Long-term effects of nasoalveolar molding on three-dimensional nasal shape in unilateral clefts.

OBJECTIVE: This objective of this study was to determine the effect of presurgical nasoalveolar molding on long-term nasal shape in complete unilateral clefts. DESIGN: The study was retrospective, and the subjects were chosen at random. Nasal casts of the subjects were scanned in three dimensions. Each nose was best fit to its mirror image, and a numerical asymmetry score was determined. SETTING: All patients were treated at the Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, New York. PATIENTS: The study subjects (n = 10) were selected from a group that had undergone presurgical nasal molding in conjunction with alveolar molding. The control subjects (n = 10) were selected from a group that had undergone presurgical alveolar molding alone. INTERVENTIONS: All subjects underwent presurgical orthopedic treatment until the age of approximately 4 months at which time the primary surgery was performed. MAIN OUTCOME MEASURE: The nasal shape following nasal molding should be more symmetrical than if molding had not been done. RESULTS: The mean asymmetry index for the nasoalveolar molding group was 0.74, and the control group was 1.21. This difference was statistically significant (p < .05). CONCLUSIONS: Presurgical nasoalveolar molding significantly increases the symmetry of the nose. The increase in symmetry is maintained long term into early childhood. The limitations of this study include (1) asymmetry alone is not an adequate shape result in most situations, (2) the children evaluated in this study were not fully grown, and (3) the control group was not age matched.

Review of devices for distraction osteogenesis of the craniofacial complex.

Over the last 50 years, Ilizarov refined a method to successfully lengthen endochondral bones and the surrounding soft tissue matrix. Given the difficulties in reconstructing deformities of the craniofacial complex, distraction osteogenesis has recently been used to avoid the problems associated with conventional surgery and to begin correction at an earlier age. Distraction devices can be categorized by whether they are internal or external, the direction of distraction, and the site of application. External devices are capable of either unidirectional, bidirectional, or multiplanar (three-dimensional) distraction. Internal or intraoral distractors are capable of unidirectional distraction only. Distraction devices used to lengthen the mandibular ramus and body, widen the mandible, augment the alveolar ridge, conduct bone transport, and advance the midface are reviewed.

Early decannulation with bilateral mandibular distraction for tracheostomy-dependent patients.

Obstructive sleep apnea in the neonatal period may originate from a hypoplastic mandibular framework causing retroposition of the base of the tongue and an inadequate hypopharyngeal space. A tracheotomy in childhood is an effective treatment for obstructive sleep apnea, but it is associated with increased morbidity, management problems, and difficulties in social interaction. Tracheostomy-dependent pediatric patients who underwent mandibular distraction were reviewed to determine the effectiveness of this technique in achieving decannulation. A clinical review was completed to determine the status of the tracheostomy after external, unidirectional distraction in tracheostomy-dependent patients. Expansion of the mandibular framework was analyzed using traditional bony landmarks on predistraction and postdistraction lateral cephalograms. The area of the lower face was analyzed, and changes in the position of the hyoid bone were determined. Four patients with tracheostomies underwent an average of 21.3 mm and 20.8 mm of distraction on the left and right hemimandibles, respectively. The average age at the time of distraction was 2.7 years (range, 2.2 to 3.2 years). All patients underwent successful decannulation at an average of 3.8 months (range, 1.5 to 5.5 months) after completion of distraction. The area of the lower face increased 26.9 percent (range, 12.2 to 53.5 percent) after distraction, and the hyoid bone advanced an average of 14.5 mm (range, 8 to 25 mm). Bilateral mandibular distraction is an effective method of expanding the mandibular framework and concomitantly advancing the base of the tongue. The technique provides a tool for early intervention and decannulation in pediatric patients with indwelling tracheostomies secondary to mandibular deficiencies.