Cleft Lip and Palate - part 7 docx

Case 5. A complete bilateral cleft and protruding pre- maxilla is shown preoperatively (Fig. 22.5). Treatment consisted of presurgical maxillary orthopedics (Lath- am), followed by bilateral GPPs and lip and nose cor- rection at 6months of age. The columellar lengthen- ing was accomplished by wide dissection of nasal skin from the alar cartilages, removal of intercrural fat,and bilateral McComb sutures. Multiple vestibular efface- ment sutures were passed, and a nasal stent was main- tained for the first postoperative week. The patient is shown at 18months of age, before closure of the palatal cleft. Case 6. A very wide complete bilateral cleft of the lip and palate with a projecting premaxilla and very wide alveolar clefts. Initially treated with presurgical max- illary orthopedics (Fig. 22.6) in preparation for the first surgery where the patient underwent a GPP, clo- sure of the alveolar clefts and closure of the anterior palate.One year later,the patient underwent closure of bilateral cleft palate and revision of the lip and nose using the McComb technique, which is shown. The patient is shown postoperatively 2 months after the final procedure. 468 S.A.Wolfe · R. Ghurani · M. Mejia Fig. 22.5 a–f. a d e f bc Chapter 22 Surgical Treatment of Clefts of the Lip 469 Fig. 22.6 a–k. a d g hi ef bc Case 7. This patient had primary closure from anoth- er surgeon of her incomplete bilateral cleft of the lip using a standard bilateral technique. As the photo- graphs show (Fig. 22.7), she did not have a Cupid’s bow, with a fairly tight upper lip and lacking nasal projection. The patient underwent an iliac bone graft to the right alveolar cleft, an Abbe flap, and a cleft lip rhinoplasty which redefined her Cupid’s bow,gave her more nasal tip projection, and a fuller upper lip. Case 8. A bilateral cleft lip was corrected in another country. The preoperative pictures show the patient following a radial forearm flap performed for a very large palatal defect following orthodontic alignment of the premaxilla (Fig. 22.8). The operative pictures show the fabrication of a complete new alar cartilage framework overlying the native alar cartilages, with a columellar strut and spreader grafts (both septal and conchal cartilage was used). There was no reduction of the nasal dorsum.A dermal fat graft was also placed in the central portion of the upper lip.The postopera- tive pictures were taken at 18months. Case 9. This patient had previous repair of a bilateral complete cleft lip by Dr. Millard and had a columellar elongation with a forked-flap.Patient remained with a slumping of the nasal tip,and irregularities of the alar cartilages (Fig. 22.9). Patient underwent a cleft lip rhinoplasty. This improved his tip projection which involved reconstruction and augmentation of the alar cartilages. The patient is shown 7 months postopera- tively. Case 10. This 6-year-old child underwent one previ- ous palatal operation in Cuba, and two subsequent procedures were performed in this country,leading to loss of all palatal tissue from the hard-soft palate junc- tion to the alveolar ridge. A radial forearm flap was performed along with a lip revision, opening the poorly repaired lip completely and thereby avoiding any other cutaneous incision (Fig. 22.10). The proce- dure was uneventful and the flap had excellent perfu- sion. 470 S.A.Wolfe · R. Ghurani · M. Mejia Fig. 22.6 a–k.(continued) j k Chapter 22 Surgical Treatment of Clefts of the Lip 471 Fig. 22.7 a–g. abc ed g f 472 S.A.Wolfe · R. Ghurani · M. Mejia Fig. 22.8 a–h. abc d fgh e Chapter 22 Surgical Treatment of Clefts of the Lip 473 Fig. 22.9 a–j. b e a f i j h g c d 474 S.A.Wolfe · R. Ghurani · M. Mejia Fig. 22.10 a–g. a de bc fg References 1. Bromley GS, Rothaus KO, Goulian D Jr. Cleft lip: morbidity and mortality in early repair. Ann Plast Surg 1983; 10(3):214–217. 2. Latham RA. Orthopedic advancement of the cleft maxil- lary segment: a preliminary report. Cleft Palate J 1980; 17(3):227–233. 3. Berkowitz S,Mejia M,Bystrik A.A comparison of the effects of the Latham-Millard procedure with those of a conserva- tive treatment approach for dental occlusion and facial aes- thetics in unilateral and bilateral complete cleft lip and palate: part I. Dental occlusion. Plast Reconstr Surg 2004; 113(1):1–18. 4. Pfeifer TM,Grayson BH, Cutting CB. Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: an outcome analysis of costs in the treatment of unilateral cleft alveolus. Cleft Palate Craniofac J 2002; 39(1):26–29. 5. Rosenstein SW, Dabo DV. Primary bone grafting. Presented at the 61st Annual Meeting and Pre-Conference Sympo- sium of the American Cleft Palate/Craniofacial Association. Mar.15,2004. 6. McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10-year review. Plast Reconstr Surg 1985; 75(6):791–799. 7. Millard DR, Jr. Cleft craft.Vol.I.Boston: Little,Brown; 1976. p.264. 8. Millard DR Jr.Cleft craft.Vol. II.Boston: Little,Brown; 1975. p.373–374. 9. Berkowitz S. Timing of palatal closure should not be based on age alone.Cleft Palate J 1986; 23(1):69–70. 10. Bardach J, Salyer K. Surgical techniques in cleft lip and palate surgery. Chicago: Year Book Medical Publishers; 1986. 11. Furlow LT,Jr.Flaps for cleft lip and palate surgery.Clin Plast Surg 1990; 17(4):633–644. 12. Cordeiro PG,Wolfe SA. The temporalis muscle flap revisit- ed on its centennial: advantages,newer uses,and disadvan- tages. Plast Reconstr Surg 1996; 98(6)980–987. 13. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery musculomuccosal (FAMM) flap. Plast Reconstr Surg 1992; 90(3):421–429. 14. Marshall D, Amjad I,Wolfe SA. The use of a radial forearm flap for deep central midfacial defects. Plast Reconstr Surg 2003; 111:56–64. 15. Wolfe SA, Berkowitz S. Orthodontic analysis and treatment planning in patients with craniofacial anomalies. In Plastic surgery of the facial skeleton. Boston: Little,Brown; 1989. 16. Nylen B, Korlor B, Arnander C, Leanderson R, Barr B, Nordin KK. Primary early bone grafting in complete clefts of the lip and palate. Scand J Plast Reconstr Surg 1974; 8:79. 17. Millard DR Jr, McLaughlin CA.Abbe flap on mucosal pedi- cle.Ann Plast Surg 1979; 3(6):544–548. 18. Polley JW, Figueroa AA. Maxillary distraction osteogenesis with rigid external distraction. Atlas Oral Maxillofac Surg Clin North Am 1999; (1):15–28. 19. Limberg, A. Neue Wege in der radikalen Uranoplastik bei angeborenen Spaltenderformationen: Osteotomia inter- laminaris und pterygomaxillaris, resectio marginis fora- minis palatini und neue Plaettchennaht. Fissura ossea oc- culta und ihre Behandlung. Zentralbl Chir 1927; 54:1745. Chapter 22 Surgical Treatment of Clefts of the Lip 475 23A.1 Protraction of the Maxilla Using Orthopedics Children with complete unilateral and bilateral cleft of the lip and palate are usually at risk for poor facial growth. They are prone to developing midfacial retru- sion related to maxillary hypoplasia or growth retar- dation secondary to excessive palatal scarring. Usual- ly, this results in an anterior dental crossbite or severely rotated maxillary incisors which may occlude in a tip-to-tip relationship with the mandibular inci- sors. Depending on the age of the patient and the extent of midfacial maldevelopment, some of these early problems can be corrected using midfacial or- thopedic protraction forces which increase growth at the circumaxillary sutures as they are repositioned anteriorly (Fig.23A.1). When all else fails, midfacial surgery is available. Some of the earlier work in this field, which en- couraged a rethinking of the use of orthopedic forces for the correction of midfacial retrusion, includes Hass [1], Delaire [2], Delaire et al. [3–5, 9], Irie and Nakamura [6], Ranta [7], Subtelny [8], Friede and Lennartsson [10], Sarnas and Rune [11], Berkowitz [12], Tindlund [13], Nanda [14], and Molstad and Dahl [15].More recently this area has been influenced by the work of Tindlund et al. [6–18] and Buschang et al. [19]. Earlier attempts by Kettle and Burnapp [20] in which anteriorly directed extraoral forces were de- rived from chin caps were relatively unsuccessful. Facial mask therapy seems to offer better control and a wider range of force application. In many cases, in the mixed dentition, palatal ex- pansion using fixed orthodontic appliances was applied simultaneously with protraction to correct a bilateral crossbite and create a more favorable condi- tion for midfacial growth and development. Prior to the use of orthopedic forces, many stan- dard orthodontic treatments designed to move the Protraction Facial Mask Samuel Berkowitz 23A Fig. 23A.1 a,b. Protraction of the maxillary complex using orthopedic forces. The maxilla articulates with nine bones: two of the cranium, the frontal and ethmoid, and seven of the face, viz., the nasal zygomatic, lacrimal, inferior and nasal concha, palatine, vomer and its fellow of the opposite side. Sometimes it articulates with the orbital surface, and sometimes with the lateral pterygoid plate of the sphenoid. Illustration showing how protraction forces applied to the maxilla depend on the disarticulation and growth at all the dependent sutures.(Cour- tesy of E.Genevoc) a b dentition to correct a Class III malocclusion due to midfacial retrusion in the absence of mandibular prognathism failed. Orthodontic forces applied to the teeth by Class III elastics would not displace the max- illa; at best they would flare the maxillary incisors without creating an adequate incisor overbite and ax- ial inclination. This treatment was found to be unsat- isfactory and soon fell out of favor. Since 1975 Berkowitz has been using a modified protraction facial mask originally popularized by De- laire et al. [3] (Figs. 23A.2–23A.4). It has been very successful in controlling the direction of protruding forces without causing severe sore spots on the chin or forehead. He has found that protraction forces do not modify the direction of mandibular growth as Delaire et al. [3] claimed, but by increasing midfacial height, the mandible is repositioned downward and back- ward with growth to make the patient’s maxillary retrusion appear less evident. Protraction forces (350–450gm per side) must be intermittent (the mask is worn only for 12 h perday), and directed downward and forward from a hook lo- cated mesial to the maxillary cuspids. Pulling down- ward from the molars should be avoided because it will tilt the palatal plane downward in the back by ex- truding the molars and thus opening the bite. When the midfacial height is deficient, protraction forces need to be modified to increase vertical as well as an- terior growth. This is done by using more vertically directed elastic forces. Berkowitz has found 350–450 gm of force per side to be adequate in most instances,but there are rare in- stances when the elastic force needs to be reduced to prevent sore spots at the chin point. Friede and Lennartsson [10] have used protraction forces be- tween 150 to 500gm per side. Ire and Nakamura [6] have used 400gm per side, Roberts and Subtelny [21] 670 gm, Sarnas and Rune [11] 300–800 gm, and Tind- 480 S. Berkowitz Fig. 23A.2. a Frontal and b lateral views of a Delaire-style pro- traction facial mask. Padded chin and forehead rests distribute reaction forces of 350–400 gm per side equally to both areas. Elastics are attached to hooks placed on the arch wire between the cuspids and lateral incisor. c Intraoral view of edgewise rec- tangular arch with hooks for protraction elastics. d, e, f Delaire- style protraction facial mask used with a fixed labial-palatal wire framework. Elastic forces of 350–400 gm per side can still be used with this intraoral framework a d bc ef [...]... unilateral cleft lip and palate Part 7: An overview of treatment and facial growth Cleft Palate J 19 87; 24 :71 77 8 Semb G A study of facial growth in patients with unilateral cleft lip and palate treated by the Oslo CLP team Cleft Palate Craniofac J 1991a; 28:1–21 9 Tindlund RS, Rygh P, Bøe OE Orthopedic protraction of the upper jaw in cleft lip and palate patients during the deciduous and mixed dentition... arch in subjects with and without cleft palate Cleft Palate J 1989; 26:21–30 36 Harvold E Cleft lip and palate: morphologic studies on the facial skeleton Am J Orthod 1954; 40:493–506 37 Subtelny JD The importance of early orthodontic treatment in cleft palate planning Angle Orthod 19 57; 27: 148– 158 38 Ogidan O, Subtelny JD Eruption of incisor teeth in cleft lip and palate Cleft Palate J 1983; 20:331–341... in unilateral and bilateral cleft lip and palate patients Cleft Palate Craniofac J 1993a; 30:208–221 12 Semb G A study of facial growth in patients with bilateral cleft lip and palate treated by the Oslo CLP team Cleft Palate Craniofac J 1991b; 28:22–39 13 Rygh P, Tindlund RS Orthopaedic expansion and protraction of the maxilla in cleft palate patients - A new treatment rationale Cleft Palate J 1982;... therapy in children with cleft lip and palate Eur J Orthod 19 87; 9:3211–3215 16 Tindlund RS, Rygh P Maxillary protraction: different effects on facial morphology in unilateral and bilateral cleft lip and palate patients Cleft Palate Crainofac J 1993; 30:208–221 17 Tindlund RS, Rygh P, Boe OE Orthopedic protraction of the upper jaw in cleft lip and palate patents during the deciduous and mixed dentition... postero-anteriorer Richtung unter Verwendung der orthopädischen Maske Forttschr Kieferorthop 1 978 ; 39: 27 40 10 Friede H, Lennartsson B Forward traction of the maxilla in cleft lip and palate patients Eur J Orthod 1981; 3:21–39 11 Sarnas K-V, Rune B Extraoral traction to the maxilla with face mask: a follow-up of 17 consecutively treated patients with and without cleft lip and palate Cleft Palate J 19 87; ... grafting of alveolar clefts: a surgical/orthodontic treatment enabling a non-prosthodontic rehabilitation in cleft lip and palate patients Scand J Reconstr Surg 1981; 15:1 27 23 Bergland O, Semb G, Abydholm F, Borchgrevink H, Eskeland G Secondary bone grafting and orthodontic treatment on patients with bilateral complete clefts of the lip and palate Ann Plast Surg 1986; 17: 460– 471 485 23B Protraction... American cleft palate- craniofacial association Parameters for evaluation and treatment of patients with cleft lip/ palate or other craniofacial anomalies Cleft Palate Craniofac J 1993; 30 (Suppl 1) 40 Bergland O, Semb G, Åbyholm FE Elimination of the residual alveolar cleft by secondary bone grafting and subsequent orthodontic treatment Cleft Palate J 1986; 23: 175 –205 41 Schjelderup H, Johnson GE A six-year... growth and development Cleft Palate Craniofac J 1993a; 39:182–194 18 Tindlund RS, Rygh P, Boe OE Intercanine widening and sagittal effect of maxillary transverse expansion in patients with cleft lip and palate during the deciduous and mixed dentitions Cleft Palate Craniofac J 1933b; 30:195–2 07 19 Buschang PH, Porter C, Genecov E, Genecov D Face mask therapy of preadolescents with unilateral cleft lip and. .. in complete clefts of the lip and palate, a Millard lip closure is performed at 3 months combined with a single-layer vomerplasty for closure of the anterior part of the palate The soft palate and isolated palatal clefts are closed at 12 months using a von Langenbeck technique Alveolar bone clefts are left open until secondary bone grafting at 8–11 years of age Between 1 971 and 1986, the lip closure... complete clefts of the lip and palate is dependent on the prevailing treatment philosophy, clinical skills, and the interaction of the Cleft Lip and Palate (CLP)/Craniofacial Team The orthodontist is mainly concerned with the achievement of normal long-term facial growth and development, based on his or her ability to recognize, prevent, and treat dentofacial anomalies Quality assurance and the cost-effectiveness . mask: a follow-up of 17 consecutively treated patients with and without cleft lip and palate. Cleft Palate J 19 87; 24:95–103. 12. Berkowitz S. Some questions, a few answers in maxilla- mandibular. unilateral and bilateral cleft lip and palate patients. Cleft Palate Crainofac J 1993; 30:208–221. 17. Tindlund RS,Rygh P,Boe OE.Orthopedic protraction of the upper jaw in cleft lip and palate patents. treatment en- abling a non-prosthodontic rehabilitation in cleft lip and palate patients. Scand J Reconstr Surg 1981; 15:1 27. 23. Bergland O, Semb G, Abydholm F, Borchgrevink H, Eske- land G. Secondary