Complete Cleft Palate Research Articles

Primary surgery effect on dental arch relationships of patients born with unilateral cleft lip and palate using the GOSLON yardstick index

To score dental arch development using the Great Ormond Street, London, and Oslo (GOSLON) yardstick index, following primary surgery in patients with a complete unilateral cleft lip and palate (UCLP), and to compare the outcome score with the GOSLON score of Cleft Care UK (CCUK) as well as with the Clinical Standards Advisory Group (CSAG), United Kingdom.Study models of patients (average age 12 years) with a non-syndromic complete UCLP, who had been surgically treated at the University of Pretoria Facial Cleft Deformity (UPFCD) clinic. They were assessed using the GOSLON yardstick index by certified raters from the Dental School in Dundee, Scotland. The mean outcome ratings were calculated from the scoring of 27 sets of plaster models. The other scoring rounds were used to calculate intraand inter-observer agreement using Cohen's weighted kappa and Fleiss's multi-rater kappa. There were strong intra- and inter-observer agreement, with a weighted kappa of 0.92. The Facial Cleft Deformity (FCD) clinic data showed a good treatment outcome with a mean GOSLON rating of 2.85 compared to a rating of 3.2 for the CSAG and 2.62 for the CCUK cohort studies. The UPFCD clinic primary surgical protocol displayed a good treatment outcome rating, in line with that of the CCUK cohort and better than the CSAG results.

Stress Distribution and Displacement of Craniofacial Structures Following Rapid Maxillary Expansion in Different Types of Cleft Palate: A Three-Dimensional FEM Study.

To evaluate displacements and stress distributions in finite element models (FEMs) of the craniofacial complex of 13-yearold male patient with complete unilateral cleft palate (UCP), a 15-year-old female patient with complete bilateral cleft palate (BCP), and a 15-year-old female patient with isolated cleft palate (ICP), which may respond differently to expansive forces. The FEMs were based on computed tomography scans of patients with UCP, BCP, and ICP who needed maxillary expansion. Von Mises stress distribution after 0.2 mm of expansion and displacements after 5 mm of expansion were investigated. The highest amount of stress was observed in the ICP model. Surprisingly, no stress was noted around the nose in the BCP model. The amount of dentoalveolar expansion decreased from anterior to posterior on the cleft side of the UCP, BCP, and ICP models. In contrast, on the non-cleft side of the UCP model, the maximum dentoalveolar expansion occurred at the molar area, decreasing toward the anterior parts. Anatomical structures expressed posterior displacement in the UCP model. In the ICP model, structures close to midline showed anterior displacement, while structures in the lateral parts showed posterior displacement. In contrast with the other 2 models, the structures in the BCP model showed anterior displacement. Vertically, all the anatomic structures in the BCP model showed inferior displacement, while in the ICP and UCP models, only the structures close to the midline showed inferior displacement. Maxillary expansion caused different patterns of stress distribution and displacement in different types of clefts. Clinicians should consider the type of the cleft, and may expect differing patterns of widening following maxillary expansion.

An Innovation of Postsurgical Nasal Retainer in a Unilateral Cleft Lip and Palate Patient.

Postoperative nasal asymmetry is a notable problem following primary cleft lip repair and cleft rhinoplasty in patients with unilateral cleft lip and palate. Postsurgical nasal retainer could play an essential role in maintaining the corrected position of the nose during the healing process. However, the manufactured retainers are usually not affordable, nor individualized. The authors report the efficacy of our custom-made postoperative nasal retainer, made from an oxygen nasal cannula, acrylic resin, and orthodontic wire made of stainless steel, in a patient with complete unilateral cleft lip and palate.

Identifying associations between dental arch relationship scores, relative deprivation and other cleft audit outcomes. Part 1.

To assess whether dental arch relationship scores are associated with speech, audiological and psychology outcomes in patients with complete unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP). One hundred 5-year-old children with non-syndromic complete UCLP and forty-two 5-year-olds with non-syndromic complete BCLP from the United Kingdom. Data were collected from five-year audit clinics for dental arch relationships, speech, hearing and psychology outcomes. Associations were assessed between ordinal prognostic covariates and the dental arch relationship outcome using a Cochrane-Armitage test for trend and comparisons with binary prognostic covariates using chi-square/Fisher's exact test. This was extended to assess associations between five-year audit outcomes and a measure of deprivation. There was no evidence of associations between dental arch relationships and outcomes for audiology and speech. Individual domain analysis of the psychology outcomes within the UCLP cohort reported a poor outcome for Pro-social score to be associated with a poor 5-year-old index score (P=.018). For the BCLP sample, a good outcome for the BCLP Deciduous Dentition Yardstick was associated with a good conduct score (P=.01). There was no association with the 5-year-old index/BCLP Deciduous Dentition Yardstick score and outcomes reported for audiology and speech. For the UCLP and BCLP cohorts, a poor dental arch relationship outcome may be associated with issues with some aspects of psychological well-being, associated with peer interactions and conduct. The deprivation index of samples had no association with the outcomes assessed.

Identifying associations between dental arch relationship scores, relative deprivation and other cleft audit outcomes. Part 2.

Identify associations between dental arch relationship scores, oral health status and deprivation index in patients with complete unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP). Ninety-two 5-year-old children with non-syndromic complete UCLP and thirty-nine 5-year-old children with non-syndromic complete BCLP from the United Kingdom. Data were collected from the 5-year audit outcomes submitted to the Cleft Registry and Audit Network (CRANE). The index of multiple deprivation (IMD) and Welsh index of deprivation were used to assess a relative measure of deprivation. Comparisons of 5-year-old index/BCLP Deciduous Dentition Yardstick outcome against IMD and dmft are performed using multivariable linear regression models. Both UCLP and BCLP had a high percentage of children with dmft >0 (47% and 49%, respectively). The mean dmft for the UCLP cohort was 2.8 and 2.6 for the BCLP cohort. In the UCLP group, a poorer 5-year-old index was associated with an increased dmft score (P=.023) and higher level of deprivation (P=.010). In the BCLP group, there was no significant associations between BCLP Deciduous Dentition Yardstick, dmft and IMD. A poorer dental arch relationship outcome may be associated with higher level of area deprivation and oral health status, in children with UCLP. Those with a poor outcome for the 5-year-old Index are more likely to have increased caries experience.

Effectiveness of Presurgical Nasoalveolar Molding Appliance in Infants With Complete Unilateral Cleft Lip and Palate.

To assess the effectiveness of the presurgical nasoalveolar molding appliance among infants with unilateral cleft lip and palate. In this prospective study, 95 pairs of casts of infants with unilateral cleft lip and palate treated by presurgical nasoalveolar molding were selected at the Children's Hospital 1 at Ho Chi Minh City, Vietnam. The average time of treatment was 3 months. All casts were scanned and measured using 3-dimensional technology before and after treatment. Paired t tests were applied for comparisons. There was a statistically significant increase in the nostril height in cleft side (P < .001), decrease in the nostril width and columella angle (P < .001), and decrease in cleft width and midline deviation (P < .001) after treatment with presurgical nasoalveolar molding appliance. Nasoalveolar molding appliance is effective in improving the morphology of nostril and maxillary alveolar. Understanding this helps orthodontists and surgeons in treatment outcome expectations.

Interdisciplinary Approach for the Treatment of Complex Bilateral Cleft Lip and Palate With Missing Premaxilla.

Complex craniofacial deformities such as complete bilateral cleft lip and palate require interdisciplinary approach for proper diagnosis and treatment. A severe skeletal discrepancy caused by bilateral cleft lip and palate and missing premaxilla was successfully managed with orthodontic preparation and distraction osteogenesis. Conventional prosthodontic treatment combined with orthodontic preparation was proven to be a viable option to manage multiple missing teeth in cleft lip and palate.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening.

The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM). A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults. Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width. Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Craniofacial Growth Analysis of Individuals With and Without Cleft Lip and Palate in Colombia.

Craniofacial growth is a dynamic and unpredictable process influenced by genetic and environmental factors, presenting phenotypic and gender differences. Evaluate the differences in craniofacial growth and development in a group of Colombian individuals with complete unilateral and bilateral cleft lip and palate (CLP) and without CLP, classified by gender and age. Five hundred forty-one profile radiographs of 126 patients with unilateral CLP, 126 with bilateral CLP, and 289 without CLP. All patients of affected groups had a history of CLP correction surgery without nasoalveolar molding with orthopedic and orthodontic treatments. This cross-sectional study was performed comparing 8 cephalometric measurements on radiographs, 5 linear/3 angular. Analysis was performed by median and interquartile range for all cephalometric measurements. Comparison between the groups was performed using Kruskal-Wallis and Mann-Whitney U, with a 95% confidence. Significant differences between the groups of patients with and without CLP, between types of clefts and genders. The skeletal structures of patients with CLP were smaller than those of control but improved with growth. Patients with unilateral CLP presented flat profiles and predominant class III malocclusions, while patients with bilateral CLP, at early ages, were class II and in the prepubertal stage, the values were progressively negative until the end of the growth period, suggesting class III. Patients with CLP presented posteroinferior rotation of the mandible, vertical measurements increased, and deflection of the cranial base. Given their growth alterations, patients with CLP benefit from orthopedic and orthodontic treatment.

Outcome of Using Medical Grade Calcium Sulfate Hemihydrate (DentoGen) in Unilateral Alveolar Cleft Repair

Objectives: The aim of this prospective study was to evaluate the efficacy of fast setting (DentoGen) bonesubstitute for secondary alveolar cleft repair.Materials and Methods: Ten patients with complete unilateral cleft lip and palate were included for alveolarcleft repair with fast setting (DentoGen) without autogenous bone graft in 2017 and 2018. Pre-operation and6 months post-operation CBCT were used for measurement of bone density and bone volume in cleft site.The data was analyzed by using Pearson’s correlation coefficient test and paired sample t-test via SPSSsoftware version 24.Results: The mean age of patients in this study was 10.4±2.657 years. The pre-operative mean alveolar cleftvolume was 0.8996±0.117cm3. Six months after grafting with fast setting (DentoGen) graft, satisfactorybone formation was observed in all patients except two patients. The mean bone density of cleft site was303±42.843 HU which was significantly lower than the non-cleft side, and the mean percentage of new boneformation was 64.74±10.290% compared with original cleft volume.Conclusion: Calcium sulfate hemihydrate (DentoGen) can represent a promising alternative to autogenousbone graft in repairing small unilateral alveolar cleft during mixed dentition.

Non-surgical treatment of vertical excess of the premaxilla in growing bilateral cleft lip and palate patients

Patients with bilateral complete cleft lip and palate (BCLP) may present a vertical excess of the premaxilla in childhood. This is a severe functional and aesthetic problem, where bone grafting is more challenging. The aim of this study was to describe a simple and reproducible non-surgical orthopaedic treatment for vertical excess of the premaxilla in the deciduous/early mixed dentition phase in BCLP patients. Six growing patients with complete BCLP with a severe vertical excess of the premaxilla were included. An intrusion device associated with a bonded rapid palatal expander was applied to intrude the premaxilla. Radiographic and photographic records obtained before and at the end of the orthodontic intrusion, at short- and long-term follow-up, were available. A flattening of the occlusal plane was achieved in all patients. Normalization of the position of the maxillary incisors and gingival display in relation to the upper lip was obtained, and an improvement in anterior nasal spine position was also observed in all cases. The novel technique described might be of assistance in treating BCLP children with vertical excess of the premaxilla during the deciduous/early mixed dentition phase. This simplified, easily reproducible method may allow the burden of care of this rare but complex problem affecting BCLP patients to be reduced significantly.

Frequency and Predictors of Fistulae Occurrence after One Stage Repair with Radical Muscle Dissection for Complete Cleft Palate

Background: The main goal in the management of patients with cleft palate is anatomical closure of the defect, normal speech development, maxillofacial growth, and hearing without any complications. Cleft palate repair can be done using a variety of surgical techniques. one-stage repair is one of the commonest. Aim of work: The objective of this study is to illustrate the frequency of fistula and fistula predictors in the closure of complete cleft palate with radical palate muscle dissection in a single-stage Patients and methods: A prospective cohort study conducted on 20 patients who underwent cleft palate closure as one-stage repair in children aged between 9 months to 5 years old. Results: Twenty patients had a one-stage cleft palate repair with radical muscle dissection. The overall occurrence of fistula formation was zero. Conclusion: Anatomical repair of levator vile palatine muscle with complete dissection & releasing it from its abnormal insertion in a defect of 10-12 mm could be an important factor for limitation of fistulae incidence after cleft palate repair.

Dental Arch Relationship Outcomes Following 2-Stage Palatoplasty for Japanese Patients With Complete Unilateral Cleft Lip and Palate: A 3-Center Study

To compare dental arch relationship outcomes following 3 different 2-stage palatal repair protocols. Retrospective, cross sectional. Three cleft palate centers (A, B, C) in Japan. Ninety (A: 39, B: 26, C: 25) consecutively treated Japanese patients with complete unilateral cleft lip and palate. In A, the soft palate and the posterior half of the hard palate were repaired at a mean age of 1 year 7 months. In B, the soft palate and hard palate were closed separately at a mean age of 1 year 6 months and 5 years 8 months, respectively. In C, the soft palate and hard palate were closed at a mean age of 1 year and 1 year 5 months, respectively. Dental arch relationships were assessed using the 5-Year-Olds' (5-Y) index by 5 raters and the Huddart/Bodenham (HB) index by 2 raters. Intra- and inter-rater reliabilities showed substantial or almost perfect agreement for the 5-Y and HB ratings. No significant differences in mean values and distributions of 5-Y scores were found among the 3 centers. The mean HB index scores of molars on the minor segment were significantly smaller in C than those in A and B (P < .05). There were no significant differences in dental arch relationships at 5 years among the times and techniques of hard palate closure. However, further analysis of the possible influence of infant cleft size as a covariable on a larger sample size is needed.

Superior Orbicularis Oris Muscle Activity in Children Surgically Treated for Bilateral Complete Cleft Lip and Palate.

The aim of this cross-sectional study was to evaluate the electromyographic activity of the superior orbicularis oris muscle both in children surgically treated for bilateral complete cleft lip and palate (BCCLP) as well as in subjects without BCCLP. The study comprised 77 children aged 6.6 to 12.5 years. All the patients with clefts had previously undergone lip and palate surgery. The upper lip electromyographic (EMG) assessments were made with a DAB-Bluetooth device (Zebris Medical GmbH, Germany) at rest, while swallowing saliva, protruding lips and compressing lips. EMG measurements were also made when the subjects produced phonemes /p/, /b/, and /m/ with the vowel /a/. The Mann-Whitney U test was applied to statistically analyze the EMG values. Significantly higher median upper lip EMG activity under working conditions such as swallowing saliva, lip compression, and production of the phoneme /p/ with the vowel /a/ was observed in patients with BCCLP compared to those without a cleft. The results of the study showed that the upper lip muscle activity increases in children with BCCLP when swallowing saliva, compressing lips and during some speech movement tasks. This may be important in the aspect of the effect of surgical lip repair on the craniofacial growth.

Beware of Optical Illusion of the Alar Base in Unilateral Cleft Lip Nasal Deformity.

Background:It is generally accepted that the alar base on the cleft side in the cleft lip nose is displaced outward and downward; therefore, it is rotated inward and upward in almost all procedures for cleft lip closure. However, nostril narrowing and collapse of the lower lateral cartilage on the cleft side are sometimes experienced. In this retrospective study, we investigated whether the preoperative alar base on the cleft side is displaced outward and downward.Methods:This was a retrospective evaluation using preoperative frontal images obtained from patients with unilateral cleft lip (n = 245). The midcolumellar and subalare points were placed, and each ratio was analyzed and compared to those of age-matched controls (n = 40).Results:The subalare on the noncleft side and subnasale were displaced upward and outward. In contrast, the subalare on the cleft side was displaced downward and inward. The displacement of the subalare was greater on the noncleft than on the cleft side. There were no significant differences between male and female patients and between the left and right sides. Among the complete cleft lip and palate, incomplete cleft lip and palate, complete cleft lip and alveolus, incomplete cleft lip and alveolus, and microform cleft lip groups, the complete cleft lip and palate group showed the greatest displacement.Conclusion:The cleft alar base appeared to shift outward and downward because of an optical illusion, but in fact, both alar bases shifted; the alar base on the cleft side was displaced inward and downward, and the alar base on the noncleft side was displaced outward and upward.

Orthodontic Pre Grafting Closure of Large Alveolar Bony and Soft Tissue Gaps: A Novel Nonsurgical Protraction of the Lesser Segments in Growing Patients With Cleft Lip and Palate

Closure of wide alveolar clefts with large soft tissue gaps and reconstruction of the dentoalveolar defect are challenging for the surgeon. Some authors successfully used interdental segmental distraction, which requires an additional surgical procedure. This study evaluates the effectiveness of tooth borne devices utilized to orthopedically advance the lesser segments, with a complete approximation of the soft tissue of the alveolar stumps, allowing traditional simultaneous soft tissue closure and bone grafting, and avoiding the need for supplementary surgery. Eight growing patients, 2 with unilateral complete cleft lip and palate (UCLP) and 6 with bilateral complete cleft lip and palate (BCLP), with large soft tissue and bony alveolar defects prior to bone grafting were prospectively selected. A banded rapid palatal expander (RPE) in BCLP and a modified RPE in UCLP combined with protraction face mask in younger patients or a modified Alt-Ramec in patients older than 12 years were applied. Radiographic and photographic records were available at T0, at the end of protraction (T1) and at least 1 year after bone grafting (T2). Patients with large gaps showed a significant reduction in the bony cleft area and approximation of the soft tissues at T1. All patients received bone grafting with good healing and ossification at T2. In growing patients with UCLP and BCLP with large gaps, presurgical orthodontic protraction seems to be an efficient method to reduce the cleft defect, minimizing the risk of post grafting fistulas, reducing the need for supplementary surgical procedures.

Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics-cost-to-charge ratio (RCC) and case volume of cleft palate repair. Retrospective cohort study. This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

Three-Dimensional Computed Tomography Reconstruction and Measurement of Nasal End Deformity in Complete Unilateral Cleft Lip and Palate.

The repair of nasal deformities secondary to cleft lip and palate is complex and requires reliable preoperative nasal 3-dimensional assessment. This study explored nasal end (defined as the lower third of the external nasal and vestibular parts of the nasal cavity) deformities secondary to unilateral complete cleft lip and palate. Three-dimensional nasal end morphometric measurements were obtained from 48 patients who had undergone Millard cleft lip repair and reached skeletal maturity (cleft group) and from 36 age- and ethnicity-matched normal subjects (control group). For the cleft group, paired t tests and 1-way analysis of covariance were used to evaluate the internal and external morphological characteristics of the cleft and noncleft sides of the nasal end, and correlation analysis was done to evaluate the relationship between cleft-side measurements. In the cleft group, the cleft side showed significantly smaller nasal vestibular volume and skin area, nostril area, nasal column length, and nostril height and greater nostril base length and nasal alar length than the noncleft side (all P < 0.05). Controlling for sex, there were significant differences in the nasal vestibular volume and skin area, internal nasal valve area, long nostril diameter, nostril base length, columella length, nostril height, and nasal alar length between the cleft and control groups (all P < 0.05). On the cleft side, the area of the skin lining of the nasal vestibule positively correlated with the alar length (r = 0.67, P < 0.05). Three-dimensional nasal end reconstruction provides a more detailed preoperative nasal end morphological evaluation than previously available techniques. Level III, case-control study.

Occlusal Outcome of Orthodontic Treatment for Patients With Complete Cleft Lip and Palate.

To assess occlusal outcomes of orthodontic treatment for patients with complete cleft lip and palate. Retrospective assessment using the Peer Assessment Rating (PAR) index. Consecutive patients treated by one consultant orthodontist at a tertiary care cleft center. One hundred twenty-seven patients with either complete unilateral cleft lip and palate (UCLP) or bilateral cleft lip and palate (BCLP) consecutively treated with fixed appliances. Fixed orthodontic appliance treatment and orthognathic surgery when required. The PAR index assessment was carried out by a calibrated-independent assessor. Treatment duration, the number of patient visits, and data on dental anomalies were drawn from patient records and radiographs. One hundred two patients' study models were assessed after exclusions. Mean start PAR score for UCLP (n = 71) was 43.9 (95% CI, 41.2-46.6, SD 11.5), with a mean score reduction of 84.3% (95% CI, 81.9-86.7, SD 10.1). The UCLP mean treatment time was 23.7 months with 20.1 appointments. Mean start PAR score for BCLP (n = 31) was 43.4 (95% CI, 39.2-47.6, SD 11.4), with a mean score reduction of 80.9% (95% CI, 76.3-85.5, SD 12.5). The BCLP mean treatment time was 27.8 months with 20.5 appointments. These results compare well with other outcome reports, including those for patients without a cleft, and reflect the standard of care provided by an experienced cleft orthodontist. As with high-volume surgeons, orthodontic treatment for this high need group is favorable when provided by a high-volume orthodontist. These findings may be used for comparative audit with similar units providing cleft care.

Function of Nasoalveolar Molding Devices in Bilateral Complete Cleft Lip and Palate: A 3-Dimensional Maxillary Arch Analysis.

This study aimed to observe and analyze the effects of nasoalveolar molding (NAM) on maxillary arch dimensions in patients with bilateral complete cleft lip and palate (BCLP) using 3-dimensional analyses. Retrospective case series. Seventeen infants were treated using modified Khon Kaen University presurgical nasoalveolar molding devices (KKU-NAM). Dental casts were evaluated 3 dimensionally at 3 time points: pretreatment (T1), after using modified KKU-NAM for 2 weeks (T2), and before cheiloplasty (T3). Repeated-measures analysis of variance and Friedman test were used to compare the maxillary arch dimensions between time points. Both sides of the cleft width, premaxilla deviation, and premaxilla protrusion had significantly reduced with the use of KKU-NAM. Premaxillary rotation had significantly improved, whereas the arch depth did not change significantly. Premaxilla width, posterior arch width, alveolar length, and height had significantly increased. The anterior arch width, intercanine width, and lateral sulcus width showed no significant changes. The intraclass correlation coefficient used to test the measurements indicated substantial reliability. The modified KKU-NAM is an effective device for reducing the severity of bilateral cleft deformities, especially in the premaxilla area.