Effect of Presurgical Nasoalveolar Molding on Nasal Symmetry in Unilateral Complete Cleft Lip/Palate Patients after Primary Cheiloplasty without Concomitant Nasal Cartilage Dissection: Early Childhood Evaluation.

OBJECTIVE: The objective of this study was to assess the efficacy of presurgical nasoalveolar molding (PNAM) on long-term nasal symmetry and shaping after primary cheiloplasty in patients with unilateral complete cleft lip/palate (UCL/P). DESIGN: This was a two-group, parallel, retrospective, randomized clinical trial. SETTING: The setting for this study was the Chang Gung Craniofacial Center in Taoyuan, Taiwan. PATIENTS: Patients were divided into one of the following two groups: infants with UCL/P who underwent PNAM (PNAM group, n = 42) and infants with UCL/P who did not undergo PNAM (non-PNAM group, n = 42). INTERVENTIONS: Interventions included PNAM and primary cheiloplasty without nasal cartilage dissection. MAIN OUTCOME MEASURES: In this study, 4- to 5-year postoperative full-face and submental oblique photographs were taken of all patients and scored from 1 to 5 points by 10 medical evaluators. The scores were statistically analyzed using repeated-measures analysis of variance, and P < .05 was considered to represent statistical significance. RESULTS: After 1 to 3 months of PNAM but before primary cheiloplasty, the displaced nasal and alveolar cartilage showed obvious improvement. However, the scores in the PNAM and non-PNAM groups at 4 to 5 years postoperatively were 66.62 ± 14.25 and 66.31 ± 15.08, respectively. There was no significant difference between the two groups ( F = 0.009, P = .923). CONCLUSION: PNAM as an early-stage adjunctive therapy for nasal deformity correction is beneficial before primary cheiloplasty, but it is insufficient to maintain long-term nostril symmetry after primary cheiloplasty without nasal cartilage dissection.

The characteristics and distribution of dental anomalies in patients with cleft.

BACKGROUND: Dental anomalies associated with different severities of cleft lip and palate have been rarely reported. This retrospective study investigates the characteristics of dental anomalies associated with different types of cleft, and compares the dental anomaly traits based on sex and severity of cleft. METHODS: Cleft patients born in 1995 with qualified diagnostic records from 7 to 11 years were included for evaluation. Records were retrieved from database of Chang Gung Craniofacial Center, including panoramic radiographs and intraoral photographs. In total, 196 patients with complete records were included in the evaluation. This study compares the dental anomalies associated with each type of cleft. RESULTS: The frequency of dental anomalies in the maxillary incisor area in the cleft palate (CP) group (20%) was significantly lower than that in other groups. The frequency of missing maxillary lateral incisors (MLIs) increased as the cleft severity increased. Supernumerary teeth and missing lower incisors exhibited the opposite trend. No sexual dimorphism appeared in terms of the frequencies of peg laterals and missing MLIs. The distribution patterns of missing MLIs and peg laterals in males, but not in females, were consistent for the three types of unilateral clefts. CONCLUSION: Regarding the characteristics of dental anomalies among the three unilateral clefts, missing MLIs, supernumerary teeth, and missing lower incisors were found to be related to cleft severity. The maxillary lateral incisor was the most affected tooth in the cleft area. The frequency of missing MLIs and peg laterals was not sexual dimorphic, but the distribution pattern was different between the sexes.

Facial nerve palsy after sagittal split ramus osteotomy of the mandible: mechanism and outcomes.

PURPOSE: Facial nerve palsy after sagittal split ramus osteotomy of the mandible (SSRO) is a rare, but serious, complication. The aim of the present study was to evaluate the incidence of this complication, the possible causative mechanisms, its subsequent management, and eventual outcomes. PATIENTS AND METHODS: All patients who underwent SSRO of the mandible at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan, from 1981 to 2008 were included in the present study. The patients reported as having postoperative facial nerve paralysis were identified and reviewed. RESULTS: A total of 3,105 patients had undergone bilateral SSRO (6,210 sagittal splits). Of these 3,105 patients, 6 were reported as having unilateral facial nerve palsy postoperatively, for an incidence of 0.1%. One case was diagnosed as Bell's palsy. None of the patients with postoperative facial nerve palsy required surgical intervention, but all received physical therapy and medications. Complete recovery was obtained without sequela in all but 1 patient, who had incomplete frontal branch recovery. CONCLUSIONS: Most facial nerve palsies that occur after SSRO of the mandible result from neurapraxia or axonotmesis, possibly from nerve compression or traction. Complete recovery can be expected in most cases, and conservative management without surgical exploration is recommended.

Surgical repair for macrostomia: significance of Z-plasty limb directions.

The objective of this study was to determine whether the direction of Z-plasty limbs incorporated into the surgical repair for macrostomia had a significant influence on the quality of the resultant scar. A total of 41 patients who underwent macrostomia repair by means of the same technique, and who had a follow up period of at least 2 years, were retrospectively reviewed through postoperative photographs and medical records. Quality of scar, lip symmetry, and commissure shape and thickness were recorded. Our results showed that a more favorable scar would be achieved in the medial limb of the Z-plasty if it was planned parallel to relaxed skin tension lines (P < 0.05). An unfavorable scar would be more likely if the medial limb of the Z-plasty was made in a horizontal direction or perpendicular to relaxed skin tension lines (P < 0.05). The quality of scar in both the central and lateral limbs of the Z-plasty was not significantly influenced by their direction.

Strategies for achieving long-term effective outcome in cleft missions: the Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital.

The Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital have partnered to deliver cleft programs to developing nations still in need of adequate cleft care. The lessons learnt through the development of the Chang Gung Cleft and Craniofacial Center from humble beginnings to its current international standing have enabled insights into devising key strategies for achieving long-lasting and compounding outcome in cleft missions. Close collaboration with local governing and health authorities, as well as establishment of ongoing support from charitable organizations that share similar philosophies, is an essential component to creating growth and sustainability of a cleft program. Identification of local "seed" physicians and key personnel, and their subsequent training at a major cleft center, is pivotal to the establishment of local cleft centers and cleft foundations that would ultimately empower local health care providers' autonomy in delivering the highest standard of care to patients with cleft in their own country.

Management of velopharyngeal insufficiency in the presence of enlarged tonsils: comparing a one-stage versus two-stage treatment result.

Alterations in velopharyngeal function after removal of enlarged tonsils were noted. However, the changes varied from previous reports. The purposes of this study were to examine the effect of tonsillectomy on velopharyngeal function and to look for proper management of velopharyngeal insufficiency in the presence of enlarged tonsils. Thirty patients who received tonsillectomy at one craniofacial centre were reviewed. The influence of tonsillectomy on velopharyngeal function was examined and correlations to nasopharyngoscopic or videofluoroscopic findings were made. The outcomes between simultaneous and staged tonsillectomy and velopharyngeal surgery were compared. Tonsillectomy was found to either improve or impair velopharyngeal function in a small proportion of patients; however, it did not alter the surgical management of velopharyngeal insufficiency. Nasopharyngoscopic or videofluoroscopic findings did not predict the influence of tonsillectomy on velopharyngeal function. Finally, simultaneous tonsillectomy and velopharyngeal surgery had an efficacy and complication rate comparable to that of the staged approach.

Comparison of outcomes of velopharyngeal surgery between the inferiorly and superiorly based pharyngeal flaps.

BACKGROUND: Pharyngeal flaps have been widely used for the correction of velopharyngeal incompetence. The aim of this study was to compare the outcomes of velopharyngeal surgery between those who received the superiorly and inferiorly based pharyngeal flaps. METHODS: A retrospective review of medical records of patients with cleft palates who received pharyngeal flap surgery for the correction of velopharyngeal incompetence at one craniofacial center was performed. The superiorly based flaps were elevated and inset using the fish-mouth method. The inferiorly based flaps were sutured to the soft palate where a distally based mucosa flap was turned over to cover the raw surface of the flap pedicle. The velopharyngeal functions were categorized as adequate, marginal, or inadequate. Complications associated with the operation were documented. Statistical comparisons between the two groups were made. RESULTS: There were 65 patients in each group. No statistically significant differences were found for sex distribution and age at operation. The outcomes of the velopharyngeal surgery were better in the group of patients who received the inferiorly based pharyngeal flaps (p = 0.030). The complications were not significantly different between the two groups, and were all relatively mild. CONCLUSION: The inferiorly based pharyngeal flap was more effective than the superiorly based pharyngeal flap for the correction of velopharyngeal incompetence. A probable explanation may be the fibrotic changes and scar contracture occurring in the pedicle of the superiorly based pharyngeal flap that may have impaired the velopharyngeal closure.

Long-term follow-up after maxillary distraction osteogenesis in growing children with cleft lip and palate.

OBJECTIVE: To evaluate the changes in maxillary position after maxillary distraction osteogenesis in six growing children with cleft lip and palate. DESIGN: Retrospective, longitudinal study on maxillary changes at A point, anterior nasal spine, posterior nasal spine, central incisor, and first molar. SETTING: The University Hospital Craniofacial Center. MAIN OUTCOME MEASURE: Cephalometric radiographs were used to measure the maxillary position immediately after distraction, at 6 months, and more than 1 year after distraction. RESULTS: After maxillary distraction with a rigid external distraction device, the maxilla (A point) on average moved forward 9.7 mm and downward 3.5 mm immediately after distraction, moved backward 0.9 mm and upward 2.0 mm after 6 months postoperatively, and then moved further backward 2.3 mm and downward 6.8 mm after more than 1 year from the predistraction position. CONCLUSION: In most cases, maxilla moved forward at distraction and started to move backward until 1 year after distraction, but remained forward, as compared with predistraction position. Maxilla also moved downward during distraction and upward in 6 months, but started descending in 1 year. There also was no further forward growth of the maxilla after distraction in growing children with clefts.

Progressive changes of columella length and nasal growth after nasoalveolar molding in bilateral cleft patients: a 3-year follow-up study.

BACKGROUND: The purpose of this study was to assess the progressive changes of columella length and nasal growth after presurgical nasoalveolar molding and primary cheiloplasty in bilateral complete cleft lip-cleft palate infants. METHODS: Twenty-two consecutive complete bilateral cleft lip-cleft palate infants were included. All of them underwent nasoalveolar molding for columella lengthening and retraction of the premaxilla for 3 to 4.5 months before primary cheiloplasty. Standard 1:1 basilar photographs were taken before and after nasoalveolar molding, 1 week after cheiloplasty, and yearly for 3 years. Nasal height and width were measured directly on the photographs. RESULTS: The results revealed that columella length was significantly lengthened after nasoalveolar molding and was further improved after primary cheiloplasty. The columella decreased in length slightly in the first and second years postoperatively and started to increase in length slightly in the third year postoperatively, whereas the rest of the nose grew significantly in height year by year. This consequently appeared as relapse of columella length. The shortage of the columella length was 1.9 mm. CONCLUSIONS: Both presurgical nasoalveolar molding and primary cheiloplasty lengthened the columella in bilateral cleft lip-cleft palate patients. However, there was a relative relapse in columella length because of the differential growth between the columella and the rest of the nose in the first and second years postoperatively.

Bilateral sagittal split osteotomy for correction of mandibular prognathism: long-term results.

PURPOSE: To identify the long-term maxillomandibular changes after surgical correction of mandibular prognathism using bilateral sagittal split osteotomy (BSSO). PATIENTS AND METHODS: Twenty patients who underwent BSSO to setback the mandible and had cephalometric radiographs taken preoperatively and postoperatively at 6 weeks, 1 year, and long-term follow-up (mean, 28 months). The cephalograms were traced and measured to determine the operative and postoperative changes. Correlation analyses were performed to see the relationship between the magnitude of setback and the amount of long-term postsurgical change at B point and pogonion. RESULTS: The mean surgical setback was 8.2 mm at B point and 8.8 mm at pogonion. The mean long-term horizontal relapse was 2.3 mm (28.0%) at B point and 3.0 mm (34.1%) at pogonion. Out of 20 patients, 12 (60.0%) relapsed horizontally greater than 2 mm at B point and 13 (65.0%) at pogonion. The mean vertical surgical changes showed downward displacement of B point (2.3 mm) and pogonion (2.0 mm). The mean long-term vertical relapse was 1.6 mm (69.6%) at B point and 1.7 mm (85.0%) at pogonion. CONCLUSION: There was no correlation between the magnitude of setback and the amount of relapse at B point and pogonion. However, there was significant correlation between the magnitude of vertical, downward surgical displacement and the amount of vertical relapse at B point and pogonion. The majority of the maxillofacial changes occurred within 1 year postoperatively.

Orthopedic intrusion of premaxilla with distraction devices before alveolar bone grafting in patients with bilateral cleft lip and palate.

Surgical repositioning of the downward displaced premaxilla in bilateral cleft lip and palate patients remains a controversial and perplexing issue because of its detrimental effects on the growth of the premaxilla. The purpose of this prospective clinical study was to introduce and evaluate the treatment results of an innovative technique for nonsurgically intruding the downward displaced premaxilla. Eight consecutive cases of bilateral cleft lip and palate at the age of mixed dentition were included for the correction of their premaxillary deformities. A pair of intraoral tooth-borne distraction devices was used for the orthopedic intrusion. Serial lateral and posteroanterior cephalometric radiographs were taken periodically for evaluating the growth of the premaxilla 1 year before the intrusion, changes during the intrusion, and growth/relapse up to 1 year after the intrusion. There was no overgrowth of the premaxilla or overeruption of the maxillary incisors during the 1-year observing period before the orthopedic intrusion. The treatment results revealed that the downward displaced premaxillae were all corrected within 1 month. Cephalometrically, 46 percent of the correction resulted from a true orthopedic intrusion and another 54 percent from a dentoalveolar effect in which the maxillary incisors were intruded and the premaxillary dentoalveolus was shortened. The cephalometric evaluations also implied that what occurred during the orthopedic intrusion was mostly the sutural contraction osteogenesis/osteolysis in the vomeropremaxillary suture combined with slightly mechanical upward displacement of the vomeronasal septum complex and nasal bones. The orthopedic intrusion of the premaxilla with distraction devices is an effective nonsurgical method for correcting the downward displaced premaxilla before alveolar bone grafting in patients with bilateral cleft lip and palate, and the results remained stable after 1 year.

Comparison of obstructive sleep apnea syndrome in children with cleft palate following Furlow palatoplasty or pharyngeal flap for velopharyngeal insufficiency.

OBJECTIVE: To evaluate the incidence and severity of obstructive sleep apnea syndrome (OSAS) in patients with cleft palate having a Furlow palatoplasty or pharyngeal flap for correction of velopharyngeal insufficiency (VPI). PATIENTS: A total of 48 nonsyndromic children with repaired cleft palate with VPI were enrolled in the study. Twenty of the children had a Furlow palatoplasty (F group) and 28 children had a pharyngeal flap (P group) for correction of VPI. INTERVENTIONS: An overnight polysomnography evaluation was done to evaluate the incidence and severity of OSAS 6 months or more postoperatively. MAIN OUTCOME MEASURES: Symptoms of OSAS, respiratory disturbance index (RDI), oxyhemoglobin desaturation index (DI), and sleep stages were measured. RESULTS: In the P group, the mean percentage of stage 2 sleep was lower than the F group (p <.05). The mean RDI and DI were larger in the P group, compared with the F group (p <.001). The incidence and severity of OSAS were higher in the P group, compared with the F group (p <.001 and p = 0.05, respectively). CONCLUSIONS: A Furlow palatoplasty should be used in deference to a pharyngeal flap whenever possible on the basis of the preoperative evaluation of VPI because of the decreased incidence and severity of OSAS.

Correction of facial asymmetry with multiplanar mandible distraction: a one-year follow-up study.

OBJECTIVE: To assess the effectiveness of multiplanar mandibular distraction by evaluating the treatment effect and 1-year stability, measuring changes on the affected and nonaffected sides, and evaluating correction of the occlusal plane and oral commissure cant. PATIENTS AND METHOD: Eleven patients aged 5 to 9.4 years (mean 6.7 years ) who underwent unilateral multiplanar mandibular distraction were included, 10 with hemifacial microsomia and one temporomandibular joint ankylosis. Intermaxillary elastics were applied to intraoral dental devices during and after distraction until bony consolidation and occlusal interdigitation were achieved. Radiographs were taken and measured before distraction, after vertical distraction, after completion of distraction, and 1 year after treatment. Frontal facial photographs were obtained to analyze the changes in the position of the oral commissure. RESULTS: The facial profile was improved by sagittal mandibular advancement. Although the facial height increased 6.6 mm during vertical distraction, with a net gain of 5.8 mm in follow-up, the mandibular plane angle was maintained. The affected mandibular length increased 8.3 mm after distraction and remained unchanged after 1 year. Ramus height increased 12.7 mm after distraction and relapsed 3.8 mm at follow-up (30%). The affected body length demonstrated postoperative growth of 3.1 mm. Correction of the chin deviation was 9.8 mm after distraction and relapsed 1.6 mm (16.3%) after 1 year. Canting of the occlusal plane and oral commissure was corrected and remained stable. CONCLUSION: Multiplanar mandibular distraction is an effective treatment for correcting facial asymmetry in young children. The 1-year follow-up revealed that the new sagittal jaw relation and mandibular body length were stable, and the achieved occlusal interdigitation was well maintained. However, the ramus height and chin deviation demonstrated some relapse.

Ex vivo gene therapy in autologous critical-size craniofacial bone regeneration.

In therapeutic bone repairs, autologous bone grafts, conventional or vascularized allografts, and biocompatible artificial bone substitutes all have their shortcomings. The bone formed from peptides [recombinant human bone morphogenetic proteins (BMPs)], demineralized bone powder, or a combination of both is small in size. Tissue engineering may be an alternative for cranial bone repair. In this study, the authors developed an animal model to test the hypothesis that replication-defective, adenovirus-mediated human BMP-2 gene transfer to bone marrow stromal cells enhances the autologous bone formation for repairing a critical-size craniofacial defect. The mesenchymal stromal cells of miniature swine were separated from the iliac crest aspirate and expanded in monolayer culture 1 month before implantation. The cultured mesenchymal stromal cells were infected with recombinant, replication-defective human adenovirus BMP-2, 7 days before implantation. Bilateral 2 x 5-cm2 cranial defects were created, leaving no osteogenic periosteum and dura behind. Mesenchymal stromal cells at 5 x 10(7)/ml were mixed with collagen type I to form mesenchymal stromal cell/polymer constructs. Mesenchymal stromal cells used for the control site were infected with adenovirus beta-Gal under the same conditions. After 6 weeks and 3 months, 10 miniature swine were euthanized and the cranium repair was examined. Near-complete repair of the critical-size cranial defect by tissue-engineered mesenchymal stromal cell/collagen type I construct was observed. The new bone formation area (in square centimeters) measured by three-dimensional computed tomography demonstrated that the improvement from 6 weeks to 3 months was significantly greater on the experimental side than on the control side (2.15 cm2 versus 0.54 cm2, p < 0.001) and significantly greater at 3 months than at 6 weeks (2.13 cm2 versus 0.52 cm2, p < 0.001). The difference between the experimental and control groups was significant at 3 months (mean difference, 2.13 cm2; p < 0.001). The maximal compressive strength of the new bone was similar to that of the normal cranial bone when evaluated by biomechanical testing (cranium bone versus tissue-engineered bone, 88.646 +/- 5.121 MPa versus 80.536 +/- 19.302 MPa; p = 0.227). Adenovirus was absent from all constructs by immunochemical staining at 6 weeks and 3 months after implantation. The successful repair of cranial defects in this experiment demonstrates the efficacy of the integration of the autologous stem cell concept, gene medicine, and polymers in producing tissue-engineered bone.

Programmed database system at the Chang Gung Craniofacial Center: part II--digitizing photographs.

BACKGROUND: The archival tools used for digital images in advertising are not to fulfill the clinic requisition and are just beginning to develop. The storage of a large amount of conventional photographic slides needs a lot of space and special conditions. In spite of special precautions, degradation of the slides still occurs. The most common degradation is the appearance of fungus flecks. With the recent advances in digital technology, it is now possible to store voluminous numbers of photographs on a computer hard drive and keep them for a long time. METHODS: A self-programmed interface has been developed to integrate database and image browser system that can build and locate needed files archive in a matter of seconds with the click of a button. This system requires hardware and software were market provided. RESULTS: There are 25,200 patients recorded in the database that involve 24,331 procedures. In the image files, there are 6,384 patients with 88,366 digital pictures files. From 1999 through 2002, NT400,000 dollars have been saved using the new system. CONCLUSION: Photographs can be managed with the integrating Database and Browse software for database archiving. This allows labeling of the individual photographs with demographic information and browsing. Digitized images are not only more efficient and economical than the conventional slide images, but they also facilitate clinical studies.

Longitudinal follow-up of obstructive sleep apnea following Furlow palatoplasty in children with cleft palate: a preliminary report.

OBJECTIVE: To longitudinally investigate the incidence and severity of obstructive sleep apnea (OSA) following Furlow palatoplasty for velopharyngeal insufficiency (VPI) in children with cleft palate. SUBJECTS: Ten children, six boys and four girls, mean age 5.1 years, at Furlow palatoplasty. DESIGN: Prospective analysis. MAIN OUTCOME MEASURES: Overnight polysomnographic studies were used to determine the incidence and severity of sleep apneas 1 day prior to Furlow palatoplasty, 1 week postoperatively, and approximately 3 and 6 months postoperatively. RESULTS: None of the patients suffered OSA prior to Furlow palatoplasty. A high incidence of mild OSA (100%) occurred during the early postoperative period (p <.001) but resolved within 3 months in all but two patients (20%). Only one OSA (10%) persisted 6 months postoperatively. CONCLUSIONS: Furlow palatoplasty for VPI in children with cleft palate might induce temporary and mild OSA.

Incidence and severity of obstructive sleep apnea following pharyngeal flap surgery in patients with cleft palate.

OBJECTIVE: To investigate the incidence and severity of obstructive sleep apnea (OSA) associated with pharyngeal flap surgery in patients with cleft palate at least 6 months postoperatively and to determine whether age or the flap width had an effect on them. The hypothesis tested in this study was that the severity of OSA associated with pharyngeal flap surgery is greater in children than in adults. SUBJECTS: Ten adults, six men and four women, with a mean age of 28.0 years at pharyngeal flap (adult group). Twenty-eight children, 13 boys and 15 girls, with a mean age of 6.3 years at pharyngeal flap (child group). DESIGN: A prospective analysis. MAIN OUTCOME MEASURES: An overnight polysomnographic study was used to determine the incidence and severity of OSA 6 months after pharyngeal flap. RESULTS: The incidence of OSA following pharyngeal flap was high but not significantly different between these two groups (90% in adults and 93% in children, p = 1.000). When OSA was stratified into different levels of severity according to the values of respiratory disturbance index, there were noticeable differences between these two groups (p =.022). In the adult group, eight patients (89%) had mild OSA and 1 patient (11%) had moderate to severe OSA. In the child group, 11 patients (42%) were found to have mild OSA, and 15 patients (58%) had moderate to severe OSA. No relation was found between the flap width and the incidence (p =.435 in adults and.640 in children) or the severity (p =.325 in adults and.310 in children) of OSA in each group. CONCLUSIONS: Six months following pharyngeal flap surgery, more than 90% of the patients with cleft palate still had OSA. The severity of OSA associated with pharyngeal flap surgery tended to be greater in children than in adults. The flap width was unrelated to the incidence and severity of OSA, no matter in adults or in children.