Alveolar Gap Research Articles

A modified nasoalveolar molding technique for correction of unilateral cleft nose deformity.

Traditional Figueroa nasoalveolar molding (NAM) requires weekly or biweekly adjustments to remove acrylic from the palatal plate to narrow the alveolar gap. These frequent adjustments create a burden for patients living far from a hospital. To minimize this burden, we developed a modified NAM technique using simplified lip taping and a passive palatal plate. Herein we present our clinical experience and outcomes using the traditional and modified methods. In this blinded, retrospective study of 66 patients with complete unilateral cleft lip and palate, 33 received the traditional NAM and 33 received the modified NAM. Pretreatment and posttreatment facial photographs and clinical charts were used to compare efficacy (nostril height ratio, nostril width ratio, columellar angle, nasal base angle), efficiency (molding frequency), incidence of complications (facial irritation, mucosal ulceration), and medical cost. Traditional and modified NAM did not differ in treatment efficacy for nostril height ratio (0.88 ± 0.14 vs. 0.90 ± 0.12), nostril width ratio (2.22 ± 0.39 vs. 2.38 ± 0.50), columellar angle (73.5 ± 9.1 degrees vs. 71.3 ± 11.8 degrees), nasal base angle (5.1 ± 2.4 degrees vs. 5.9 ± 2.7 degrees), or alveolar gap width (2.0 ± 2.0 mm vs. 2.0 ± 1.7 mm) (all p > 0.05). Traditional NAM was less efficient, i.e., required more adjustments (8.6 ± 2.0 vs. 6.7 ± 1.1), and cost more (22016.4 ± 2012.7 New Taiwan dollars vs. 20137.6 ± 1173.4 New Taiwan dollars) (both p < 0.001). Both NAM techniques similarly improved nasal deformities and reduced alveolar gaps, but the modified technique was more efficient and cost less in terms of insurance reimbursement and supplies (labial tapes).

Use of Osteocutaneous Second-Toe Free Flap for Anterior Oronasal Fistulas.

Palatal fistula is a known complication of cleft lip-cleft palate repair. Fistulas anterior to the incisive foramen can be particularly difficult to repair because of the lack of available tissue. Adjacent tissue has inherent limitations, and multiple free-flap techniques have been described; however, there remains no single solution for this difficult problem. The authors present an alternative strategy of replacing "like with like" by using an osteocutaneous free tissue transfer of the second toe for anterior oronasal fistulas. Use of the osteocutaneous second-toe free flap provides skin lining to both the oral side and the nasal side to close oronasal fistulas. It also bridges the alveolar gap with vascularized bone. This flap can be considered as an elegant alternative for anterior oronasal fistulas.

Presurgical nasoalveolar molding for cleft lip and palate: the application of digitally designed molds.

The authors present a novel nasoalveolar molding protocol by prefabricating sets of nasoalveolar molding appliances using three-dimensional technology. Prospectively, 17 infants with unilateral complete cleft lip and palate underwent the authors' protocol before primary cheiloplasty. An initial nasoalveolar molding appliance was created based on the patient's first and only in-person maxillary cast, produced from a traditional intraoral dental impression. Thereafter, each patient's molding course was simulated using computer software that aimed to narrow the alveolar gap by 1 mm each week by rotating the greater alveolar segment. A maxillary cast of each predicted molding stage was created using three-dimensional printing. Subsequent appliances were constructed in advance, based on the series of computer-generated casts. Each patient had a total three clinic visits spaced 1 month apart. Anthropometric measurements and bony segment volumes were recorded before and after treatment. Alveolar cleft widths narrowed significantly (p < 0.01), soft-tissue volume of each segment expanded (p < 0.01), and the arc of the alveolus became more contiguous across the cleft (p < 0.01). One patient required a new appliance at the second visit because of bleeding and discomfort. Eleven patients had mucosal irritation and two experienced minor mucosal ulceration. Three-dimensional technology can precisely represent anatomic structures in pediatric clefts. Results from the authors' algorithm are equivalent to those of traditional nasoalveolar molding therapies; however, the number of required clinic visits and appliance adjustments decreased. As three-dimensional technology costs decrease, multidisciplinary teams may design customized nasoalveolar molding treatment with improved efficiency and less burden to medical staff, patients, and families. Therapeutic, IV.

Repair of complete bilateral cleft lip with severely protruding premaxilla performing a premaxillary setback and vomerine ostectomy in one stage surgery

BackgroundThe authors present a technique for selected cases of CBCL. The primary repair of the CBCL with a severely protruding premaxilla in one stage surgery is very difficult, essentially because a good muscular apposition is difficult, forcing synchronously to do a premaxillary setback to facilitate subsequent bilateral lip repair and, thus, achieving satisfactory results. We achieve this by a reductive ostectomy on the vomero-premaxillary suture.Material and Methods4 patients with CBCL and severely protruding premaxilla underwent premaxillary setback by vomerine ostectomy at the same time of lip repair in the past 24 months. The extent of premaxillary setback varied between 9 and 16 mm. The required amount of bone was removed anterior to the vomero-premaxillary suture. The authors did an additional simultaneous gingivoperiosteoplasty in all patients, achieving an enough stability of the premaxilla in its new position, to be able to close the alveolar gap bilaterally. The authors have examined the position of premaxilla and dental arch between 6 and 24 months. We did not do the primary nose correction, because this increased the risk of impairment of the already compromised vascularity of the philtrum and premaxilla.ResultsThe follow-up period ranged between 6 and 24 months. None of the patients had any major complication. During follow-up, the premaxilla was minimally mobile. We achieved a good lip repair in all cases: adequate muscle repair, symmetry of the lip, prolabium and Cupid’s bow, as well as good scars.ConclusionsTo our knowledge, there are few reports of one stage surgery with vomerine ostectomy to repair CBCL with severely protruding premaxilla. Doing this vomerine ostectomy, we don’t know how it will affect the subsequent growth of the premaxila and restrict the natural maxillary growth. Applying this alternative treatment for children with CBCL and protruded premaxilla without any preoperative orthopedic, we can successfully perform, in a single-stage surgery, a good primary lip repair at our center. Further confirmations of this surgery with follow up and anthropometric studies of these patients during childhood and adolescence are required. Key words: Protruding premaxilla, bilateral cleft lip, vomerine ostectomy, one stage surgery, Millard II technique.

Early Effect of Vomerine Flap Closure of the Hard Palate at the Time of Lip Repair on the Alveolar Gap and Other Maxillary Dimensions

Comparison of the effects of vomerine flap (VF) closure of the hard palate at the time of lip repair with non-closure of the hard palate in subjects with unilateral cleft lip and palate (UCLP). Retrospective, single-blinded, cohort study. Study model sets of 40 consecutive, non-syndromic, infants with complete UCLP operated on between 1988 and 1998. All subjects were operated on by a single consultant plastic surgeon immediately before and after the unit's change of protocol (1993), when VF closure of the hard palate was incorporated at the time of lip repair. Subjects were divided into two groups: VF ( n = 18) and non-VF (n = 22), which acted as a control group. Each subject had maxillary impressions taken before lip repair at 3 months (VF mean age = 11.7 weeks; non-VF mean age = 13.4 weeks) and before palate repair at 6 months (VF mean age = 22.8 weeks; non-VF mean age = 24.0 weeks). Seven predetermined landmarks and four maxillary dimensions were computed following single-blinded analysis using a reflex microscope. Repeatability tests showed good measurement precision. The operator measurement errors were 0.00018 mm in a horizontal plane (X and Y) and 0.00028 in the vertical plane (Z). The VF group showed significant changes in the alveolar cleft width. There were no statistically significant changes in any arch-form variable between the VF and non-VF groups. The decrease of alveolar arch gap width at palate repair (6 months) in the VF group was significantly more than the decrease observed in the non-VF group, and there was no significant decrease in the, anterior and posterior arch width or anteroposterior length of the hard palate in the VF group compared with the non-VF group.

Comparative Outcomes of Two Nasoalveolar Molding Techniques for Bilateral Cleft Nose Deformity

Bilateral cleft nose deformity is increasingly being treated before primary repair with nasoalveolar molding. With the Grayson technique, nasal molding is started when the alveolar gap is reduced to 5 mm, whereas with the Figueroa technique, nasal molding and alveolar molding are performed at the same time. Both techniques significantly lengthen the columella, but their comparative efficacy, efficiency, and incidence of complications have not been investigated. In this blinded, retrospective study of 58 patients with complete bilateral cleft lip-cleft palate, 27 underwent Grayson nasoalveolar molding and 31 underwent Figueroa nasoalveolar molding. Outcomes were compared by analyzing pretreatment and posttreatment facial photographs and clinical charts for efficacy (i.e., columella length ratio, alar width ratio, alar base width ratio, nostril shape, nasal tip angle, nasolabial angle, and nasal base angle), efficiency (i.e., molding frequency), and incidence of complications (e.g., facial irritation and oral mucosal ulceration). Grayson and Figueroa nasoalveolar molding did not differ in treatment efficacy for columellar length ratio, alar width ratio, alar base width ratio, nostril shape, nasal tip angle, nasolabial angle, or nasal base angle (all p > 0.05). Grayson nasoalveolar molding was less efficient (i.e., required more adjustments) (10.8 ± 4.1 versus 7.6 ± 1.5; p = 0.001) and had a higher incidence of oral mucosal ulceration (26 percent versus 3 percent; p < 0.05). Both Grayson and Figueroa nasoalveolar molding similarly improve nasal deformities and reduce alveolar gaps; however, the Figueroa technique is associated with fewer oral mucosal complications and more efficiency.

A novel pre-surgical maxillary orthodontic device using β-titanium wire for wide unilateral cleft lip and palate patients: Preliminary study of its efficacy and impact for the maxillary formation

For patients with a wide, complete, unilateral cleft lip and palate, pre-surgical maxillary orthodontic treatments have been used to reduce the alveolar gap before cheiloplasty. However, most of these treatments are complicated and laborious for patients and for medical professionals. Thus, we developed an original pre-surgical orthodontic device made with two separate acrylic resin plates connected with a spring-shaped β-titanium wire (β-TW). When the device was applied on the palate, each segment of the maxilla was automatically aligned for our target formation with the elastic force of β-titanium alloy. This study aimed to evaluate the efficacy of the new device and the size of the maxilla in comparison with the conventional Hotz procedures. A total of 47 patients with a wide unilateral cleft lip and palate were retrospectively evaluated; 33 patients were treated with our new device (β-TW plate group) and 14 were treated with a Hotz plate (HP group). We evaluated the alveolar gap reduction and the size of the maxilla between the two groups, obtaining intraoral maxillary impressions at birth, at 3 months and 1 year. The width of the alveolar gap in the β-TW plate group was significantly reduced compared with that in the HP group 1 month after the treatment (p < 0.001). The alveolar gap reduction continued until the age of 1 year (p = 0.02). By contrast, no significant difference in the maxillary size was observed between the two groups at any examination period. Our treatment protocol using the β-TW plate was not only easy and simple to apply but it was also cost-effective, with highly predictable outcomes. Moreover, it provided the ideal alveolar cleft reduction without detrimental collapse of the alveolar segments. Therefore, we consider our β-TW plate device to be useful for application in pre-surgical orthodontic treatments.

Treatment algorithm for bilateral alveolar cleft based on the position of the premaxilla and the width of the alveolar gap

The efficacy of conventional secondary bone grafting is limited in instances of a bilateral alveolar cleft with a wide cleft gap and malpositioning of the premaxilla. The purpose of this study is to suggest a systematic algorithm to guide individualised treatment of a bilateral alveolar cleft according to the position of the premaxilla and the width of the alveolar gap. A total of 51 patients with bilateral alveolar clefts were investigated between January 2000 and February 2008. The average age was 9.2 years, and the mean follow-up period was 47 months. Conventional alveolar bone grafting (ABG) was performed for patients with both a narrow cleft gap and acceptable position of the premaxilla. Patients with both a wide cleft gap and acceptable premaxilla position were initially managed by interdental distraction osteogenesis. Premaxilla repositioning was indicated in patients with both sagittally and/or vertically unfavoured positioning of the premaxilla. The extent of bone resorption following bone grafting was evaluated using the Abyhölm criteria. Of 102 grafts, 98 grafts (96.1%) showed satisfactory bony take (Grade I-II). Only four grafts (3.9%) exhibited a poor outcome, with more than 50% bony resorption (Grade III-IV). The average hospital stay was 5.7 days and no serious complications were observed. Our approach resulted in satisfactory surgical outcomes. This suggests the feasibility of a standardised approach for the correction of a bilateral alveolar cleft. Our algorithm should be helpful for systematic and coordinated team approaches to rectify bilateral alveolar clefts.

Comparative Outcomes of Two Nasoalveolar Molding Techniques for Unilateral Cleft Nose Deformity

Nasoalveolar molding is increasingly being used to treat unilateral cleft nose deformity before primary repair. The Grayson technique starts nasal molding when an alveolar gap is reduced to 5 mm, whereas the Figueroa technique performs nasal and alveolar molding at the same time. The authors investigated the comparative efficacy, efficiency, and incidence of complications of the two techniques. A blinded, retrospective study was conducted on 63 patients with complete unilateral cleft lip-cleft palate; 31 underwent the Grayson nasoalveolar molding and 32 underwent the Figueroa nasoalveolar molding. Pretreatment and posttreatment facial photographs and clinical charts were used to compare efficacy (nostril height ratio, nostril width ratio, columellar angle), efficiency (molding frequency), and incidence of complications (facial irritation, mucosal ulceration). The Grayson and Figueroa techniques did not differ in treatment efficacy for nostril height ratio (0.86 ± 0.09 versus 0.85 ± 0.09; p > 0.05) and columellar angle (84.0 ± 4.5 degrees versus 85.3 ± 2.6 degrees; p > 0.05). Although the Grayson technique was more effective for reducing nostril width ratio (1.21 ± 0.29 versus 1.27 ± 0.19, p = 0.05), it was less efficient (i.e., required more adjustments) (10.9 ± 2.5 versus 8.8 ± 1.9; p < 0.001) and had a higher incidence of mucosal ulceration (23 percent versus 3 percent; p < 0.05). The two nasoalveolar molding techniques differed in efficacy, efficiency, and incidence of complications in patients with complete unilateral cleft lip-cleft and palate. Understanding these differences may help surgeons and orthodontists improve outcome expectations and consultations with patients' families. Therapeutic, III.

Alveolar Cleft Closure by Osseodistraction

Segmental maxillary osseodistraction is a proper method to close alveolar gaps in patients with clefts of lip, palate, and alveolus. The technique is mainly used in very wide clefts after failure of conventional bone grafting procedures. The aim of the study was to analyze problems that may occur during the distraction process. Patients with uncommon wide alveolar clefts or recurrent oronasal fistulas and patients with bilateral clefts of lip, plate, and alveolus and an additional vertical deficit of the posterior cleft segment underwent distraction procedures. The patients were subdivided according to the vector of distraction: linear (following the dental arch) and vertical. The devices for horizontal distraction were tooth-borne and manufactured to the specific clinical situation. For vertical distraction, standard devices were used. Of this sample, patients with complications occurring during or after surgery and during the distraction period were selected as the study participants. On the basis of the data collected on these complications, the need for additional bone grafting procedures was evaluated. Results suggest that modifications in preoperative planning and the construction of the distraction devices may be necessary to prevent unexpected problems in segmental maxillary distraction procedures. Considerations concerning the placement of distraction devices are discussed.

Initial treatment of alveolar gaps in cases of labio-maxillary-palatal clefts

Treatment teams use different approaches for correcting the alveolar cleft sector of labio-palatal clefts. Age of patient, whether or not bone grafts are used, and the type of bone grafted are some of the differences. Our team performs a gingivoperioplasty with a graft of iliac cancellousboneonpatients 4to 6 yearsold. This procedure is carried out within the framework of orthodontic treatment designed to restore transverse dimension pre-operatively with a quad helix and to retain the expansion with 6 months of retention. The gingivoperioplasty is accomplished in a zone free of any scar tissue that might have resulted from a primary cheiloplasty followed by closure of the palatal cleft. In our view all teams must eventually utilize cone beam X-rays for their radiographic evaluations becausetheyaretheonlytoolthatprovidesresultsofobjectiveanalysisthatareof high quality and have demanded a very low level of radiation.

Composite correction of a unilateral cleft lip nose deformity and alveolar bone grafting

ABSTRACT Background: Managing the cleft lip nasal deformity has always been a challenge. Even now, there is no single established universally accepted method of correction. The open alveolar gap and the ipsilateral hypoplastic maxilla are two major problems in achieving consistently good results in a cleft lip nasal deformity. In our study, after first assuring the orthodontic realignment of maxillary arches, we combined bone grafting in the alveolar gap and along the pyriform margin, with a formal open rhinoplasty approach. Methods: All the patients underwent orthodontic treatment for preparation of the alveolar bone grafting. During the process of alveolar bone graft, a strip of septal cartilage graft was harvested from the lower border of the septum which also helps to correct the septal deviation. The cancellous bone graft harvested from the iliac crest was used to fill the alveolar gap and placed along the pyriform margin to gain symmetry. Through open rhinoplasty along the alar rim and additionally using Potter's incision extending to the lateral vestibule, the lateral crura of the alar cartilage on the cleft side was released from its lateral attachment and advanced medially as a chondromucosal flap in a V–Y fashion, in order to bring the cleft-side alar cartilage into a normal symmetric position. The harvested septal cartilage graft was used as a columellar strut. The cleft nostril sill was narrowed by a Y–V advancement at the alar base and any overhanging alar rim skin was carefully excised to achieve symmetry. Results: The results of this composite approach were encouraging in our series of 15 patients with no additional morbidity and a better symmetry of the nose and airway especially in the adolescent age group. Conclusion: This concept of simultaneous approach when appropriate for nasal correction at the time of alveolar bone grafting showed an encouraging aesthetic and functional outcome.

Composite correction of a unilateral cleft lip nose deformity and alveolar bone grafting

Background:Managing the cleft lip nasal deformity has always been a challenge. Even now, there is no single established universally accepted method of correction. The open alveolar gap and the ipsilateral hypoplastic maxilla are two major problems in achieving consistently good results in a cleft lip nasal deformity. In our study, after first assuring the orthodontic realignment of maxillary arches, we combined bone grafting in the alveolar gap and along the pyriform margin, with a formal open rhinoplasty approach.Methods:All the patients underwent orthodontic treatment for preparation of the alveolar bone grafting. During the process of alveolar bone graft, a strip of septal cartilage graft was harvested from the lower border of the septum which also helps to correct the septal deviation. The cancellous bone graft harvested from the iliac crest was used to fill the alveolar gap and placed along the pyriform margin to gain symmetry. Through open rhinoplasty along the alar rim and additionally using Potter's incision extending to the lateral vestibule, the lateral crura of the alar cartilage on the cleft side was released from its lateral attachment and advanced medially as a chondromucosal flap in a V–Y fashion, in order to bring the cleft-side alar cartilage into a normal symmetric position. The harvested septal cartilage graft was used as a columellar strut. The cleft nostril sill was narrowed by a Y–V advancement at the alar base and any overhanging alar rim skin was carefully excised to achieve symmetry.Results:The results of this composite approach were encouraging in our series of 15 patients with no additional morbidity and a better symmetry of the nose and airway especially in the adolescent age group.Conclusion:This concept of simultaneous approach when appropriate for nasal correction at the time of alveolar bone grafting showed an encouraging aesthetic and functional outcome.

Correction of the Alveolar Gap and Nostril Deformity by Presurgical Passive Orthodontia in the Unilateral Cleft Lip

The use of the nasoalveolar molding technique (NAM) aims to reduce passively the width of the alveolar gap, while improving the AP discrepancy but also focusing on the nose. We developed a within-subjects study in which 11 infants with unilateral lip deformity and varying degrees of alveolar gaps were treated by NAM. Patients included in the study presented alveolar gap at the first appointment to configure the molding device. Alveolar gap was then measured again at the time of lip repair to evaluate the impact of the appliance utilization, and the nostril shape was reassessed to verify the benefit relative to nose symmetry. All patients obtained significant reduction of the alveolar gap. The appliance also facilitated primary nasal positioning, significantly improving nasal symmetry and nostril shape. NAM constitutes an important adjunct to ameliorate the results of primary definitive lip repair while also improving the surgeon's ability to provide nasal symmetry.

Pre-surgical naso-alveolar moulding in children with cleft lip and palate

Cleft lip and palate may show considerable variation in severity and form. Extensive clefts with extreme deficiency in hard and soft tissue present a challenge to obtain functional and aesthetic results at the end of the surgery. To reduce the severity of the initial cleft deformity and to achieve better aesthetic and functional outcomes in cleft lip and palate children, pre-surgical naso-alveolar moulding can be applied using an intraoral moulding plate with specially designed nasal stents. Naso-alveolar moulding enables reduction of the alveolar gap width, retraction of the deviated larger segment in unilateral clefts and pre-maxilla in bilateral clefts, correction of the nasal cartilage deformity and elongation and uprighting of the columella in bilateral cases.

Results of Randomized Controlled Trial of Soft Palate First versus Hard Palate First Repair in Unilateral Complete Cleft Lip and Palate

To compare the outcomes for primary repair of unilateral cleft lip and palate, operating on the soft palate first versus the hard palate first. Randomized controlled trial. The Regional Cleft Service of West Nepal. Forty-seven consecutive patients with nonsyndromic unilateral cleft lip and palate, of whom 37 were assessed 4 to 6 years after completing primary surgical repair. Primary repair of unilateral cleft lip and palate by two differing sequences: (1) soft palate repair, with hard palate and lip repair 3 months later; and (2) lip and hard palate repair, followed by the soft palate repair 3 months later. Analysis of dental study models, weight gain, and speech recordings. Four to 7 years after completing the cleft closure, there was no significant difference in facial growth between the two types of repair sequencing. Completing posterior repair first had no effect on anterior alveolar gap width. It narrowed the hard palate gap by reducing the intercanine distance. Anterior repair dramatically closed the anterior alveolar gap, and narrowed the intercanine distance. Comparing anterior alveolar gap width with age at first presentation demonstrated that there was no spontaneous narrowing of the cleft in older children. Completing posterior closure first had a weight gain advantage over anterior closure first. Improved oropharyngeal closure, and thus swallowing, is the likely explanation. Changing the sequencing of cleft closure has no demonstrable difference in facial growth at 4 to 7 years after completion of the primary surgery.

Unilateral Complete Cleft Lip and Palate Repair Using Lip Adhesion Combined with a Passive Intraoral Alveolar Molding Appliance: Surgical Results and the Effect on the Maxillary Alveolar Arch

A number of combined maxillary orthopedic and surgical treatment protocols have been proposed for the initial phase of therapy for infants with a complete cleft lip and palate. Lip adhesion was used in combination with a passive intraoral molding appliance to treat a unilateral complete cleft lip and palate. The proposed protocols are lip adhesion, along with positioning of a passive alveolar molding appliance, at 4 to 6 weeks of age, then definitive cheiloplasty at 4 to 5 months of age, and palatoplasty at 12 months of age. Twenty-five patients with a complete cleft lip and palate were treated using this protocol between 1994 and 2003. The follow-up period was between 6 months and 10 years. The alveolar gap, the length of the maxillary alveolar cleft, and the palatal gap were 10.1 +/- 4.2 mm, 6.1 +/- 0.9 mm, and 13.4 +/- 2.9 mm for lip adhesion, 3.1 +/- 1.4 mm, 2.6 +/- 0.8 mm, and 9.6 +/- 1.5 mm for definitive cheiloplasty, and 0.2 +/- 0.1 mm, 1.5 +/- 0.7 mm, and 8.3 +/- 1.1 mm for palatoplasty. For the following maxillary dental casts for 3 to 10 year olds, the intercanine width and canine arch lengths were within the normal value. The intermolar width and the molar arch length, however, decreased slightly compared with the control normal values. Lip adhesion and a passive alveolar molding appliance achieved a normal position and stabilized the arch in a symmetrical platform.

Reduced Need for Alveolar Bone Grafting by Presurgical Orthopedics and Primary Gingivoperiosteoplasty

The purpose of this study was to evaluate if narrowing and approximation of the alveolar cleft through presurgical alveolar molding followed by gingivoperiosteoplasty (GPP) at the time of lip repair reduces the need for a bone-grafting procedure. This was a retrospective blind study of patients with unilateral or bilateral alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon. Alveolar bone formation was assessed prior to the eruption of the maxillary lateral incisor or canine by clinical examination, panoramic and periapical radiographs, and/or a dental CT scan. The criterion for bone grafting was inadequate bone stock to permit the eruption and maintenance of the permanent dentition. This study was performed at the Institute of Reconstructive Plastic Surgery by the members of the Cleft Palate Team. All patients with unilateral (n = 16) or bilateral (n = 2) alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon from 1985 to 1988 were studied. The control population consisted of all alveolar cleft patients (n = 14) who did not undergo alveolar modeling or GPP during the same time period. Presurgical alveolar modeling was performed with an intraoral acrylic molding plate. This plate was modified on a weekly basis to align the alveolar segments and close the alveolar gap. The surgical intervention consisted of a modified Millard GPP. The primary study outcome measure was the elimination of the need for a secondary bone graft in patients who underwent presurgical alveolar molding and GPP. Of the 20 sites in the 18 patients who underwent GPP, 12 sites did not require an alveolar bone graft. Of the 8 sites requiring a bone graft, 4 presented minimal bony defects. All 14 patients in the control group required bone grafts. In this series of 20 alveolar cleft sites treated with presurgical orthopedics and GPP, 60% did not need a secondary alveolar bone graft in the mixed dentition.

Bucconasal Fistula with Bilateral Supernumary Teeth in an Operated Cleft Lip and Palate Patient (A Case Report)

SummaryThis article summons a 6 years boy born with congenital complete cleft of lip and palate of left side. The lip and palate was closed in two stages. But he had persistent bucconsal fistula and bilateral supernumary teeth, one each on either nostril, The left was erupted and right one was unerupted. The supernumary tooth were extracted in two stages. The fistula was closed in three layers with the transposition of labial mucosal flap for alveolar gap with successful result.

Bone grafting of the alveolus followed by orthopedic alignment of the alveolar arch in infants with complete cleft lip and cleft palate

The orthopedic aspects of complete cleft palate have been reviewed briefly with regard to the influence of early surgical intervention upon the growing maxilla. McNeil's 13 method of orthodontic alignment of the alveolar arch in early infancy, before lip repair, has been mentioned, as well as my method in which the orthopedic procedure is begun immediately after the lip repair. The goal is prevention of unfavorable secondary arch deformities following surgical intervention. Remaining defects of a complete cleft palate are mobility of the premaxilla in bilateral clefts and deficiency of bone tissue at the alveolar process. A bone-grafting procedure has been developed to stabilize the alveolar arch in these cases along with orthopedic arch alignment. An original technique performed on infants is described. This technique permits implantation of bone after closure of the alveolar gap in two layers by means of a vomer flap, the back part of which will be anteflected for covering of the graft. A full-thickness piece of autogenous rib is removed for grafting. Photographs of typical cases have been included to illustrate the indications for bone grafting and the combined surgico-orthopedic technique. Follow-up casts and roentgenograms, taken up to 3 years postoperatively, show that the arch can be reconstructed and the premaxilla stabilized. During this observation period there was no interference with growth of the maxilla. A normal interarch relationship, overjet, and facial profile could be obtained.