Definitive Lip Research Articles

The unilateral cleft lip repair

ObjectiveTo determine if there is a benefit of 2-stage cleft lip repair in regard to improving facial symmetry and facilitating definitive lip, nose, and palate repair. Study designRetrospective chart review of patients born with complete, unilateral cleft lip deformity that underwent a two-stage repair described as a stage 1 straight line repair and a stage 2 modified Millard repair, for which a complete set of records, and peri-operative and post-operative photos were available. All cases were performed by a single surgeon. SettingTertiary care center craniofacial team. MethodsMeasurements were taken from intraoperative, perioperative, and postoperative images of patients before and after each stage. Ratios were then created comparing the affected size to the unaffected side, and these were averaged between observers. ResultsA 19% increase in the width of area of the presumptive C flap was obtained between the unrepaired and the post-stage I images. The nostril width of the cleft side was 1.2× the width of the unaffected side, demonstrating a 140% decrease in nostril width at the completion of stage II. The cleft side nostril width was maintained slightly larger than the noncleft side as desired. Symmetry of the upper lip length was achieved, as the length of the cleft side lateral lip after stage II was 92% of the unaffected side. ConclusionWe believe this study provides evidence for our observations that a two-stage repair can be performed with functionally and aesthetically pleasing outcomes as an alternative to presurgical nasoalveolar molding.

Quantitative Effects of Cleft Lip and Nose Adhesion on Nostril and Alveolar Discrepancy

BACKGROUND: Although there are considerable data quantifying the effects of nasoalveolar molding on definitive lip repair, less is known about the effect of cleft lip and nose adhesion (CLNA) on the alveolar segments and nostril shape in patients who are unable to undergo craniofacial orthodontics. CLNA approximates the lip segments, resulting in the conversion of a complete cleft lip to an incomplete cleft lip while sparing the tissues and landmarks for eventual definitive lip repair. In resource-constrained environments or situations where patients cannot undergo craniofacial orthodontics, CLNA has been shown to qualitatively improve nostril shape before definitive reconstruction in wide cleft. However, less is known about the effects of CLNA alone on the nostril and alveolar cleft segments dimensions. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, a single-center retrospective review of unilateral cleft lip patients undergoing CLNA was performed. Measurements were taken at the time of CLNA and at formal repair. The following data points were extracted for the cleft and noncleft side: nostril height (NH), nostril width (NW), alveolar height (AH), and alveolar width (AW). Dimensional changes from the time of CLNA and time of formal repair were statistically analyzed using a paired Student’s t test. RESULTS: A total of 1,053 surgical cases were reviewed. Eight patients met criteria for inclusion. Average NH before CLNA was 2.3 mm on the cleft side and 5.6 mm on the noncleft side (P = 0.020). After CLNA, the NH on the cleft versus noncleft side was 4.5 and 5.0 mm, respectively (P = 0.553). Average NW before CLNA was 14.8 mm on the cleft side, compared to 7.3 mm on the noncleft side (P = 0.003). After CLNA, the average NW on the cleft side was 11.2 mm, compared to 7.1 mm on the noncleft side (P = 0.007). CLNA resulted in a significant reduction in NW on the cleft side (P = 0.002). The average AW discrepancy, measured as the gap between alveolar segments, was 9.9 mm before CLNA and significantly decreased to 1.5 mm before definitive repair (P = 0.002). AH discrepancy decreased from 11.4 to 6.5 mm (P = 0.060). CONCLUSION: This study reports quantitative changes with CLNA, a powerful tool for reshaping the nostril and approximating the alveolar segments in cases where nasoalveolar molding is not an option. This study demonstrates that CLNA alone achieves a cleft NH which approaches the noncleft side, improved AH and width discrepancy by closure of the gap between alveolar segments, and significant reduction in NW.

The effect of dynaCleft® on presurgical orthopedics in bilateral cleft lip and palate patients

Aims: The aim of this study was to determine the effects DynaCleft® has on patients with bilateral cleft lip and palate. Subjects and Methods: Comparative data were collected from a total of 46 infants diagnosed with bilateral cleft lip and palate between 1981 and 2017. Twenty-three infants were treated with DynaCleft® and an obturator and 23 infants received an obturator only. Maxillary impressions were taken at each infant's initial clinic visit and again on the day of his/her surgical cleft lip repair. Differences in maxillary retraction, sagittal repositioning, and cleft widths were compared between the two groups. Statistical Analysis Used: Paired t-tests were used to determine if there was significant change before and after DynaCleft® therapy, and two-sample t-tests were used to compare the data between the two study groups. Results: Clinically, DynaCleft® averaged more maxillary retraction and cleft size reduction on both the right and left sides compared to the control group. Within the DynaCleft® group, a statistically significant difference was found for premaxillary retraction on both the right and left sides. However, all the other comparisons between the two groups were not found to be statistically significant. Conclusions: DynaCleft® as a presurgical orthopedic therapy may help to limit uncontrolled physiological changes and reposition the premaxillary segment, while reducing cleft widths prior to definitive lip surgery.

Bilateral cleft surgery: Pre-surgical orthopaedics may facilitate primary definitive lip repair without need for revision and bilateral vomerine flaps are safe

Bilateral cleft surgery: Pre-surgical orthopaedics may facilitate primary definitive lip repair without need for revision and bilateral vomerine flaps are safe

Effects of labial adhesion on maxillary arch dimensions and nasolabial esthetics in cleft lip and palate: a systematic review.

Labial adhesion is a preliminary surgical lip approximation used in the early management of unilateral and bilateral cleft lip and palate. Our objective was to evaluate its effects on the maxillary arch dimensions and nasolabial esthetics by means of a systematic review. The literature search (1955-2016) was based on MEDLINE via PubMed, Web of Science, EMBASE, and the Cochrane Library. Studies with labial adhesion as a single preliminary step for definitive lip closure, in combination with nasoalveolar molding or in combination with infant orthopedics were considered eligible. Fifteen articles were identified (1978-2015), including 587 patients who underwent labial adhesion. Reduction in alveolar cleft width was between 60.9% and 100% in unilateral cases and between 47.5% and 100% in bilateral cases. Reduction in palatal cleft width was between 28.4% and 59.8% in unilateral cases and between 37.5% and 50.5% in bilateral cases. No conclusive results could be drawn about the effect on nasolabial esthetics. This systematic review comprises the available literature of the last 50years about labial adhesion. It showed reduction of alveolar and palatal cleft width after a treatment with labial adhesion with or without infant orthopedics. The treatment effect on nasolabial esthetics, especially in the long term, remains unclear.

Occlusal Classification in Relation to Original Cleft Width in Patients with Unilateral Cleft Lip and Palate

To determine a correlation between the width of the cleft palate measured at the time of lip adhesion, definitive lip repair, and palatoplasty and the subsequent occlusal classification of patients born with unilateral cleft lip and palate. Retrospective, observational study. Referral, urban, children's hospital Participants : Dental models and records of 270 patients were analyzed. None. Angle occlusion classification. The mean age at which occlusal classification was determined was 11 ± 0.3 years. Of the children studies, 84 were diagnosed with Class I or II occlusion, 67 were diagnosed with Class III occlusion, and 119 were lost to follow up or transferred care. Mean cleft widths were significantly larger in subjects with Class III occlusion for all measures at time of lip adhesion and definitive lip repair (P < .02). At time of palatoplasty, cleft widths were significantly greater at the alveolus (P = .025) but not at the midportion of the hard palate (P = .35) or posterior hard palate (P = .10). Cleft widths from the lip through to the posterior hard palate are generally greater in children who are diagnosed with Class III occlusion later in life. Notably, the alveolar cleft width is significantly greater at each time point for patients who went on to develop Class III occlusion. There were no significant differences in cleft widths between patients diagnosed later with Class I and Class II occlusions.

Peter Randall, M.D., 1923 to 2014.

Peter Randall, M.D., 1923 to 2014.

Different modalities for the management of bilateral cleft lip

Objectives The aim of this randomized prospective trial was to evaluate the different modalities for the management of bilateral cleft lip including primary and secondary deformities. Background Cleft lip repair will remain the aim of cleft surgeons. The complexity of deformity and the delicate interrelation between muscular arrangement and external lip features require a comprehensive approach for proper management. This study describes technical refinements in the skin design and modifications in the muscle repair in bilateral cleft lip. Materials and methods From January 2012 to April 2014, 16 patients with bilateral cleft lip deformities received surgical treatment in the form of either (group A, n = 10 patients) closure of the primary cleft according to the type and amount of protrusion of the premaxilla or (group B, n = 6 patients) repair of secondary deformities according the presentation. Demographic data, operative time, post, hospital stay, duration of incapacity for work, postoperative complications (infection, wound dehiscence, hypertrophic scar), symmetry, vermillion red alignment, quality of the scar, and patient satisfaction were recorded. Results The overall results were very satisfactory in function and appearance, without major complications. The lip adhesion procedure was performed at the age of 2-8 weeks postnatally, definitive lip closure at the age of 3-6 months (primary repair 10 cases), and secondary repair at the age of 2 years until adulthood (secondary repair six cases). Wound dehiscence occurred in two cases that healed spontaneously without intervention. Conclusion This method of comprehensive primary muscle, soft tissue, and skin reconstruction in bilateral cleft lip addresses the major sites of distortion in the lip, sulcus, and nasal floor, producing a full central segment, prominent philtral ridges, adequate white roll, and thick vermilion with a seam-like median tubercle in addition to a deep gingivo-labial sulcus and alar base symmetry. Nasal deformity postponed with secondary repair.

Management of Prominent Premaxilla in Bilateral Cleft Lip and Alveolus

Our aim was to describe the early management protocol of the prominent premaxilla in bilateral cleft lip and alveolus and its rationale, as used in the Cleft Centre at the 1st Department of Pediatrics and at the Department of Pedodontics and Orthodontics at the Semmelweis University Budapest. The non-surgical and surgical procedures included lip taping, nasoalveolar molding, lip adhesion and definitive one-stage lip closure. With this treatment sequence, arch management was satisfactory and at the time of the definitive lip closure the position of the premaxilla did not interfere with adequate surgical repair.

The Financial Impact of Multidisciplinary Cleft Care

The purpose of this study was to determine the financial impact of cleft care on the hospital and to evaluate trends in reimbursement over the past 6 years. Medical and accounting records of 327 consecutive infants undergoing cleft repair between 2005 and 2011 were reviewed. Charges, payments, and direct cost data were analyzed to illustrate hospital revenue and margins. Hospital payments for all inpatient services (cleft and noncleft) during the first 24 months of life were $9,483,168. Mean hospital payment varied from $5525 (Medicaid) to $10,274 (managed care) for a cleft lip repair (p < 0.0001) and from $6573 (Medicaid) to $12,933 (managed care) for a cleft palate repair (p < 0.0001). Hospital charges for a definitive lip or palate repair to both Medicaid and managed care more than doubled between 2005 and 2011 (p < 0.0001). Overall, mean hospital margins were $3904 and $3520, respectively, for a cleft lip repair and cleft palate repair. Medicaid physician payments for cleft lip and palate were, respectively, $588 and $646. From 2005 to 2006, 2007 to 2008, and 2009 to 2010, 41 percent, 43 percent, and 63 percent of patients, respectively, were enrolled in Medicaid. Cleft care generates substantial revenue for the hospital. For their mutual benefit, hospitals should join with their cleft teams to provide administrative support. Bolstered reimbursement figures, based on the overall value of cleft care to the hospital system, would better attract and retain skilled clinicians dedicated to cleft care. This may become particularly important if Medicaid enrollment continues to increase.

An evaluation of surgical outcome of bilateral cleft lip surgery using a modified Millard′s (Fork Flap) technique

The central third of the face is distorted by the bilateral cleft of the lip and palate and restoring the normal facial form is one of the primary goals for the reconstructive surgeons. The history of bilateral cleft lip repair has evolved from discarding the premaxilla and prolabium and approximating the lateral lip elements to a definitive lip and primary cleft nasal repair utilising the underlying musculature. The aim of this study was to review surgical outcome of bilateral cleft lip surgery (BCLS) done at the Lagos University Teaching Hospital. A review of all cases of BCLS done between January 2007 and December 2012 at the Lagos University Teaching Hospital was done. Data analysis included age and sex of patients, type of cleft deformity and type of surgery (primary or secondary) and whether the cleft deformity was syndromic and non-syndromic. Techniques of repair, surgical outcome and complications were also recorded. A total of 39 cases of BCLS involving 21 males and 18 females were done during the period. This constituted 10% (39/390) of all cases of cleft surgery done during the period. There were 5 syndromic and 34 non-syndromic cases. Age of patients at time of surgery ranged between 3 months and 32 years. There were 24 bilateral cleft lip and palate deformities and 15 bilateral cleft lip deformities. Thirty-one of the cases were primary surgery, while 8 were secondary (revision) surgery. The most common surgical technique employed was modified Fork flap (Millard) technique, which was employed in 37 (95%) cases. Bilateral cleft lip deformity is a common cleft deformity seen in clinical practice, surgical repair of which can be a challenge to an experienced surgeon. A modified Fork flap technique for repair of bilateral cleft lip is a reliable and versatile technique associated with excellent surgical outcome.

Lip adhesion revisited: A technical note with review of literature.

Context (Background):Lip adhesion is a direct edge approximation without changing lip landmarks or disturbing tissue required for definitive closure. This converts a complete cleft into an incomplete cleft, facilitating and enhancing subsequent definitive lip and nose repair.Aim:The study aims to describe our technique of lip adhesion and its morbidity, and discuss the rationale for its use.Settings and Design:Retrospective follow-up study of complete clefts operated upon in the Bruges Cleft and Craniofacial Centre, at the supra regional teaching hospital AZ St. Jan, Bruges, between June 1, 1991 and May 1, 2009.Methods and Material:The group comprised 33 unilateral and 24 bilateral lip adhesion procedures. The medical files were reviewed for changes in surgical technique, morbidity, and complications and their treatment.Results:The lip adhesion procedure was performed at the age of two to eight weeks postnatal, and definitive lip closure, at the age of four to six months. In all cases, segment repositioning was further controlled by a palatal guidance plate. Wound dehiscence occurred in eight patients (14.0%), and three patients (5.3%) required reoperation.Conclusions:Although complications occurred, the beneficial effects of lip adhesion in combination with a guidance plate outweighed the risks for anatomical reconstruction of a platform for definitive lip and nose repair. Modifications are suggested to reduce these complications.

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.

The Basis for Presurgical Orthopedic Treatment of Infants with Unilateral Complete Cleft Lip and Palate

The purpose of this study was to describe the posttreatment morphology of the upper part of the oral cavity of complete unilateral cleft lip and palate (UCLP) patients and to compare it to noncleft contemporaries. Patients were treated according to a protocol designed to keep a proper resting posture of the oral cavity. Retrospective study on dental casts. The study was performed at a maxillofacial center serving a population of 2 million inhabitants. Data for noncleft subjects are the result of a longitudinal study at the same institution. Twenty-one Caucasian UCLP patients (13 males, 8 females) aged 5 to 9 years with no other congenital anomalies and no postoperative orthodontic treatment. Each patient received 5 to 6 months of preoperative orthopedics with a passive plate and external nonelastic strapping with definitive lip repair at age 5 to 7 months, soft palate repair at 11 to 15 months, and hard palate repair with mucoperiosteal closure of the alveolus at 30 to 36 months. Each patient was compared to the mean values obtained from a longitudinal study of a group of 25 healthy noncleft children of the same ethnic group (11 males, 14 females). Analysis of dental casts indicated that 16 patients had a width, depth, and length of the alveolar arch in the range of the mean normal values minus two standard deviations. Their analyzed palates were flatter than normal. Six of 21 children had too small an alveolar arch for their ages, and they did not acquire a correct posture of the oral cavity. The results indicate that the upper part of the oral cavity of UCLP patients can reach the dimensions of noncleft contemporaries despite surgery.

The Basis for Presurgical Orthopedic Treatment of Infants with Unilateral Complete Cleft Lip and Palate

Abstract Objective: The purpose of this study was to describe the posttreatment morphology of the upper part of the oral cavity of complete unilateral cleft lip and palate (UCLP) patients and to compare it to noncleft contemporaries. Patients were treated according to a protocol designed to keep a proper resting posture of the oral cavity. Design: Retrospective study on dental casts. Setting: The study was performed at a maxillofacial center serving a population of 2 million inhabitants. Data for noncleft subjects are the result of a longitudinal study at the same institution. Patients: Twenty-one Caucasian UCLP patients (13 males, 8 females) aged 5 to 9 years with no other congenital anomalies and no postoperative orthodontic treatment. Interventions: Each patient received 5 to 6 months of preoperative orthopedics with a passive plate and external nonelastic strapping with definitive lip repair at age 5 to 7 months, soft palate repair at 11 to 15 months, and hard palate repair with mucoperiosteal closure...

Early Maxillary Orthopedics in a Child with an Oblique Facial Cleft

Oblique facial clefts are extremely rare. In view of their variability, surgical treatment cannot be standardized. To date, early maxillary orthopedics in the treatment of oblique facial clefts have not been reported. The case described here presents a newborn child with a Tessier 3 cleft. Because of the enormous width of the alveolar cleft, a narrowing of the segments was regarded as prerequisite for definitive lip closure. To bring the segments together, an actively working plate with a forward pull was designed.After a period of 4 weeks, proper alignment and proximity of the segments were achieved, so that definitive lip closure and plastic reconstruction of the remaining soft tissue defect could be easier performed.

Comparison of Facial Form in Primary Alveolar Bone-Grafted and Nongrafted Unilateral Cleft Lip and Palate Patients: Intercenter Retrospective Study

The purpose of this study was to describe and compare posttreatment craniofacial morphology in samples of complete unilateral cleft lip and palate (CUCLP) patients treated at two leading clinics: The Children's Memorial Hospital Cleft Palate Clinic, Chicago, Illinois, and the Lancaster Cleft Palate Clinic, Lancaster, Pennsylvania. These centers have well-defined treatment protocols that allow the long-term effects on craniofacial form of the following treatment regimes to be contrasted: (1) Chicago--primary alveolar bone grafting, with definitive lip repair at age 4 to 6 months and hard and soft palate repair at 6 to 12 months; and (2) Lancaster--definitive triangular-flap lip repair at 3 months of age, followed by staged surgeries of the hard and soft palates, both completed by 18 months of age, but without primary alveolar bone grafting. Although the Lancaster center now performs secondary alveolar bone grafting, the majority of the patients studied here were treated before this procedure became part of their protocol. Patients were eligible for inclusion if they had no other congenital anomalies and no previous orthodontic treatment. A sample of 43 (24 male, 19 female) CUCLP patients was obtained from the Chicago Center, each of which was then matched to a nongrafted Lancaster CUCLP patient. The matching criteria were age, sex, and sella-nasion distance (to control, at least in part, for size differences). Lateral cephalometric radiographs of these 86 CUCLP patients were traced, digitized, and analyzed. Additionally, all linear data were adjusted to a standard magnification of 8% because the cephalograms from each center featured different enlargements. The Chicago and Lancaster samples had mean posttreatment ages of 10.32 years (SD = 1.96) and 10.40 years (SD = 2.18), respectively. The grafted Chicago group had faces that were on average less maxillary protrusive compared with the nongrafted Lancaster sample; it appeared, however, that the mandible compensated for the maxillary position by downward and backward rotation. As a result, a similar maxillomandibular relationship was noted in both groups, although, in the Chicago group, the lower anterior facial height increased.

Lip adhesion

A lip adhesion is a simple operation that can easily convert a difficult wide complete cleft into a much easier incomplete cleft. Tissue is used from the cleft margins away from the site of the usual incisions. The operation can be done at virtually any age under either local anesthesia with sedation or under general anesthesia. After the adhesion, when the tissues have softened (which is usually in 3 to 4 months), a definitive lip repair can be done with less tension, a more even bony structure, and more easily identified landmarks.

Does Reduced Hospital Stay Affect Morbidity and Mortality Rates Following Cleft Lip and Palate Repair in Infancy?

Insurance carriers affected decisions regarding admissions and length of stay in our hospital in 1987. Charts were reviewed retrospectively to determine whether this affected morbidity and mortality rates following cleft lip and palate operations in infants. Two periods were studied: May of 1983 through April of 1987 (group I) and April of 1987 through May of 1991 (group II). A total of 248 infants with cleft lip and/or palate underwent 398 operations: lip adhesion (74), definitive lip repair (130), and palatoplasty (194). Half were performed in each period. Admission status, length of stay, length of operation, and short-term morbidity were documented. Morbidity included spontaneous and traumatic lip dehiscence, palatal dehiscence, and palatal fistula. Intergroup analysis was performed by the chi-squared method; p < or = 0.05 was statistically significant. In group I, 93 percent of patients were admitted before surgery. In group II, 5 percent were admitted before surgery and 79 percent the day of surgery. Hospital stay decreased nearly 2 days for each operation. There was no statistically significant difference between groups in distribution of operations, length of operations, or morbidity: lip surgery complications (p = 0.263), palatoplasty complications (p = 0.624). Reductions of hospital admissions and length of stay do not affect outcome of cleft lip and palate surgery in infants. The reduction in hospital days is equivalent to a savings of $138,000 (1991 dollars).

Bilateral Cleft Lip: An Unorthodox Management

Successful repair of bilateral cleft lip requires attention to the soft-tissue anomalies of the lip and nose and the hard-tissue defects of the maxilla. An algorithm for the management of the infant with bilateral cleft lip is presented. A multidisciplinary approach that uses lip adhesion and passive alveolar molding plates to set the stage for subsequent definitive lip and columellar reconstruction is discussed. This approach differs from most others because of reliance on the mucosal circulation of the prolabium.