Nasolabial Repair Research Articles

Postoperative Nasal Conformers in Cleft Rhinoplasty: Are They Efficacious?

Lip and nose symmetry the goal of repair of unilateral cleft lip and different preoperative and postoperative treatments have been developed with this purpose. The objective of this study was to compare 2 techniques used for primary cleft lip nose repair. This is an retrospective study between 2 groups of patients with unilateral cleft lip and palate who underwent primary nasolabial repair either with or without postoperative nasal conformers. Data collection was accomplished by evaluation of nasal symmetry through anthropometric measurements under general anesthesia during primary cleft palate repair. Our comparative study did not find a statistically significant difference regarding percentile indexes of nasal asymmetry between the 2 groups. Major revision requirement (>3mm of asymmetry in any of the nose measurements) was observed in 3.84% of nasal conformer group and 4.65% of the group without nasal conformers. The results obtained from this study provides showed that placement of postoperative nasal conformers did not improve nasal symmetry in patients with unilateral cleft lip and palate. Based on these findings and available scientific evidence, definitive conclusions about the effectiveness of these devices on nasal symmetry after unilateral cleft lip nose repair cannot be drawn.

Longitudinal Morphological Changes in the Mucosal Free Margin After Unilateral Cleft Lip Repair.

Weakness of the mucosal free margin is common in secondary cleft lip deformities. However, the incidence is rarely reported after a long-term follow-up. We evaluated the evolution of patient mucosal free margin after primary repair and until the end of growth. Blinded retrospective study (photography and chart reviews). Tertiary care hospital; private practice. Forty-eight patients with unilateral cleft lip with or without cleft palate who underwent primary nasolabial repair between 1996 and 2004 were followed up until their end of growth marked at 18 and 16 years of age for male and female patients, respectively. Primary nasolabial repair using a straight-line closure without a triangular flap on the vermilion was performed; if needed, a revision surgery was performed at 5 years of age (85%). The contour of the mucosal free margin was classified into nodular, smooth, and recessed types at 1, 5, and 10 years and at the end of growth. At 1 year of age, the nodular type was more common (58%). However, the recessed type was more common (75%) at the end of growth. The mucosal free margin continued to change after 10 years of age. At the end of growth, half of the patients with incomplete cleft experienced center weakness, and the others had cleft-side weaknesses. Patients with incomplete clefts showed favorable results at early ages. However, two-thirds of the patients with complete and incomplete clefts showed focal weakness at the end of growth.

The Unilateral Cleft Lip Nasal Deformity: Revisions within 20 Years after Primary Correction.

As patients grow older, the unilateral cleft lip nasal deformity becomes more noticeable than the repaired lip. The authors assessed nasal revisions over 20 years of the senior author's management of unilateral complete cleft lip. One hundred patients who underwent primary two-stage nasolabial correction of unilateral complete cleft lip between 1991 and 2001 were reviewed. The median patient age was 21 years at the time of analysis. Only 13 percent of patients did not require nasal revision after primary nasolabial repair. One to two nasal revisions were undertaken in 65 percent of patients. The extent of nasal maneuvers during primary labial repair was associated with the number of revisions. Recently treated patients had fewer revisions. Female patients were more likely to undergo several revisions. Of patients who had semiopen suspension sutures at primary repair, 61 percent had this maneuver repeated two or more times. In contrast, patients who had closed suspension sutures at primary repair underwent more nasal revisions and later required more nasal maneuvers. Nasal revision before skeletal maturity was significantly associated with another nasal revision after completion of skeletal growth. Twenty-seven percent of patients eventually required an aesthetic or functional rhinoplasty in adulthood. Patients with a severe initial nasal deformity require multiple revisions. Semiopen suspension sutures are associated with fewer revisions. Revision of the nasal cartilages or alar base can often be performed in the intermediate phase, in combination with other operations. Therapeutic, IV.

Interdisciplinary Considerations for Nasolabial Repair During a Global Pandemic.

At the declaration of the global pandemic on March 11, 2020, many hospitals and institutions developed a tiered framework for the stratification and prioritization of elective surgery. Cleft lip and palate repair was classified as low acuity, and nasoalveolar molding (NAM) clinics were closed. Anticipating the consequences of delayed cleft care and the additional burden this would cause families, we reassessed our risk-stratification and perioperative algorithms. We hypothesized we could safely optimize nasolabial repair without burdening our care systems and without increasing COVID-19-related morbidity/mortality. Our multidisciplinary cleft team reevaluated patient selection to maximize surgical impact. Perioperative protocols were adjusted, and COVID-19 preoperative testing was utilized before nasolabial repair and prior to suture removal under anesthesia. Early in the pandemic, unilateral cleft repair was prioritized and successfully completed on 9 patients. There were no complications related to COVID-19. Nasoalveolar molding clinic was reopened after total patient volume was significantly decreased. We offer an approach for surgical management of nasolabial clefts during a global pandemic. Although guidelines have suggested postponing all cleft care, we found that at our dedicated pediatric hospital with low burden of COVID-19 and adequate resources, we could follow a strategy to safely resume cleft care while decreasing burden on our patients' families and care delivery systems.

S9B-02 SESSION 9B: FACE RESEARCH - PART II USING AUGMENTED REALITY TO REMOTELY TEACH CLEFT SURGERY: BUILDING LONG- TERM INTERNATIONAL CAPACITY AND SUSTAINABILITY

Introduction: Building capacity and long-term sustainability for global cleft care requires continued presence. Augmented Reality (AR) is a novel technology that permits a remote yet “hands-on” virtual interactive presence. A 2014 multi-center proof-of-concept investigation demonstrated AR is safe, reliable, and accurate/precise. Here, we investigate AR’s efficacy in building capacity/sustainability of comprehensive cleft care at one international center. Methods: A 12-month AR-based curriculum was designed and approved by the Ministry of Health in Trujillo, Peru. Global Smile Foundation and PROXIMIE, L.L.C. provided logistical/technical partnerships; grant support was provided by CPF and PSF. Three semi-annual site visits engaged Peruvian colleagues in evidence-based didactics, on-site cleft surgery, and familiarization with the AR platform. Each month, AR was used to remotely guide cleft repairs in Trujillo, Peru. Quarterly assessments by Peruvian and U.S. surgeons utilized Lickert Surveys and VAS Questionnaires. Results: Two surgeons were recruited, serving a population of over 3,000,000. Neither had specialized cleft training. Mulliken’s technique for unilateral/bilateral nasolabial repair was taught during site visits and remote sessions. Sustained gains in seven areas of cleft care were demonstrated by self-reporting and by assessment of the remote surgeon. Site visits preferentially augmented capacity for anatomic diagnosis, principles of repair, and intra-operative decision-making. Remote sessions preferentially developed capacity for cleft anthropometry, operative anatomy, and operative efficiency. 18 months after completion of AR-based curriculum, no child with cleft lip required transfer to tertiary care center (Lima, Peru) because of diagnosis or severity of cleft lip; 6 patients were transferred for treatment of additional congenital anomalies. Conclusion: A curriculum combining on-site training and AR-based “hands-on” remote teaching can build sustained capacity of comprehensive cleft care in under-resourced international areas. Specific needs assessments and established partnerships/trust are pre-requisites. We plan to next test the efficacy of an AR-based curriculum in developing sustained international capacity for NasoAlveolar Molding (NAM).

A Foxtail-Shaped Vermilion Flap to Reconstruct the Medial Tubercle in Asymmetric Bilateral Cleft Lip With Contralateral Lesser Form Defect.

There have been few reports addressing asymmetric bilateral cleft lip repair with contralateral lesser form defects. Two studies have described the thin medial tubercle as the most common remaining labial deformity. In this study, we aimed to evaluate the use of a foxtail-shaped vermilion flap to reconstruct the median tubercle in primary repair. A blinded retrospective study of photography and chart review. Shinshu University Hospital, tertiary care. Private practice. Forty-nine patients with asymmetric bilateral cleft lip with lesser form defects treated using a primary "unilateral" repair by the senior author (S.Y.) between 2007 and 2017. The foxtail-shaped vermilion flap was applied at the time of the primary nasolabial repair. This flap is similar to Noordhoff laterally based triangular vermilion flap but with modifications to the shape and length. The body of the flap is wider than the pedicle to add tissue to the center of the vermilion, and the length is sufficiently elongated to reach the lesser side. Lip shape was graded on a 4-point scale when patients were 1 year old. Twenty-two patients were treated with the foxtail-shaped vermilion flap (group A) and 27 patients with Noordhoff triangular vermilion flap (group B). Group A had a better lip shape than group B (P = .006). The foxtail-shaped vermilion flap is useful to reconstruct the median tubercle in asymmetric bilateral cleft lip repair with contralateral lesser form defects.

Clinical Outcomes Utilizing a "Modified Latham" Appliance for Presurgical Infant Orthopedics in Patients With Unilateral Complete Cleft Lip and Palate.

Presurgical infant orthopedic manipulation is utilized prior to cleft lip/nasal repair to facilitate a gingivoperiosteoplasty (GPP) and primary nasolabial repairs. The Latham dentomaxillary advancement appliance uses a screw that must be tightened daily to approximate the cleft segments in unilateral complete clefts. Our cleft center has been utilizing a "modified Latham" appliance since 1987, including an orthodontic elastic power chain to close the gap in a shorter amount of time. We performed a retrospective chart review of all patients undergoing treatment at Johns Hopkins All Children's Hospital (JHACH) with a unilateral complete cleft lip and palate between 1987 and 2017. Patients were identified by the International Classification of Diseases, Ninth Revision code (749.21). The majority of the patients represent the experience of the senior authors (E.R. and R.F.). Two hundred and eighty-one patients with unilateral complete cleft lip/palate were identified. Seventy-five patients were treated with a "modified Latham" appliance prior to their lip repair. The "modified Latham" appliance remained in place on average 20.6 days (range: 4-82), and average hospital stay after placement was 1.18 days. Nearly 96% of patients underwent a successful GPP at the time of nasolabial repair. Modification of the Latham appliance by utilizing an elastic power chain and eliminating the screw allows rapid closure of the alveolar cleft with limited need for adjustments and outpatient visits. Direct approximation of the palatal segments allows successful completion of a GPP in 95.9% of patients with limited dissection.

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

BackgroundFunctional closure of the orbicularis oris muscle and esthetic reconstruction of nasolabial components are impossible in patients with severely deformed premaxilla. Here, we review a surgical strategy for patients with unremedied premaxilla retrospectively.ResultsVomerine ostectomy and premaxillary setback with nasolabial repair were performed in 12 patients with bilateral cleft lip and palate. The mean age of patients was 21.7 months. The extent of ostectomy varied between 3 and 11 mm. There were no serious complications from defective perfusion to the premaxilla or the philtral flap. The follow-up period ranged from 2 to 25 months. Proper positioning of the premaxilla and satisfactory nasolabial esthetics were achieved in all patients.ConclusionsWe performed nasolabial repair after premaxillary setback without jeopardizing the premaxillary segment or the philtral flap. Our surgical strategy could be recommended in poor socio-economic circumstances due to the cost effectiveness of limiting the number of surgeries.

Oronasal Transfixion Suture to Prevent Uplifted Nasal Floor Deformity in Cleft Lip and Palate Patients: A 5-Year Follow-Up.

In unilateral cleft lip and palate, the reconstructed nasal floor is sometimes uplifted regardless of the reconstructive method used. We used a 5-0 absorbable anchoring suture, the oronasal transfixion suture (ONT suture), to fasten the reconstructed nasal floor to the orbicularis oris muscle to prevent this deformity. This study was performed to evaluate the effects of the ONT suture. Blind retrospective study of photography and chart review. Shinshu University Hospital, tertiary care, Nagano, Japan. Private practice. Ninety-three consecutive patients with unilateral complete cleft lip and palate who had undergone primary nasolabial repair in our department and affiliated hospitals between 1999 and 2011 participated in this study. Finally, 45 patients were included. The ONT suture was put in place at the time of primary nasolabial repair. The height of the nasal floor was evaluated on submental view photographs at 5 years old. The ONT suture was applied in 21 patients. The height of the nasal floor on the cleft side was significantly closer to that on the noncleft side with the ONT suture than without the ONT suture ( P = .008). The ONT suture is effective to prevent uplifted nasal floor deformity on the cleft side// in unilateral complete cleft lip and palate at the time of primary nasolabial repair.

Cleft Lip and Palate in CHARGE Syndrome: Phenotypic Features That Influence Management.

Infants with syndromic cleft lip and/or cleft palate (CL/P) often require more complex care than their nonsyndromic counterparts. Our purpose was to (1) determine the prevalence of CL/P in patients with CHARGE syndrome and (2) highlight factors that affect management in this subset of children. This is a retrospective review from 1998 to 2016. Patients with CHARGE syndrome were diagnosed clinically and genetically. Prevalence of CL/P was determined and clinical details tabulated: phenotypic anomalies, cleft types, operative treatment, and results of repair. CHARGE syndrome was confirmed in 44 patients: 11 (25%) had cleft lip and palate and 1 had cleft palate only. Surgical treatment followed our usual protocols. Two patients with cardiac anomalies had prolonged recovery following surgical correction, necessitating palatal closure prior to nasolabial repair. One of these patients was too old for dentofacial orthopedics and underwent combined premaxillary setback and palatoplasty, prior to labial closure. Velopharyngeal insufficiency was frequent (n = 3/7). All patients had feeding difficulty and required a gastrostomy tube. All patients had neurosensory hearing loss; anomalies of the semicircular canals were frequent (n = 3/4). External auricular anomalies, colobomas, and cardiovascular anomalies were also common (n = 8/11). Other associated anomalies were choanal atresia (n = 4/11) and tracheoesophageal fistula (n = 2/11). CHARGE syndrome is an under-recognized genetic cause of cleft lip and palate. Hearing loss and speech and feeding difficulties often occur in these infants. Diagnosis can be delayed if the child presents with covert phenotypic features, such as chorioretinal colobomas, semicircular canal hypoplasia, and unilateral choanal atresia.

Three-Dimensional Analysis of Nasal Symmetry Following Primary Correction of Unilateral Cleft Lip Nasal Deformity.

To evaluate nasal symmetry using three-dimensional photogrammetry following primary tip rhinoplasty with or without an internal splint in patients with unilateral complete cleft lip/palate. We captured three-dimensional images of patients with unilateral complete cleft lip/palate who underwent nasolabial repair by rotation-advancement of the lip and primary tip rhinoplasty, either with or without an internal resorbable splint, and normal control subjects. We assessed nasal symmetry by identifying the plane of maximum symmetry and the root-mean-square deviation between native and reflected surfaces. We imaged 38 controls and 38 subjects with repaired unilateral complete cleft lip/palate (20 with, 18 without an internal splint). Nasal asymmetry root-mean-square deviation clustered between 0.19 and 0.50 mm (median = 0.24 ± 0.08 mm) for controls; whereas, those with repaired unilateral complete cleft lip/palate ranged from 0.4 to 1.5 mm (median = 0.75 ± 0.40 mm). Although root-mean-square deviation ranges overlapped, patients with repaired unilateral complete cleft lip/palate had significantly greater asymmetry than controls (P < .001). We found no difference in asymmetry between patients with or without an internal splint (P = .5). Three-dimensional photogrammetry was used to successfully compare symmetry among different patient and control groups. Although "normal" nasal symmetry was attained in some patients following cleft lip/nasal repair, most had persistent asymmetry compared with normal controls. Placement of a resorbable internal splint did not improve symmetry in patients with unilateral complete cleft lip/palate.

Longitudinal Photogrammetric Analysis of the Columellar-Labial Angle following Primary Repair of Bilateral Cleft Lip and Nasal Deformity.

The changing nasolabial dimensions after repair of bilateral cleft lip and nasal deformity can be documented by anthropometry; however, the columellar-labial angle is rarely measured. This is a study of white patients who had synchronous repair of bilateral cleft lip performed by one surgeon (J.B.M.). The columellar-labial angle was measured on lateral photographs with the subject in neutral head position. Average values for columellar-labial angle at two or more time points were analyzed with a general estimating equation and cubic modeling. Values for complete and incomplete bilateral cleft lips were compared to each other and to Farkas' norms. Direct anthropometric measurements of intraoperative columellar length were compared to the postoperative columellar-labial angle using Pearson correlation analysis. Eighty-five patients were studied (64 complete and 21 incomplete clefts). The average photographic follow-up interval was 10 years (range, 1.8 to 19.5 years). The columellar-labial angle in bilateral complete clefts was significantly greater than in incomplete forms (p = 0.002). Although the angles decreased with time, they remained significantly greater than Farkas' normative values in both cleft groups (all p < 0.05). There was no correlation between the magnitude of columellar lengthening achieved during primary nasal correction and the postoperative columellar-labial angle. An obtuse columellar-labial angle can occur following synchronous nasolabial repair of a bilateral cleft lip, particularly in patients with a complete deformity. Although the angle narrows in time, it remains 1 to 2 SD greater than normal values. Secondary nasal correction may be needed if there is excessive tip rotation after completion of growth and orthognathic surgery. Therapeutic, IV.

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

To analyze indications and outcomes for primary premaxillary setback. Retrospective. Academic children's hospital. All children with bilateral complete cleft lip age ≤2 years of age who had premaxillary setback by one surgeon (1992 to 2011). Twenty-five patients with bilateral complete cleft lip underwent primary premaxillary setback at an average age of 9 months; the mean follow-up was 47 months. There were three indications: failed dentofacial orthopedics (n = 9), delayed referral precluding manipulation (n = 10), and intact secondary alate (n = 6). Of 19 patients with bilateral complete cleft lip/palate, primary setback was combined with nasolabial repair (n = 11), adhesions (n = 2), or palatoplasty (n = 6). Patients who had nasolabial closure and setback were significantly younger than those who had combined palatal closure and setback (6.5 versus 16 months, P = .01). No patient exhibited postoperative premaxillary instability. Serial anthropometry showed similar growth of nasolabial features after both primary setback (n = 9) and active dentofacial orthopedics (n = 35). Primary premaxillary ostectomy and setback permits synchronous bilateral nasolabial-alveolar closure or alveolar-palatal repair in a child with intact secondary palate. This procedure should be considered whenever dentofacial orthopedics cannot be accomplished. Speech is paramount in an older child; setback with palatal closure is scheduled before nasolabial repair. Disturbance of midfacial growth is likely following primary premaxillary ostectomy and setback in patients with bilateral complete cleft lip/palate; however, most already need maxillary advancement. Furthermore, premaxillary setback permits proper primary nasolabial design and construction in appreciation of expected changes with growth.

Outcomes of Primary Unilateral Cheiloplasty in Same-Day Surgical Settings.

BackgroundFinancial, clinical, and psychological considerations have made same-day surgery an attractive option for a variety of procedures. This article aimed to analyse the postoperative results of same-day primary unilateral cleft nasolabial repair.MethodsThis study was performed from 2011 to 2014. Unilateral cleft lip patients fulfilling the inclusion criteria were preoperatively classified as mild, moderate, and severe. All patients underwent same-day surgery and were discharged after satisfying the appropriate clinical criteria, receiving thorough counselling, and the establishment of a means of communication by phone. Postoperative outcomes were assessed and stratified according to preoperative severity and the type of repair.ResultsA total of 423 primary unilateral cleft lip patients were included. Fisher's anatomical subunit approximation technique was the most common procedure, followed by Noordhoff's technique. The postoperative outcome was good in 89.8% of cases, fair in 9.9% of cases, and poor in 0.2% of cases. The complication rate was 1.18% (n=5), and no instances of mortality were observed. The average hospital stay was 7.5 hours, leading to a cost reduction of 19% in comparison with patients who stayed overnight for observation.ConclusionsMild unilateral cleft lip was the most common deformity for which Fisher's anatomical subunit approximation technique was performed in most of the cases, with satisfactory postoperative outcomes. Refinements in the cleft rhinoplasty techniques over the course of the study improved the results regarding cleft nasal symmetry. Single-day primary unilateral cleft cheiloplasty was found to be a cost-effective procedure that did not pose an additional risk of complications.

Immediate fat grafting in primary cleft lip repair

Successful cleft lip repair creates symmetric nasolabial morphology with minimal scar. Fat grafting is used in cosmetic and reconstructive settings to provide contour, condition tissue and aid healing. This study employs immediate fat grafting concurrent with primary cleft nasolabial repair. We hypothesize that simultaneous fat transfer is safe and may optimize the result. This retrospective analysis included a series of consecutive infants who underwent primary cleft lip repair with immediate fat grafting. Demographic and peri-operative details were recorded. Post-operative photographs were analyzed by three blinded reviewers (Al-Omari et al. and Asher-McDade et al.). Kappa statistics were employed to assess inter-rater reliability (Randolph and Watkins MW). 30 children, 37 sides (13 left, 10 right, 7 bilateral; 62% complete, 38% incomplete) who underwent cleft lip repair at Yale were included. 20 underwent nasolabial repair with simultaneous fat grafting. Mean age of repair was 3.5 mo (range 1.5-6.4). Fat was hand suctioned from the thighs (15 left; 2 right; 3 both) with mean yield of 2.1 cc (range 1-5 cc). An average of 1.4 cc (range 0.5-2.5 cc) was injected to the philtrum, vermillion, piriform and ala. No complications were experienced with lip repair, fat harvest or graft injection. Mean follow-up was 24.7 months (range 12.4-60.2 months). Postoperative photographic assessment revealed minimal residual cleft stigmata with inter-rater reliability. Each ordinal score was statistically significant compared fat grafted repairs to those without fat grafting (p < 0.05). Simultaneous fat grafting and cleft lip repair can be performed safely. The augmentation and modulation of scar formation may optimize results. Prospective comparison is necessary to further corroborate our findings. Therapeutic (Level IV).

Current Surgical Management of Bilateral Cleft Lip in North America

This study was undertaken to determine contemporary surgical management of bilateral cleft lip. A survey was sent to North American cleft surgeons. Variables included number of bilateral cleft lip repairs per year, surgical specialty, and methods of nasolabial correction. The authors analyzed possible relationships between surgical specialty/volume and operative techniques. The response rate was 40 percent (241 of 600). Annual bilateral nasolabial repairs per surgeon were as follows: zero to two, 30 percent; three to five, 46 percent; and six or more, 25 percent. For bilateral complete cleft lip, dentofacial orthopedics was used by 71 percent of respondents; synchronous closure was most commonly performed (88 percent); infrequent techniques were preliminary labial adhesions (11 percent) and staged labial closure (1 percent); and 50 percent undertook primary nasal repair. One half of respondents used nostril splinting following primary or secondary nasal correction. For bilateral incomplete cleft lip, 90 percent of surgeons performed synchronous labial repair and 36 percent did primary nasal correction. For both complete and incomplete bilateral cleft lips, high-volume surgeons were more likely to excise prolabial vermilion and use lateral vermilion-mucosal flaps to form the median tubercle. For bilateral asymmetrical cleft lip, 85 percent of surgeons practiced synchronous labial repair and 54 percent used dentofacial orthopedics on the complete side. Synchronous repair was the most frequent method for bilateral cleft lip; one-half of surgeons practiced primary nasal correction. There were no associations between surgical specialty/volume and operative principles or techniques for bilateral nasolabial repair, except for construction of the median tubercle.

Positioning the Caudal Septum During Primary Repair of Unilateral Cleft Lip

Since 1995, the senior surgeon has straightened the deviated anterocaudal septum in all infants undergoing primary repair of unilateral complete cleft lip/palate. A retrospective assessment was done on 17 patients who did not have septal correction and 17 patients who did have septal correction at the time of nasolabial repair. Operative reports were reviewed, and secondary procedures on the nose were documented.Posterior-anterior cephalograms were used to measure septal deviation from the midline, angle of septal deviation, and width of the inferior turbinate on the noncleft side. The angle subtended by the superior and inferior segments of the cartilaginous septum was measured at the point of maximal septal deviation. The uncorrected group had a mean maximal septal deviation from the midline of 5.8 mm compared with 4.1 mm in the corrected group (P < 0.01). The uncorrected group had a mean width of the contralateral inferior turbinate of 12.7 mm compared with 10.2 mm in the corrected group (P < 0.01). The uncorrected group had a mean subtended angle of 137.8 degrees compared with 147.9 degrees in the corrected group (P < 0.01). Positioning the anterior caudal septum during primary repair of unilateral complete cleft lip results in less septal deviation and a smaller contralateral turbinate as documented by posteroanterior cephalometry in adolescence.

Role of orthognathic surgery in assisting double dentition denture in the treatment of secondary deformities of cleft lip and palate: a report of two cases

Introduction: It was generally accepted and further developed by scholars all over the world after the principle of cleft lip and palate team approach treatment had been put forward in the 1930 s. Today, the ‘team approach’ treatment has become the mainstream principle of cleft lip and palate treatment without doubt. However, it takes a longer course of treatment, more referrals, and higher cost. For patients with secondary deformities who have some difficulties in accepting ‘team approach’ treatment, we use a double dentition denture as a treatment alternative, which can correct the maxillary hypoplasia before taking nasolabial repair surgery. But in severe skeletal angle III malocclusion cases (ANB <–4°), as a result of a larger anti-overjet, it is difficult to obtain normal overjet and overbite while doing single dental treatment. In order to create conditions for prosthodontic treatment, we attempt to push mandible backward by mandibular sagittal split ramus osteotomy (SSRO), and then wear the double dentition denture.

Treatment result of oral submucous fibrosis with prediction of coronoid process impingement by self-developed computer program

Purpose: Study the treatment result of oral submucous fibrosis (OSF) and investigate if any correlation between open mouth limitation and coronoid process impingement in the OSF patients. Patients and methods: 32 OSF patient who have received surgical release in the Department of Oral and Maxillofacial Surgery from 1996 June to 2006 June were include in this study. The surgical procedures included scar releasing, bilateral coronoidoctomy, buccal fat pad repair or split-thickness skin graft. A patient was excluded because of using nasolabial repair on one side.

Binderoid complete cleft lip/palate.

A small subset of infants with complete cleft lip/palate look different because they have nasolabiomaxillary hypoplasia and orbital hypotelorism. The authors' purpose was to define the clinical and radiographic features of these patients and to comment on operative management, classification, and terminology. The authors reviewed 695 patients with all forms of incomplete and complete cleft lip/palate and identified 15 patients with nasolabiomaxillary hypoplasia and orbital hypotelorism. All 15 patients had complete labial clefting (5 percent of 320 patients with complete cleft lip/palate), equally divided between bilateral and unilateral forms. The female-to-male ratio was 2:1. Of the seven infants with unilateral complete cleft lip/palate, one had an intact secondary palate and all had a hypoplastic septum, small alar cartilages, narrow basilar columella, underdeveloped contralateral philtral ridge, ill-defined Cupid's bow, thin vermilion-mucosa on both sides of the cleft, and a diminutive premaxilla. Of the eight infants with bilateral complete cleft lip, one had an intact secondary palate. The features were the same as in patients with unilateral cleft, but with a more severely hypoplastic nasal tip, conical columella, tiny prolabium, underdeveloped lateral labial elements, and small/mobile premaxilla. Central midfacial hypoplasia and hypotelorism did not change during childhood and adolescence. Intermedial canthal measurements remained 1.5 SD below normal age-matched controls. Skeletal analysis (mean age, 10 years; range, 4 months to 19 years) documented maxillary retrusion (mean sagittal maxillomandibular discrepancy, 13.7 mm; range, 3 to 17 mm), absent anterior nasal spine, and a class III relationship. The mean sella nasion A point (S-N-A) angle of 74 degrees (range, 65 to 79 degrees) and sella nasion B point (S-N-B) angle of 81 degrees (range, 71 to 90 degrees) were significantly different from age-matched norms ( = 0.0007 and = 0.004, respectively). The ipsilateral central and lateral incisors were absent in all children with unilateral cleft, whereas a single-toothed premaxilla was typically found in the bilateral patients. Several modifications were necessary during primary nasolabial repair because of the diminutive bony and soft-tissue elements. All adolescent patients had Le Fort I maxillary advancement and construction of an adult nasal framework with costochondral or cranial graft. Other often-used procedures were bony augmentation of the anterior maxilla; cartilage grafts to the nasal tip and columella; and dermal grafting to the median tubercle, philtral ridge, and basal columella. Infants with complete unilateral or bilateral cleft lip/palate in association with nasolabiomaxillary hypoplasia and orbital hypotelorism do not belong on the holoprosencephalic spectrum because they have normal head circumference, stature, and intelligence, nor should they be referred to as having Binder anomaly. The authors propose the term cleft lip/palate for these children. Early recognition of this entity is important for counseling parents and because alterations in standard operative methods and orthodontic protocols are necessary.