Purpose To examine the growth rate discrepancy of the affected and unaffected ramus heights in Pruzansky Type I and Type II mandibles. Methods This is a serial retrospective longitudinal growth study of 30 untreated patients (21 males and 9 females) with UCMF (age range from 5 years to 14 years). The mean age of patients was 8.5 years, and the mean follow-up records were 3.7 years. There were 13 patients in group I with a Pruzansky Type I mandible and 17 patients in group II with a Pruzansky Type II. The unaffected side of the mandible served as a control. Eighteen cephalometric parameters were examined at each of the two-time intervals. Results In patients with Pruzansky Type I mandible, the affected ramus grew on average 1.41 mm per year; the unaffected ramus grew 1.66 mm per year during the same period. In patients with Pruzansky Type II mandible, the affected ramus grew on average 0.84 mm per year; during the same period, unaffected ramus grew 1.79 per year. When the growth rate of the ramus height on the affected side was compared to the unaffected side, there was no statistically significant difference in Pruzansky Type I mandibles (p > .05); however, there was a statistically significant difference in the Pruzansky Type II mandibles (p < .05). Conclusion The growth rate discrepancy of the affected and unaffected ramus heights was more severe in Pruzansky Type II mandibles than Pruzansky Type I mandibles explaining the progressive nature of facial asymmetry in Pruzansky II mandibles.

Purpose: Gingivoperiosteoplasty (GPP) can avoid secondary alveolar bone graft in up to 60% of patients. The effects of GPP on maxillary growth are a concern. However, palatoplasty can also negatively impact facial growth. This study quantifies the isolated effects of GPP and cleft palate repair on maxillary growth at the age of mixed dentition. Methods: A single institution, retrospective study of all patients undergoing primary reconstruction for unilateral cleft lip and alveolus (CLA) or cleft lip and palate (CLP) was performed. Study patients had lateral cephalograms at age of mixed dentition. Patients were stratified into four groups: CLA with GPP (CLA+GPP), CLA without GPP (CLA-GPP), CLP with GPP (CLP+GPP), and CLP without GPP (CLP-GPP). Cephalometric measurements included: sella-nasion-point A (SNA), sella-nasion-point B (SNB), and A point-nasion-B point (ANB). Landmarks were compared between patient groups and to Eurocleft Center D data. Results: 110 patients met inclusion criteria: 7 CLA-GPP, 16 CLA+GPP, 24 CLP-GPP, and 63 CLP+GPP patients. There were no significant differences in SNA, SNB, and ANB between CLA+GPP and CLA-GPP, or between CLP+GPP and CLP-GPP groups. In patients who did not receive GPP, SNA was significantly lower in patients with a cleft palate compared to patients with an intact palate (p < 0.05). There were no significant differences in SNA or SNB of CLP-GPP or CLP+GPP groups when compared to Eurocleft data. Conclusion: When controlling for the effects of cleft palate repair, GPP does not appear to negatively affect midface growth at the age of mixed dentition.

Background/Purpose: This paper describes the changes in maxillary arch morphology in infants with bilateral cleft lip and palate (BCLP) following nasoalveolar molding (NAM) and with follow up to assess the need for secondary alveolar bone grafting (ABG) and premaxillary repositioning surgery at preadolescence. Methods/Description: Treatment records of infants with BCLP treated with NAM between 2003 and 2013 were reviewed. Patients with complete BCLP who underwent NAM and had complete sets of maxillary casts at T 0 pre-NAM (mean = 27 days), T 1 post-NAM (mean = 6 months and 5 days), and T 2 before palate surgery (mean = 11 months and 15 days) were included. The sample comprised 23 infants (18 male, 5 female). Casts were digitized and analyzed using three dimensional software. The need for secondary ABG and premaxillary repositioning surgery was assessed at preadolescent follow-up (mean = 8.3 years). Results: Cleft width was reduced on average by 4.73 mm (SD±3.15 mm) and 6.56 mm (SD±4.65) on the right and left sides, respectively. At T 1, 13 (56.52%) patients underwent bilateral gingivoperiosteoplasty (GPP), 8 (34.78%) patients unilateral GPP, and 2 patients (8.7%) did not undergo GPP. 34/46 clefts sites (73.91%) underwent GPP while 12 (26.08%) did not. At preadolescent follow-up of 19 patients, 7 patients (36.84%) did not need ABG on either side, 8 (42.10%) needed ABG on 1 side, and 4 (21.05%) needed ABG on both sides. None of the patients needed premaxillary repositioning surgery. Conclusions: Nasoalveolar molding treatment significantly improves the position of the premaxilla before primary repair, and there is a significant reduction in the need for secondary ABG and premaxillary repositioning surgery at preadolescence.

Objective Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance.Design Cross-sectional survey-based evaluation.Setting International comprehensive cleft care workshop.Participants Total of 489 participants.Interventions Three-day simulation-based hybrid comprehensive cleft care workshop.Main Outcome Measures Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance.Results The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 +/- 3.08 vs 27.63 +/- 3.93; P = .04) and perceived impact on their clinical practice (22.37 +/- 3.42 vs 21.02 +/- 3.45 P = .01).Conclusion Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Introduction: Simultaneous Le Fort III/I (LF III/I) osteotomies are often performed when a differential advancement of the upper and lower midface is needed. This study aims to evaluate midface position preoperative and 1 week postoperative in patients with severe midface hypoplasia. In addition, this study aims to compare the planned surgical movements to the actual postoperative movements. Materials and Methods: A retrospective review was conducted using cephalometry for patients treated with a simultaneous LF III/I osteotomy at a single institution. Osteotomies were performed during 1980-2018 on skeletally mature patients with a craniofacial syndrome, with clinical and radiographic follow-up available. Results: Twelve patients met the inclusion criteria with a mean age of 20.2±6.4 years. Treatment resulted in statistically significant anterior movements related to Orbitale, anterior nasal spine, A Point, and the upper incisor tip, and inferior movements related to anterior nasal spine, A Point, upper and lower incisor tips, B point, and pogonion. Stability after 1 year showed only statistically significant changes at ANB. The predictable error for planned movements versus actual movements was greater in the vertical plane than the horizontal plane. Conclusions: A simultaneous LF III/I osteotomy significantly improved the midface position and occlusal relationship in syndromic patients with midface hypoplasia in a predictable manner. Further multicenter studies with larger sample sizes are needed to validate the conclusions.

Background: The aim of this investigation was to determine whether the nasal form of patients with unilateral cleft lip and palate treated with presurgical nasoalveolar molding therapy, primary lip-nose surgery, and postsurgical nostril retainer was different from that of patients treated with presurgical nasoalveolar molding and primary lip and nose surgery alone. Methods: This cross-sectional, retrospective review focused on 50 consecutive patients with nonsyndromic unilateral cleft lip and palate: 24 treated with nasoalveolar molding and primary lip and nose surgery followed by postsurgical nostril retainer (group 1) compared with 26 patients treated with nasoalveolar molding and primary lip and nose surgery without postsurgical nostril retainer (group 2). Polyvinyl siloxane nasal impressions were performed at an average age of 12 months and 6 days. Bilateral measurements of alar width at maximum convexity, total alar base width, nasal tip projection, columella length, and nostril aperture width and height were recorded. Statistical comparisons of cleft-side versus noncleft side nasal measurements were performed within group 1 and group 2, as well as comparisons of differences between the two groups. Results: Cleft-side nasal dimension was statistically significantly better in group 1 than in group 2 across all measures except nasal projection ( p < 0.05). Group 1 showed less difference between the cleft side and noncleft side in all six measurements than did group 2 ( p < 0.05). Conclusions: There was a significant difference in the nasal shape of patients who used a postsurgical nostril retainer compared with those who did not. Patients who used a postsurgical nostril retainer showed better nasal shape at an average age of 12 months compared with the control group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

OBJECTIVE:To compare the prevalence of dental malformations and agenesis in patients who received or did not receive gingivoperiosteoplasty (GPP).DESIGN:Retrospective cohort study.PATIENTS:Review of patients born January 1, 2000, to December 31, 2007, with unilateral cleft lip and alveolus, with or without clefting of the secondary palate, who received GPP and/or secondary alveolar bone grafting (ABG). Patients were included if they had clinical images and dental radiographs available at ages 5 to 9 and 10 to 12 years. Ninety-four patients met the inclusion criteria; 46 treated with GPP, and 48 who did not receive GPP.OUTCOME MEASURES:Records were assessed for supernumerary, missing, and malformed teeth by a blinded examiner, and prevalence compared between groups using χ2 tests.RESULTS:Cleft side lateral incisors were absent in 54% of GPP patients, compared to 50% in the no-GPP group. Two patients in the GPP group and 1 in the no-GPP group had supernumerary lateral incisors. Most lateral incisors were undersized or peg shaped in both the no-GPP (83.3%) and GPP (71.4%) groups. In the GPP group, 5 (10.9%) patients exhibited central incisor agenesis, and 3 had significant hypoplasia. In the no-GPP group, 4 (8.3%) patients exhibited central incisor agenesis, and 5 (10.5%) significant hypoplasia. These differences were not statistically significant.CONCLUSIONS:Gingivoperiosteoplasty was not associated with increased prevalence of dental malformation or agenesis. When performed appropriately, GPP is a safe treatment technique that does not increase the risk of dental anomalies.

Aim: To assess treatment outcome and 1-year stability of LeFort I advancement in patients with complete cleft lip and palate. Methods: Thirty-five patients (age 20.65 +/- 2.20 years) with unilateral (n = 25) or bilateral (n = 10) complete cleft lip and palate who underwent LeFort I advancement were included. Lateral cephalograms before surgery (T1), immediately postsurgery (T2), and at 1-year follow-up (T3) were superimposed, and the position of anterior nasal spine (ANS), A-point, and U1 Tip assessed using an x, y coordinate system. Differences between landmark positions at the 3-time points were analyzed using paired sample t-tests, with a significance defined as alpha <= 0.05. Results: The mean surgical advancement in the horizontal direction (T2-T1) was 6.50 +/- 2.62 mm at ANS (P < 0.001) and 7.05 +/- 2.51 mm at A-point (P < 0.001). At a 1-year follow-up (T3-T2), the mean horizontal relapse at ANS was -1.41 +/- 1.89 mm (P < 0.001) and -0.79 +/- 1.48 mm at A-point (P 0.003). Mean horizontal relapse was 21.7% and 11% of surgical advancement when assessed at ANS and A-point, respectively. The central incisor tip position remained stable during the postsurgical period (0.12 +/- 2.11 mm, P 0.732). At A-point, the mean vertical surgical change (T2-T1) was -0.96 +/- 2.57 mm (P < 0.001). No significant post-treatment (T3-T2) vertical changes were detected at ANS or A-point. Phenotypic stability was excellent, with all patients maintaining positive overjet at 1-year follow-up. Conclusions: LeFort I advancement in complete cleft lip and palate is stable, with less than a 2 mm relapse after 1-year. Surgical overcorrection by 10% to 20% is recommended to compensate for the expected skeletal relapse.

BACKGROUND:The authors present outcomes analysis of the nasoalveolar molding treatment protocol in patients with a cleft followed from birth to facial maturity.METHODS:A single-institution retrospective review was conducted of cleft patients who underwent nasoalveolar molding between 1990 and 2000. Collected data included surgical and orthodontic outcomes and incidence of gingivoperiosteoplasty, alveolar bone grafting, surgery for velopharyngeal insufficiency, palatal fistula repair, orthognathic surgery, nose and/or lip revision, and facial growth.RESULTS:One hundred seven patients met inclusion criteria (69 with unilateral and 38 with bilateral cleft lip and palate). Eighty-five percent (91 of 107) underwent gingivoperiosteoplasty (unilateral: 78 percent, 54 of 69; bilateral: 97 percent, 37 of 38). Of those patients, 57 percent (52 of 91) did not require alveolar bone grafting (unilateral: 59 percent, 32 of 54; bilateral: 54 percent, 20 of 37). Twelve percent (13 of 107) of all study patients underwent revision surgery to the lip and/or nose before facial maturity (unilateral: 9 percent, six of 69; bilateral: 18 percent, seven of 38). Nineteen percent (20 of 107) did not require a revision surgery, alveolar bone grafting, or orthognathic surgery (unilateral: 20 percent, 14 of 69; bilateral: 16 percent, six of 38). Cephalometric analysis was performed on all patients with unilateral cleft lip and palate. No significant statistical difference was found in maxillary position or facial proportion. Average age at last follow-up was 20 years (range, 15 years 4 months to 26 years 10 months).CONCLUSIONS:Nasoalveolar molding demonstrates a low rate of soft-tissue revision and alveolar bone grafting, and a low number of total operations per patient from birth to facial maturity. Facial growth analysis at facial maturity in patients who underwent gingivoperiosteoplasty and nasoalveolar molding suggests that this proposal may not hinder midface growth.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

This is a retrospective study to evaluate the postsurgical position of the maxilla and mandible in 5 matured craniofacial patients with unilateral craniofacial microsomia who underwent 2 jaw surgical procedures using computerized surgical planning. The craniofacial surgeon and orthodontist completed the virtual surgical treatment plan with a biomedical engineer's assistance via a web meeting. The treatment plan of each patient included 2 jaw surgery with genioplasty. At the maxillary dental midline, the planned mean advancement was 4 mm; yaw, a rotational correction towards the unaffected side was 4.96 mm; and impaction was 2.74 mm. The mean advancement measured at point B was 10.5 mm, and the rotational correction towards the unaffected side was 6.58 mm. The mean advancement following genioplasty was 8.43 mm, and the mean transverse correction was 6.33 mm towards the midsagittal plane. The intermediate surgical splint, final surgical splint, bone graft templates, and cutting guides were constructed utilizing computer-aided design/computer-aided manufacturing technology. The surgeon executed the treatment plan in the operating room using appropriate computer-generated guides and splints. A postsurgical cone-beam computed tomography scan was obtained and superimposed on the surgical treatment plan using Simplant OMS 10.1 software. The cranial base was used as a reference for superimposition. Three-dimensional color-coded displacement maps were generated to visually and quantitatively assess the surgical outcome. There was a mean error of 0.88 mm (+0.30) for the position of the maxillary anatomical structures from the planned position, and the anterior mandibular anatomical structures were on average 0.96 mm (+0.26) from the planned position.

OBJECTIVE:To assess social and demographic influences on caregiver success and difficulty with nasoalveolar molding (NAM).DESIGN:Retrospective review identified patients who began NAM between April 22, 2013, and April 18, 2017, at the New York University Langone Medical Center. Records were reviewed, and the following sociodemographic data retrieved: parental marital status, parental ages, number of siblings, distance traveled to clinic, insurance coverage, concurrent medical conditions, and need for an interpreter.PATIENTS:Patients were included if complete charting was available; 106 patients met the inclusion criteria; 79 patients with unilateral and 27 with bilateral clefts.OUTCOME MEASURES:Chart entries indicating incorrect appliance usage, emergency visits, phone calls, and noncompliance were recorded. Alveolar cleft gap closure was measured on pre- and posttreatment models in unilateral cases. Multiple regression analyses were performed to assess the influence of social variables on these outcomes.RESULTS:Alveolar cleft gap closure was 7.2 ± 3.0 mm, or 78.5% ± 19.1%. Cleft closure increased with paternal age by 0.33 mm (P = .007) or 2.0% (P = .017) per year, decreased with maternal age by 0.29 mm (P = .041) per year, and increased in married and partnered parents by 39% (P = .018). Incorrect appliance usage averaged 0.62 fewer instances for married and partnered parents (P = .018) and 0.43 fewer for those with private insurance (P = .019).CONCLUSIONS:Alveolar cleft gap closure was more successful for older fathers, younger mothers, and married couples. Married couples were also less likely to experience treatment difficulties such as incorrect appliance usage or inadequate duration of wear, as were those with private insurance coverage.

Objective: Utilize 3-dimensional (3D) photography to evaluate the nasolabial changes in infants with bilateral cleft lip and palate (BCLP) who underwent nasoalveolar molding (NAM) and primary reconstructive surgery. Design: This is a retrospective serial longitudinal study of consecutively enrolled infants from September 2012 to July 2016 with BCLP who underwent NAM before primary lip and nose reconstructive surgery. It included infants who had digital 3dMD stereophotogrammetry records at initial presentation (T1), completion of NAM (T2), and 3 weeks following primary repair (T3). Twelve infants fulfilled the inclusion criteria. 3dMD Vultus software was used to orient images and plot 16 nasolabial points with x, y, z coordinates to obtain the linear and angular measurements. Nasal form changes were measured and analyzed between T1 (0.5 months old), T2 (5 months old), and T3 (6 months old). Intraclass correlation coefficient was performed for intrarater reliability. Averaged data from the 3D images was statistically analyzed from T1 to T2 and T2 to T3 with Wilcoxon tests. Unaffected infant norms from the Farkas publication were used as a control sample. Results: After NAM therapy, statistically significant changes in the position of subnasale and labius superius improved nasolabial symmetry. Both retruded after NAM were displaced downward after NAM and surgical correction with respect to soft tissue nasion. The nasal tip's projection was maintained with NAM and surgical correction. The columella lengthened from 1.4 to 4.71 mm following NAM. Conclusions: There was a significant improvement in the nasolabial anatomy after NAM, and this was further enhanced after primary reconstructive surgery.

Background: The aim of this study is to assess the effect of nasoalveolar molding (NAM) versus no-NAM on nasal morphology in patients with unilateral cleft lip and palate (UCLP) at the time of nasal maturity. Methods: A retrospective, single-institution review was conducted on all non-syndromic patients with UCLP. Inclusion criteria included age 14 years or above, unilateral cleft repair at the time of infancy, and adequate photography taken at nasal maturity and prior to rhinoplasty. Exclusion criteria included age less than 14 years, syndromic diagnosis, and rhinoplasty prior to nasal maturity. Ten parameters were measured twice from standardized clinical photographs using the Dolphin Imaging Software for establishment of intrarater reliability. Subjective analysis was achieved through completion of the Asher McDade grading scale by 3 expert cleft practitioners. Results: Nostril height, columellar angle, alar cant, vertical alar height, alar height angle, nasofacial angle, and nasolabial angle were found to be significantly less severe in patients who had undergone NAM in conjunction with surgical repair when compared with those who had undergone surgical repair alone. Asher McDade grading revealed significant improvement in nasal form, nasal symmetry/deviation, nasal profile, vermillion border, and overall score in patients who underwent NAM compared to no-NAM. Conclusion: The use of presurgical NAM during infancy can improve nasal symmetry and nasal proportions at the time of nasal maturity.

Purpose: Global Smile Foundation (GSF) is a non profit foundation that provides comprehensive cleft care to underserved patients. GSF focuses on long-term follow up and sustainability of local healthcare teams, having engaged in 32 years of follow up in Ecuador. In 2012, GSF added presurgical NasoAlveolar Molding (NAM) therapy for their patients in Guayaquil, Ecuador, as part of its sustainability and empowerment initiative. We present longitudinal data on 189 patients treated with NAM and discuss the challenges/barriers to its completion. Methods: Data was collected from GSF surgical and dental records including patient diagnosis, completion/incompletion and length of NAM therapy. Surgeon, patient age, peri, intra, and post-operative procedural data, were collected for primary cleft lip/nose and palate repair, and any additional surgeries. Follow up clinical and photographic data was retrieved to document long-term outcomes. Results: A total of 207 patients were treated with pre-surgical therapy: 189 patients received NAM therapy, while 18 patients were treated with lip tape and/or nasal elevator. Of the 189 NAM patients who received NAM, long-term follow up was available for 96 patients (50.8 %), while 84 (44.4%) were lost to follow up or subsequently seen by another foundation, and 9 (4.8%) are currently undergoing NAM or awaiting primary surgery. Of the 96 patients with long term follow up, 70 (72.9%) had Unilateral Cleft Lip and Palate and 26 (27.1%) had Bilateral Cleft Lip and Palate; 64 (66.67%) were male and 32 (33.3%) were female. Of those 96 patients, 58 (60.4%) completed NAM therapy, 17 (17.7%) failed to complete it, and 21 (21.8%) had incomplete NAM documentation. The average age at NAM initiation was 36.36 ± 31.39 days (range: 0-157 days) and average length of NAM therapy was 118.98 ± 82.68 days (range: 1-222 days). Patients underwent an average of 2.13± 0.93 (range: 1-5) surgeries after NAM Initiation, with an average of 0.17 ± 0.43 (0-2) Cleft Lip/Nose Revisions, 0.06 ± 0.28 (0-2) GingivoPerioPlasty, 0.06 ± 0.28 (0-1) pre-maxillary setbacks, 0.07 ± 0.30 (0-2) fistula repairs, and 0.03 ± 0.17 (0-1) Velopharyngeal Insufficiency corrections. Over an 8 year period, 12 NAM providers were trained in Ecuador, 7 provided treatment in Ecuador, and 5 provided treatment internationally, making Ecuador a site for information exchange. Follow-up for NAM patients was an average of 2.00 ± 1.77 (0.22 - 6.67) years after NAM initiation and 1.45 ± 1.77 (0 - 6.52) years after their primary Cleft Lip/Nose Repair. This includes continued long term follow up and comprehensive cleft care in addition to NAM therapy. Conclusion: With yearly patient follow-up and year-round partnership with local professionals, our model shows successful long-term delivery of NAM therapy as part of a sustainable comprehensive cleft care strategy in outreach settings.

preoperative hormone therapy, for <1 year (n = 1), 1–5 years (n = 4), 6–10 years (n = 2), or >10 years (n = 3). Thirty percent (n = 3) reported a history of tobacco use. Self-reported pre-operative most masculine facial features were the jaw/ chin (n = 6), nose (n = 5), and forehead/brow (n = 5). Secondary and revisionary FFS procedures included brow reduction (n = 9), genioplasty (n = 7), mandibular contouring (n = 6), tracheal shave (n = 2), and rhinoplasty (n = 6). Mean facial feminization outcome scores improved from 51.2 preoperatively (SD = 8.9) to 71.9 at longest follow-up (SD = 14.7), P < 0.01. Mean postoperative satisfaction was 3.0. Cephalometric values indicating successful feminization included decreased glabellar angle by 6.7° (from 98.9° to 92.2°; P < 0.05) and increased nasofrontal angle by 6.0° (from 138.0° to 144.0°; P < 0.05), with other statistically nonsignificant changes as well. Complications included hypertrophic scarring (n = 1) and orbital hematoma requiring surgical drainage (n = 1).

BACKGROUND:Le Fort III advancement and/or distraction involve osteotomies and dysjunction in the region of the maxillary tuberosity in proximity to the maxillary posterior tooth buds. The purpose of this study was to determine the effect of early conventional Le Fort III advancement and/or distraction on development and eruption of the maxillary posterior permanent molars.METHODS:A retrospective review of patients diagnosed with syndromic craniosynostosis, who underwent early Le Fort III or early midface distraction and late surgical intervention, was analyzed.RESULTS:In the early conventional Le Fort III surgery group, 93 percent of maxillary second molars and 28 percent of maxillary first molars experienced a disturbance in eruption. In the early distraction group, 82 percent of maxillary second molars and 20 percent of maxillary first molars experienced a disturbance in eruption. In the control group, the late conventional Le Fort III and the late distraction groups, only 26 percent of maxillary second molars and none of maxillary first molars experienced a disturbance in eruption.CONCLUSIONS:A common disruption seen postoperatively in the early Le Fort III and distraction groups was displacement of the second molars. The majority of the displaced tooth buds were located in the maxillary sinus. Overall, the early Le Fort III surgery groups experienced more frequent disturbances for both first and second molars, with the common sequela of displacement in the maxillary sinus, leading to the question of whether presurgical planning in cases of early intervention to address midface retrusion should include extraction/enucleation of the second molar tooth buds.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

Introduction: The purpose of this study was to evaluate the surgical outcomes of combined LeFort III and I osteotomies in the treatment of craniofacial patients with severe midface hypoplasia. Methods: A single-institution retrospective review of all patients who underwent combined LeFort III/I surgery from 1980 to 2018 (38 years). Inclusion criteria included 1) Le Fort III/I surgery at skeletal maturity 2) lateral cephalograms at pre-surgical and one week post-surgery and 3) computerized and traditional surgical planning records. 15 consecutive patients met the inclusion criteria (11 male and 4 female patients). Of the 15 patients, 7 patients had one year follow-up records. The mean age at the time of the surgery was 19.1± 6.1 years (range 17 to 26 years). Patient diagnosis included: Crouzon (N=9), Pfeiffer (N=2), Apert (N=1), Antley-Bixler (N=1), fronto-nasal dysplasia (N=1) and cleidocranial dysplasia (N=1). All study patients underwent a standard subcranial LeFort III with repositioning using an intermediate splint followed by interposition bone graft and rigid fixation. After fixation of LeFort III segment, a LeFort I osteotomy was performed and a final splint was used to repositioned the LeFort I segment prior to rigid fixation. Lateral cephalograms were studied at pre surgery (T1), immediate one week post surgery (T2), and one year post surgery (T3). Results: Mean blood loss during surgery was 888 ± 800 ml and mean duration of surgery was 7.3 ± 3.3 hrs. The LeFort III segment was planned for a 7.6 ±2.2mm advancement measured at orbitale. The LeFort I segment was planned to advance a total of 12.1±5.2mm at A point and 12.1± 5.5mm at upper incisor edge. One week post-LeFort III/I advancement shows that the LeFort III segment was advanced 5.8 ±4.3mm anteriorly and displaced 2.6±4.3mm inferiorly measured at Orbitale. The LeFort I segment advanced a net total of 10.1 ± 3.4mm anteriorly, 3.8 ±5.4mm inferiorly at A point and 8.9±4.1mm anteriorly, 4.2 ±5.6mm inferiorly at upper incisor edge. ANB angle increased by 6.6±4.6 degrees from T1 to T2. At one year follow-up, ANB angle decreased by 1.3±1.5 degrees compared to T2. Additionally, when compared to T2, Orbitale advanced 0.37 ± 2.9mm, A Point decreased by 3.4±3.5mm, and upper incisor edge retracted 1.9±2.5 mm at T3 post surgery. Conclusion: Combined LeFort III and I advancement surgery significantly improved midface position and occlusal relationship in patients with midface hypoplasia. At one year follow up, LeFort III/I segments shows about 20% relapse at upper incisal edge and 35% at point A. However, patients still maintained a positive overjet and overbite. Overcorrection is recommended to compensate for the post-surgical relapse.

Introduction: LeFort III distraction osteogenesis may be indicated in the treatment of syndromic craniosynostosis with severe midface retrusion. This study investigates long-term changes in patients undergoing distraction as children, and compares outcomes to an unaffected, untreated control. Methods:Fifteen patients (9 males, 6 females) with syndromic craniosynostosis treated by LeFort III distraction at an average age of 4.9 +/- 1.5 years were identified. Lateral cephalograms at predistraction, immediate, 1-, 5-, and 10-year postdistraction were superimposed using the best-fit of cranial base details. An untreated, unaffected matched control was obtained from the American Association of Orthodontists Foundation Legacy Collection. Differences in landmark location and cephalometric relationships were assessed between time points and between treatment and control groups. Results: LeFort III distraction produced an average advancement of 14.86 +/- 5.14 mm at A-point and 10.54 +/- 3.78 mm at orbitale. This advancement produced overcorrection of anteroposterior occlusal relationships and phenotypic correction of midface position. Surgical stability over a 10-year follow-up was excellent. Posttreatment growth was characterized by absent anteroposterior maxillary growth, preservation of dentoalveolar development and maxillary remodeling, and delayed mandibular growth. Subsequent growth resulted in a long-term phenotypic relapse of pretreatment Class III maxillomandibular relationship and negative overjet. Conclusions: LeFort III distraction osteogenesis produces stable advancement of the midface. Overcorrection is required for long-term phenotypic stability because of deficient postdistraction sagittal midface growth. Late mandibular growth contributes to underestimation of the amount of distraction required to produce long-term phenotypic correction.

BACKGROUND:Simulation is progressively being integrated into surgical training; however, its utility in plastic surgery has not been well described. The authors present a prospective, randomized, blinded trial comparing digital simulation to a surgical textbook for conceptualization of cleft lip repair.METHODS:Thirty-five medical students were randomized to learning cleft repair using a simulator or a textbook. Participants outlined markings for a standard cleft lip repair before (preintervention) and after (postintervention) 20 minutes of studying their respective resource. Two expert reviewers blindly graded markings according to a 10-point scale, on two separate occasions. Intrarater and interrater reliability were calculated using intraclass correlation coefficients. Paired and independent t tests were performed to compare scoring between study groups. A validated student satisfaction survey was administered to assess the two resources separately.RESULTS:Intrarater grading reliability was excellent for both raters for preintervention and postintervention grading (rater 1, intraclass correlation coefficient = 0.94 and 0.95, respectively; rater 2, intraclass correlation coefficient = 0.60 and 0.92, respectively; p < 0.001). Mean preintervention performances for both groups were comparable (0.82 ± 1.17 versus 0.64 ± 0.95; p = 0.31). Significant improvement from preintervention to postintervention performance was observed in the textbook (0.82 ± 1.17 versus 3.50 ± 1.62; p < 0.001) and simulator (0.64 ± 0.95 versus 6.44 ± 2.03; p < 0.001) groups. However, the simulator group demonstrated a significantly greater improvement (5.81 ± 2.01 versus 2.68 ± 1.49; p < 0.001). Participants reported the simulator to be more effective (p < 0.001) and a clearer tool (p < 0.001), that allowed better learning (p < 0.001) than textbooks. All participants would recommend the simulator to others.CONCLUSION:The authors present evidence from a prospective, randomized, blinded trial supporting online digital simulation as a superior educational resource for novice learners, compared with traditional textbooks.