Microform or Incomplete Median Cleft Lip: Strategy and Management

Abstract

Sir: Median cleft of the upper lip is a congenital midline vertical cleft because of the absence of the prolabium. Long-term data and a treatment algorithm for the minor form of median cleft deformity and its associated problem (e.g., frenula anomalies and upper incisor diastema) are lacking. This retrospective review includes five patients between 1982 to 1994, two male and three female patients. The follow-up ranged from 10 to 20 years. The patients exhibited microform median cleft of the upper lip and survived like other normal infants. The straight-line lip repair was performed at 3 months of age (Fig. 1) and followed by orthodontic treatment. The skin lining was excised and the mucosa, orbicularis oris muscle, and skin were repaired without Z-plasty or other lengthening techniques. Alveolar bone grafting was also performed at the age of 5 years, before eruption of the permanent maxillary incisors.1 The results were evaluated by using the classification published by Abyholm et al.2 and evaluated by occlusal radiographs 1 week, 6 months, and 1 year after surgery.Fig. 1.: One midline notch on the upper lip and extending halfway up the philtrum. A median dysgenesis remnant was localized in the central part of the philtrum.An aesthetic and symmetrical philtrum column and upper lip were achieved. The length of the philtrum column was adequate (Fig. 2). All patients achieved type I results of alveolar bone grafting, and the dental radiographs showed new bone reaching alveolar ridges. Long-term dental occlusion proved stable results of diastema correction.Fig. 2.: Good symmetry of vermilion and Cupid's bow, minimized scar formation, and adequate length of the upper lip were achieved.Pathologic findings of the remnant in the first case demonstrated cutaneous tissue with a partial cartilaginous component that was different from the pure cutaneous component in other articles. In this series, the straight-line technique was chosen instead of the forked flap procedure described by Millard to correct the upper lip notch at 3 months of age.3 The midline ridge was excised, narrowed, and lengthened by advancement of the forked flap in his series. The straight-line mark along the bilateral philtrum column margin was designed. Simple excision helps narrow the column, maintain the concavity, and avoid altering the Cupid's bow and tubercle. The adequate length and nondisfigured philtrum and symmetric upper lip indicate that it was not necessary to use specific techniques to camouflage the upper lip scar. A median cleft associated with alveolus cleft and diastema has been described.4 Diastema caused by midline bony clefts tends to relapse earlier and was resistant to conventional treatment.5 The relationship between notching on the upper lip and relapse of maxillary diastema was also reported. A V-shaped bony cleft between two central incisors typically occurs in these patients. The bony cleft interrupts the formation of transeptal fibers and fails to proliferate across the midline cleft. In brief, restoration of bony support should precede the orthodontic correction in incisor diastema. Early secondary bone grafting was performed between 4 and 7 years of age. We recommend bone grafting at the age of 5 years, before permanent incisor eruption. Successful bone grafting provides better support when new teeth erupt and helps maintain subsequent orthodontic results. In our series, diastema larger than 4 mm may be aesthetically and functionally restored by early bone grafting. Erh-Kang Chou, M.D. Department of Plastic Surgery China Medical University Hospital Taichung, and School of Medicine China Medical University Taichung, Taiwan Ellen Wen-Ching Ko, D.D.S., M.S. Department of Dentistry Philip Kuo-Ting Chen, M.D. Department of Plastic Surgery Chang Gung Memorial Hospital Chang Gung University College of Medicine Taoyuan, Taiwan Jack Chung-Kai Yu, M.D., D.M.D. Section of Plastic and Reconstructive Surgery Medical College of Georgia Augusta, Ga. Sophia Chia-Ning Chang, M.D., Ph.D. Department of Plastic Surgery China Medical University Hospital Taichung, and School of Medicine China Medical University Taichung, Taiwan