than 10 mm, but carried the risk of premaxilla mobility (n = 20, 37.7%) and midface retrusion (n = 10, 18.9%).

CONCLUSION

In younger patients, lip repair is performed first with preoperative orthopedics or lip adhesion. In older patients, the palate is more commonly repaired first compared with the lip; however, there is no difference in complication rate.

Osteotomy of the Premaxilla in Bilateral Cleft Lip: A Useful Technique Following Failure of Primary Lip Closure

OBJECTIVES

Successful aesthetic repair of the bilateral cleft lip and palate (BCLP) is one of the most challenging cases encountered by a surgeon. This challenge is heightened when the premaxilla is anteriorly protruded in relation lateral maxillary segments. Our aim is to demonstrate a useful technique for reducing the cleft size before secondary lip repair. We use a premaxillary osteotomy to posteriorly reposition the premaxilla between the lateral segments.

METHODS

Six patients with BCLP underwent repositioning of the protruded premaxilla. Five patients had previous primary lip closure procedures with unsatisfactory results. The cleft size was reduced by premaxillary osteotomy from nasal septum and partial removal of the vertical vomer. The osteotomized premaxilla was then repositioned, fixed with a custom-made orthodontic appliance. Following this procedure, the lip was closed in a traditional fashion.

RESULTS

All patients demonstrated satisfying lip closure without tension. In each case, the premaxilla was vital and exhibited partial stabilization during follow-up.

CONCLUSIONS

In this study the authors demonstrate the usefulness of a premaxillary segment setback as an adjunct to improved function and aesthetics in bilateral lip repair. This method serves as useful technique for previously unsuccessful closure of BCLP.

Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts

ABSTRACT

Management of residual clefts of the alveolus and maxilla requires the coordinated effort of multiple members of the craniofacial team including surgeon, orthodontist, and when teeth are hypoplastic or absent, the prosthodontist to achieve complete habilitation. Such cooperation among specialists begins early in the patient's life and continues through completion of care.Although numerous publications on this topic exist, few present definitive multidisciplinary reconstructive outcomes with longterm results. In this review paper, the authors present our comprehensive, multidisciplinary protocols, experience, and techniques as they have evolved with over 35 years of practice at our Craniofacial Center.Details of our updated protocols for each intervention and procedure, including our current thoughts on appropriate timing, follow up and advantages from the incorporation of current technologies are discussed. Close cooperation among specialists at all stages of care, the use of evolving technology, and adherence to, and modification where indicated, of time honored team protocols enables us to consistently achieve successful functional and esthetic outcomes, while minimizing complications.

Presurgical Alignment of Bilateral Cleft Segments With 3D Simulation Under Special Consideration of the Vomer: A Technical Note

Background:

The main goal of presurgical orthopedics (PSO) for patients with bilateral cleft lip and palate is to correct the protruded and/or twisted premaxilla. However, PSO is associated with the risk of uncontrolled development of the vomer, which has received little attention to date.

Solution:

We present a removable orthodontic device that can be used to keep or align the vomer and the premaxilla in the midline during preoperative molding of cleft segments independently and 3 dimensionally.

Cleft Lip and Palate in Ectodermal Dysplasia

OBJECTIVE

Ectodermal dysplasia (ED) comprises multiple syndromes that affect skin, hair, nails, and teeth, and sometimes are associated with orofacial clefting. The purpose of this study is to (1) identify the prevalence and characteristics of cleft lip and/or palate (CL/P) in patients with ED and (2) describe the management and outcomes.

DESIGN

Retrospective review from 1990 to 2019.

PATIENTS

All patients with ED treated at Boston Children's Hospital.

MAIN OUTCOMES MEASURES

Prevalence of CL/P was calculated and clinical details recorded: phenotypic anomalies, cleft type, operative treatment, and results of repair.

RESULTS

Of 170 patients with a purported diagnosis of ED, 24 (14%) had CL/P. Anatomic categories were bilateral CL/P (67%), unilateral CL/P (8%), and cleft palate only (25%). The most common ED syndrome (37%) was ectrodactyly, ectodermal dysplasia, and cleft lip/palate (EEC). Pathogenic variants in TP63 were the most frequent finding in the 11 patients who had genetic testing. Aberrations from a typical clinical course included failure of presurgical dentofacial orthopedics, dehiscence of nasolabial adhesion, and total palatal absence requiring free-flap construction. Two patients had prolonged postoperative admission for respiratory infection. High fistula (8%) and velopharyngeal insufficiency (33%) rates reflected the predominance of bilateral complete forms.

CONCLUSIONS

As in other types of syndromic CL/P, cleft phenotypic expression in ED is more severe than the general cleft population. Further studies are needed to correlate genotype and phenotype for the distinct syndromes included in the ED spectrum.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding

BACKGROUND

Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results.

METHODS

We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated.

RESULTS

We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils.

CONCLUSION

The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

Lag screw fixation of the premaxilla during bilateral cleft lip repair

In synchronous primary premaxillary setback and cleft lip repair for bilateral cases with severely protruding premaxilla, stabilization of the premaxilla is mostly achieved by gingivoperiosteoplasty. This kind of repair carries risk of impairment of blood supply to the premaxilla and/or prolabium, and at the same time it cannot ensure adequate stabilization of the premaxilla postoperatively. To overcome these problems, we have developed a unique technique of fixation of the premaxilla. In this paper, we discussing this technique, its advantages, and potential complications associated with it. From 2016, 10 patients aged 4-10 months, with bilateral cleft lip and palate with premaxillary protrusion (≥10 mm) underwent premaxillary setback and cheilorhinoplasty in the same stage. Instead of gingivoperiosteoplasty, a 'lag screw' fixation technique was used to stabilize the premaxilla. The follow-up period ranged between 5 and 32 months. In all the cases, we achieved adequate stabilization of the premaxilla. None of the patients had any issue related to the vascularity of the premaxilla or prolabium. There was no impairment in the eruption process of deciduous teeth in the premaxillary segment. Overall aesthetic outcomes of the lip and nose were acceptable. This technique of premaxillary fixation with lag screw gives us the liberty to perform primary cheilorhinoplasty along with premaxillary setback in the same stage, without risking the vascularity of premaxilla and prolabium. It ensures adequate stabilization of the premaxilla, but evaluation of regular growth of the midface and, if needed, corrective orthodontic and surgical treatment in the follow-up periods are advisable.

Orthodontic premaxillary setback versus premaxillary osteotomy with gingivoperiosteoplasty for Bilateral cleft lip and palate patients: 4-year observation outcomes

Patients with bilateral cleft lip and palate (BCLP) generally require several stages of treatment, and adequate maxillary development without orthognathic surgery is not easy to achieve. The purpose of this study was to determine short-term outcomes of orthodontic premaxillary setback (OPS) and premaxillary osteotomy (PO) for complete BCLP treatment.

PATIENTS AND METHODS

Twenty-six patients with BCLP were consecutively treated for 4 years by a single surgeon. All patients were categorized by three indications for the first operation: OPS1, cheiloplasty + gingivoperiosteoplasty (GPP) + palatoplasty; OPS2, cheiloplasty + GPP; and PO, cheiloplasty + GPP + PO. Cephalograms for maxillary growth and velopharyngeal function (VPF) were judged at 4 years old, before orthodontic treatment.

RESULTS

OPS1 was performed in 14 cases, OPS2 in 8 cases, and PO in 4 cases. As for cephalometric analysis at 4 years old, no significant differences between groups were seen in any cephalometric measurements. As for speech outcomes, assessment of VPF at 80.8±14.8 months was good in 17 cases, slightly impaired in 8 cases, and marginally impaired in 1 case, with no severely impaired cases.

DISCUSSION

No significant differences in maxillary growth or speech outcomes were seen between OPS1, OPS2, and PO groups at 4 years old, possibly because all groups showed the same position of the premaxilla after the first operation.

CONCLUSIONS

No significant differences in maxillary growth or speech outcomes were seen for 26 patients with BCLP between OPS1, OPS2, and PO groups at 4 years old. However, the long-term growth characteristics remain unclear.

Management of the protuberant premaxilla: where does it fit in?

PURPOSE OF REVIEW

To discuss multidisciplinary treatment options for the protuberant premaxilla associated with bilateral cleft lip and palate. Lessons have been learned throughout the years regarding the effect of growth restriction after early and aggressive therapy. Multiple surgical and orthodontic interventions are discussed. Recent literature will be highlighted and discussed.

RECENT FINDINGS

A paucity of long-term studies was noted. Recent literature revealed numerous studies introducing innovative presurgical orthopedic devices as less expensive and easier to use alternatives to nasoalveolar molding. Multiple approaches to premaxillary setback were presented, offering multiple approaches to improve success rates and minimize burden to the patient. Novel orthodontic and advanced microvascular procedures were discussed as additional tools for treatment of the malpositioned premaxilla once skeletal maturity is reached.

SUMMARY

Multidisciplinary team management of the protuberant premaxilla and bilateral cleft lip and palate is becoming increasingly embraced worldwide. Numerous surgical procedures and orthodontic treatments are required to optimally reposition the premaxilla; however, these interventions can inhibit growth, resulting in maxillary retrusion. Long-term follow-up studies are needed to determine what protocol is best. Studies should also include ways to overcome barriers to treatment success, such as late intervention, resource disparity, and limited access to care.

Bilateral cleft lip repair with simultaneous premaxillary setback and primary limited rhinoplasty

Background

Functional closure of the orbicularis oris muscle and esthetic reconstruction of nasolabial components are impossible in patients with severely deformed premaxilla. Here, we review a surgical strategy for patients with unremedied premaxilla retrospectively.

Results

Vomerine ostectomy and premaxillary setback with nasolabial repair were performed in 12 patients with bilateral cleft lip and palate. The mean age of patients was 21.7 months. The extent of ostectomy varied between 3 and 11 mm. There were no serious complications from defective perfusion to the premaxilla or the philtral flap. The follow-up period ranged from 2 to 25 months. Proper positioning of the premaxilla and satisfactory nasolabial esthetics were achieved in all patients.

Conclusions

We performed nasolabial repair after premaxillary setback without jeopardizing the premaxillary segment or the philtral flap. Our surgical strategy could be recommended in poor socio-economic circumstances due to the cost effectiveness of limiting the number of surgeries.

Stress Distribution Patterns within Viscero- and Neurocranium during Nasoalveolar Molding: a Finite Element Analysis

Background

The purpose of this study was to evaluate the stress distribution patterns within the viscero- and neurocranium of neonates during nasoalveolar molding.

Methods

Finite element models of 3 different healthy neonates at different times of life (date of birth, 4 weeks, and 3.5 months) were generated on the basis of computed tomography scans. A validated workflow, including segmentation, meshing, setting of boundary conditions, and implementation of a bone density-dependent material model, was carried out for each model. A small and a large unilateral alveolar and hard palatal cleft were virtually cut in each model. The stress distribution pattern in each model was then analyzed by using Ansys APDL.

Results

Convergence analysis validated the results. The virtual experiments at the date of birth showed a stress pattern above a previously defined threshold value of 30,000 Pa in the ipsilateral naso-orbital-complex, frontal sinus, and the anterior fossa of the base of the skull, with von Mises values > 35,000 Pa. Stress patterns at the age of 4 weeks and 3.5 months showed reduced von Mises values at < 15,000 Pa.

Conclusions

Nasoalveolar molding therapy is a safe presurgical treatment modality without significant influence on the viscero- and neurocranium of neonates. Treatment, considering the stress distribution at the naso-orbital-complex and anterior fossa of the base of the skull, should begin in the second week of life, and treatment initiation of preterm infants should be adapted respectively.

Synchronous Premaxillary Osteotomy with Primary Cheiloplasty for BCLP Patients with Protrusion of the Premaxillae

Supplemental Digital Content is available in the text.

Background:

In bilateral cleft lip and palate (BCLP) patients with protrusion and/or torsion of the premaxillae, it is difficult to achieve a good outcome. We have developed a series of procedures of premaxillary osteotomy with primary cheiloplasty for BCLP patients who did not respond well to presurgical orthodontics (PSO).

Methods:

A total of 27 BCLP patients with protrusion and/or torsion of the premaxillae underwent PSO. For 3 BCLP patients in whom the protruded premaxillae could not be returned to a good position, a primary premaxillary osteotomy and gingivoperiosteoplasty (GPP) with cheiloplasty were performed simultaneously. Subsequently, Furlow palatoplasty was performed by one and a half years of age. Maxillary growth was evaluated by dental occlusion at 4 years of age.

Results:

A premaxillary osteotomy and GPP with cheiloplasty were performed at 6 months. The patients’ facial structures improved, their premaxillae were positioned more superiorly, and normal inclination of the incisors was achieved. They had edge-to-edge occlusions or cross bites at 4 years of age.

Conclusions:

As advantages, the patients’ facial structures improved, and the alveolar bones were formed by GPP. As a disadvantage, premaxillary necrosis might occur because of poor blood circulation. It is important to secure the following 2 blood supplies: from the periosteum and soft-tissue of the anterior premaxillae and from the periosteum and mucosa of the nasal septum. Synchronous premaxillary osteotomy and GPP with primary cheiloplasty are appropriate when the premaxillae cannot be properly repositioned by PSO or PSO cannot be done.

Does a Premaxillary Setback and Lip Adhesion Have a Negative Impact on Lip Outcome in Bilateral Cleft Patients?

BACKGROUND

The early premaxillary setback and lip adhesion remains as a controversial maneuver in the treatment of bilateral cleft lip and palate patients. This study aimed to assess extent of preoperative deformity and lip outcomes during the first year after surgery in bilateral cleft patients who underwent premaxillary setback and lip adhesion and to compare to those with primary lip repair.

METHODS

A retrospective observational study was conducted of 16 nonsyndromic consecutive bilateral complete cleft lip patients (with and without Simonart band), who underwent primary cleft lip repair. Patients were allocated in group 1 without premaxillary setback and group 2 with premaxillary setback and lip adhesion. Preoperative and postoperative linear measurements were used for intergroup and intragroup comparisons.

RESULTS

Cutaneous lip height of patients in group 2 significantly (P < 0.05) improved after combined premaxillary setback and lip adhesion and primary cleft lip repair. There were no significant (all P > 0.05) differences in intragroup 1 comparisons, and in intergroup comparisons.

CONCLUSION

Bilateral cleft patients with a protruded and deviated premaxilla over 10 mm discrepancy of the lateral maxillary achieved noninferior lip symmetry 1 year postoperatively compared with patients with less severe original deformity.

Direct Anthropometry of Repaired Bilateral Complete Cleft Lip: A Long-Term Assessment

BACKGROUND

Repair of bilateral complete cleft lip requires more than following a design in a textbook. The operative strategy should incorporate knowledge of anticipated nasolabial changes with growth.

METHODS

Direct nasolabial anthropometry was recorded in 174 children with bilateral complete cleft lip before and immediately after primary repair. Serial measurements were taken in 66 Caucasian patients between the ages of 6 months and 15 years and compared to Farkas' normal values. Data for upper philtral width were unavailable; therefore, this dimension was measured in 454 nonsyndromic Caucasian male and female subjects aged 1 year to adulthood. Rates and types of revision were also documented.

RESULTS

Inter-medial canthal width stayed above the mean and within normal limits throughout puberty. Interalar width was initially narrowed and hovered in the high normal range throughout adolescence. Columellar height and nasal projection were constructed slightly long and paralleled normal growth. Available cutaneous philtral length was used in the primary repair; however, this dimension remained short. The philtrum was made narrow and matched normal values throughout adolescence. Normal inferior/superior philtral width ratio was 1.60 for female subjects and 1.59 for male subjects. A full median tubercle was built at primary repair but, sometimes in late childhood, necessitated secondary augmentation with a dermal graft in 31 of 174 patients (18 percent), usually performed in late childhood or adolescence.

CONCLUSIONS

Serial anthropometry documented postoperative changes in nasolabial dimensions compared to normal growth curves. Repair of bilateral complete cleft lip requires primary correction of nasal and labial features based on their differential growth, with special attention to nasal width, philtral height and proportions, and size of the median tubercle.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.