Introduction: This study aims to describe the burden of care (BoC) for the management of patients with nonsyndromic cleft lip and palate (CLP) by identifying provider burden, characterizing an interaction burden, and calculating an economic burden associated with their health system interactions. Methods: A retrospective chart review was conducted of patients with nonsyndromic CLP treated at a pediatric tertiary hospital between January 1, 1999, and April 30, 2021. Healthcare utilization data for inpatient and outpatient interactions were extracted. Community outpatient data were obtained from affiliated specialists. Bottom-up microcosting was utilized for hospital costing, the provincial tariff guide for provider reimbursement, and zip code for calculating patient costs. Results: In total, 58 patients identified with CLP had a median of 148.5 healthcare interactions (consults/follow-ups/surgeries) between the ages of 0 and 18 years. Patients had a median of 10.5 surgical procedures, and a median 135.8 outpatient interactions. The most used specialty service was orthodontics, with a median of 71.5 orthodontic interactions per patient. The median cost of care, including direct hospital costs, physician costs, community healthcare costs, and indirect costs, was $73,398. Conclusions: Patients born with nonsyndromic CLP have a very high frequency of healthcare encounters, out of proportion to cost associated with healthcare, suggesting an overall significant BoC.

Chapter 9 Nasoalveolar molding in unilateral cleft lip and palate Pradip R. Shetye, Pradip R. ShetyeSearch for more papers by this authorTravis L. Gibson, Travis L. GibsonSearch for more papers by this author Pradip R. Shetye, Pradip R. ShetyeSearch for more papers by this authorTravis L. Gibson, Travis L. GibsonSearch for more papers by this author Book Editor(s):Pradip R. Shetye DDS, BDS, MDS, Pradip R. Shetye DDS, BDS, MDS Associate Professor of Plastic Surgery (Orthodontics), NYU Grossman School of Medicine Adjunct Associate Professor of Orthodontics, NYU College of Dentistry Craniofacial Orthodontist, Hassenfeld Children's Hospital, NYU Langone Health Director of Orthodontics and Director of Craniofacial Orthodontic Fellowship Program Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USASearch for more papers by this authorTravis L. Gibson DMD, MSc, Travis L. Gibson DMD, MSc Clinical Assistant Professor, Faculty of Dentistry, University of British Columbia Craniofacial Orthodontist British Columbia Children's Hospital, Vancouver, BC, CanadaSearch for more papers by this author First published: 19 December 2022 https://doi.org/10.1002/9781119778387.ch9 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onEmailFacebookTwitterLinkedInRedditWechat Summary This chapter discusses nasoalveolar molding (NAM) therapy in infants with unilateral cleft lip and palate (UCLP). The primary goal of NAM in patients with UCLP is to reduce the nose, lip, and alveolar cleft deformity before primary reconstructive surgery. NAM treatment for UCLP begins within the first two weeks after birth and lasts approximately three months to prepare the infant for primary reconstructive surgery. UCLP exhibits a range of different clinical presentations, and not all patients will need or benefit from NAM therapy. Presurgical NAM is best reserved for patients with severe alveolar and nasal deformity. Infants with incomplete cleft lip, nose, and alveolus may benefit from some presurgical infant orthopedic, depending on the severity of the deformity. For patients with UCLP, a single retention button is added to the NAM appliance. Alveolar segment alignment can be initiated by making an adjustment to the intraoral molding plate and retentive tape tension. References Baek , S.H. and Son , W.S. ( 2006 ). Difference in alveolar molding effect and growth in the cleft segments: 3-dimensional analysis of unilateral cleft lip and palate patients . Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 102 ( 2 ): 160 – 168 . 10.1016/j.tripleo.2005.09.009 PubMedWeb of Science®Google Scholar Barillas , I. , Dec , W. , Warren , S.M. et al. ( 2009 ). Nasoalveolar molding improves long-term nasal symmetry in complete unilateral cleft lip-cleft palate patients . Plast. Reconstr. 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Assessment of presurgical clefts and predicted surgical outcome in patients treated with and without nasoalveolar molding . J. Craniofac. Surg. 26 ( 1 ): 71 – 75 . 10.1097/SCS.0000000000001233 PubMedWeb of Science®Google Scholar Rubin , M.S. , Clouston , S.A.P. , Esenlik , E. et al. ( 2019 ). Midface growth in patients with unilateral cleft lip and palate treated with a nasoalveolar molding protocol . J. Craniofac. Surg. 30 ( 6 ): 1640 – 1643 . 10.1097/SCS.0000000000005356 PubMedWeb of Science®Google Scholar Saad , M.S. , Fata , M. , Farouk , A. et al. ( 2020 ). Early progressive maxillary changes with nasoalveolar molding: randomized controlled clinical trial . JDR Clin. Trans. Res. 5 ( 4 ): 319 – 331 . 10.1177/2380084419887336 CASPubMedWeb of Science®Google Scholar Santiago , P.E. , Grayson , B.H. , Cutting , C.B. et al. ( 1998 ). Reduced need for alveolar bone grafting by presurgical orthopedics and primary gingivoperiosteoplasty . Cleft Palate Craniofac. 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Chapter 10 Nasoalveolar molding in bilateral cleft lip and palate Pradip R. Shetye, Pradip R. ShetyeSearch for more papers by this authorTravis L. Gibson, Travis L. GibsonSearch for more papers by this author Pradip R. Shetye, Pradip R. ShetyeSearch for more papers by this authorTravis L. Gibson, Travis L. GibsonSearch for more papers by this author Book Editor(s):Pradip R. Shetye DDS, BDS, MDS, Pradip R. Shetye DDS, BDS, MDS Associate Professor of Plastic Surgery (Orthodontics), NYU Grossman School of Medicine Adjunct Associate Professor of Orthodontics, NYU College of Dentistry Craniofacial Orthodontist, Hassenfeld Children's Hospital, NYU Langone Health Director of Orthodontics and Director of Craniofacial Orthodontic Fellowship Program Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USASearch for more papers by this authorTravis L. Gibson DMD, MSc, Travis L. Gibson DMD, MSc Clinical Assistant Professor, Faculty of Dentistry, University of British Columbia Craniofacial Orthodontist British Columbia Children's Hospital, Vancouver, BC, CanadaSearch for more papers by this author First published: 19 December 2022 https://doi.org/10.1002/9781119778387.ch10 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onEmailFacebookTwitterLinkedInRedditWechat Summary In 1993, Cutting and Grayson described preoperative columella lengthening in patients with bilateral cleft lip and palate (BCLP) using the nasoalveolar molding (NAM) appliance, allowing the surgeon to perform a one-stage repair of the lip, nose, and alveolus. This chapter describes NAM therapy for patients with BCLP, with a focus on the key goals of premaxillary retraction, columella elongation, and nasal cartilage molding prior to primary reconstructive surgery. In contrast to the unilateral NAM appliance, the bilateral NAM plate has two retention buttons and two nasal stents. Soon after birth, the premaxilla in infants with BCLP is very mobile. Once the NAM plate is inserted, there are two biomechanical methods for premaxillary retraction. In many patients, it is possible to achieve complete alveolar gap closure on both sides while maintaining an appropriate arch form and maxillomandibular alveolar relationship. Columella elongation is an important and complex part of NAM therapy in infants with BCLP. References Cutting , C. and Grayson , B. ( 1993 ). The prolabial unwinding flap method for one-stage repair of bilateral cleft lip, nose, and alveolus . Plast. Reconstr. Surg. 91 ( 1 ): 37 – 47 . 10.1097/00006534-199301000-00006 CASPubMedWeb of Science®Google Scholar Dec , W. , Shetye , P.R. , Davidson , E.H. et al. ( 2013 ). Presurgical nasoalveolar molding and primary gingivoperiosteoplasty reduce the need for bone grafting in patients with bilateral clefts . J. Craniofac. Surg. 24 ( 1 ): 186 – 190 . 10.1097/SCS.0b013e318270fd21 PubMedWeb of Science®Google Scholar Farkas , L.G. ( 1994 ). Anthropometry of the Head and Face . New York : Lippincott Williams & Wilkins . Google Scholar Garfinkle , J.S. , King , T.W. , Grayson , B.H. et al. ( 2011 ). A 12-year anthropometric evaluation of the nose in bilateral cleft lip-cleft palate patients following nasoalveolar molding and cutting bilateral cleft lip and nose reconstruction . Plast. Reconstr. Surg. 127 ( 4 ): 1659 – 1667 . 10.1097/PRS.0b013e31820a64d7 CASPubMedWeb of Science®Google Scholar Grayson , B.H. and Shetye , P.R. ( 2009 ). Presurgical nasoalveolar moulding treatment in cleft lip and palate patients . Indian J. Plast. Surg. 42 ( Suppl ): S56 – S61 . PubMedGoogle Scholar Harrison , L.M. , Hallac , R.R. , and Derderian , C.A. ( 2021 ). Three-dimensional analysis of bilateral cleft lip and palate nasal deformity . Cleft Palate Craniofac. J. 58 ( 1 ): 105 – 113 . https://doi.org/10.1177/1055665620940190 . 10.1177/1055665620940190 PubMedWeb of Science®Google Scholar Isik Aslan , B. , Gulsen , A. , Findikcioglu , K. et al. ( 2018 ). Effects of nasoalveolar molding therapy on alveolar and palatal cleft deformities in unilateral and bilateral cleft lip and palate . J. Craniofac. Surg. 29 ( 2 ): e179 – e184 . 10.1097/SCS.0000000000004243 PubMedWeb of Science®Google Scholar Lee , C.T. , Garfinkle , J.S. , Warren , S.M. et al. ( 2008 ). Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate . Plast. Reconstr. Surg. 122 ( 4 ): 1131 – 1137 . 10.1097/PRS.0b013e318184590c CASPubMedWeb of Science®Google Scholar Liou , E.J. , Subramanian , M. , and Chen , P.K. ( 2007 ). Progressive changes of columella length and nasal growth after nasoalveolar molding in bilateral cleft patients: a 3-year follow-up study . Plast. Reconstr. Surg. 119 ( 2 ): 642 – 648 . 10.1097/01.prs.0000239600.79638.6f CASPubMedWeb of Science®Google Scholar Mancini , L. , Avinoam , S. , Grayson , B.H. et al. ( 2022 ). Three-dimensional nasolabial changes after nasoalveolar molding and primary lip/nose surgery in infants with bilateral cleft lip and palate . Cleft Palate Craniofac. J. 59 ( 4 ): 475 – 483 . https://doi.org/10.1177/10556656211012858 . 10.1177/10556656211012858 PubMedWeb of Science®Google Scholar Matthews , D.N. ( 1952 ). The premaxilla in bilateral clefts of lip and palate . Br. J. Plast. Surg. 5 ( 2 ): 77 – 86 . 10.1016/S0007-1226(49)80015-4 CASPubMedGoogle Scholar Meazzini , M.C. , Chiavenna , C. , Autelitano , L. et al. ( 2018 ). Photometric evaluation in adolescence of patients with bilateral cleft lip and palate treated with nasoalveolar molding and primary columella lengthening . Cleft Palate Craniofac. J. 55 ( 4 ): 568 – 573 . 10.1177/1055665617732785 PubMedWeb of Science®Google Scholar Millard , D.R. Jr. and Latham , R.A. ( 1990 ). Improved primary surgical and dental treatment of clefts . Plast. Reconstr. Surg. 86 ( 5 ): 856 – 871 . 10.1097/00006534-199011000-00006 PubMedWeb of Science®Google Scholar Nayak , T. , Bonanthaya , K. , Parmar , R. et al. ( 2019 ). A comparative cephalometric study of nasoalveolar molding- and non-nasoalveolar molding-treated bilateral cleft patients at early mixed dentition period . Cleft Palate Craniofac. J. 56 ( 5 ): 569 – 575 . 10.1177/1055665618802151 PubMedWeb of Science®Google Scholar Oosterkamp , B.C. , van Oort , R.P. , Dijkstra , P.U. et al. ( 2005 ). Effect of an intraoral retrusion plate on maxillary arch dimensions in complete bilateral cleft lip and palate patients . Cleft Palate Craniofac. J. 42 ( 3 ): 239 – 244 . 10.1597/03-109.1 PubMedWeb of Science®Google Scholar Pool , R. and Farnworth , T.K. ( 1994 ). Preoperative lip taping in the cleft lip . Ann. Plast. Surg. 32 ( 3 ): 243 – 249 . 10.1097/00000637-199403000-00003 CASPubMedWeb of Science®Google Scholar Potter , J. ( 1968 ). The nasal tip in bilateral hare lip . Br. J. Plast. Surg. 21 ( 2 ): 173 – 179 . 10.1016/S0007-1226(68)80010-4 CASPubMedGoogle Scholar Schultz-Coulon , H.J. and Eckermeier , L. ( 1976 ). Postnatal growth of nasal septum . Acta Otolaryngol. 82 (1-2, 142 ): 131 . 10.3109/00016487609120872 CASPubMedWeb of Science®Google Scholar Seibert , R.W. ( 1983 ). Lip adhesion in bilateral cleft lip . Arch. Otolaryngol. 109 ( 7 ): 434 – 436 . 10.1001/archotol.1983.00800210010002 CASPubMedGoogle Scholar Suri , S. , Disthaporn , S. , Atenafu , E.G. , and Fisher , D.M. ( 2012 ). Presurgical presentation of columellar features, nostril anatomy, and alveolar alignment in bilateral cleft lip and palate after infant orthopedics with and without nasoalveolar molding . Cleft Palate Craniofac. J. 49 ( 3 ): 314 – 324 . 10.1597/10-204 PubMedWeb of Science®Google Scholar Traube , I.M. , Cutting , C.B. , Grayson , B.H. , and Shetye , P.R. ( 2021 ). Effect of one-stage bilateral cleft lip, nose, and alveolus repair following nasoalveolar molding on the premaxilla position at preadolescence: an 8-year retrospective study . J. Craniofac. Surg . https://doi.org/10.1097/SCS.0000000000007976 . Epub ahead of print. PMID: 34260466. 10.1097/SCS.0000000000007976 Google Scholar Cleft and Craniofacial Orthodontics ReferencesRelatedInformation

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.

This chapter aims to capture the bigger picture care for individuals with cleft lip and/or cleft palate (CL/P) and to consider the whole child and their journey before and after they transition from the orthodontic clinic. It discusses the concept of trauma-informed practice and the literature on adverse childhood experiences, resiliency, positive (protective) childhood experiences, and how these relate to children and youth with orofacial clefts. Child and adolescent health is complex and multifactorial. It is widely understood that experiences in childhood can impact later adult life, including happiness and health. The chapter also discusses the literature on barriers to accessing CL/P care, burden of care, and quality of life for patients and their families with CL/P. Social, demographic, financial, geographic, and medical factors can contribute to difficulties in navigating the medical system and accessing the care a patient needs.

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.

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.

Background: The exophthalmos and class III malocclusion seen in Crouzon syndrome can be treated by Le Fort III advancement/distraction. However, reconstructive options for zygomatic retrusion are limited. The authors describe the repair of isolated exorbitism in a patient with Crouzon syndrome, via bilateral zygomatic rotation-advancement. Methods: A 34-year-old woman with Crouzon syndrome complained of exorbitism and malar hypoplasia. Four years prior, she declined Le Fort III advancement and underwent orthodontic/orthognathic correction of malocclusion. Radiographs were used to develop a computerized surgical plan. Bilateral periorbital osteotomy with advancement/rotation of the zygomatic process was performed using custom osteotomy guides and plates. Images obtained immediately postoperative and 3- and 19-month postoperative were compared to assess surgical stability, accuracy, and soft tissue changes. Results: Decreased globe exposure and increased malar prominence have improved facial balance. Superimposed pre- and postoperative radiographs demonstrate bilateral advancement of the zygomatic body and inferior orbital rim. Superimposition of immediate postoperative and 19-month radiographs showed no relapse. Soft tissue histogram showed increased prominence of the malar eminence, lateral orbital rim, and cheek. Conclusions: Zygomatic rotation-advancement proved a safe, effective, stable, and predictable treatment for isolated malar hypoplasia in a patient with Crouzon syndrome. Virtual planning can enhance novel complex craniofacial procedures.

Many orthodontists working on patients with cleft lip and palate (CLP) have shown great enthusiasm for presurgical infant orthopedics (PSIO) to improve surgical outcomes with minimal intervention. Even though every clinician aims to use the best treatment modality for their patients, PSIO effects can be confounded by surgical type and timing of the primary repair, as is discussed in many studies. In such cases, one should be cautious when evaluating the particular outcomes for patients with CLP since it is difficult to differentiate the sole effect of an individual surgical or orthodontic intervention. As with any treatment methodology, nasoalveolar molding (NAM) has both benefits and limitations. Commonly cited concerns with NAM, and PSIO in general, include increased cost, increased burden of care, and a negative impact on maxillary growth. However, NAM cannot be deemed as having apparent long-term negative or positive effects on skeletal or soft tissue facial growth, based on previous studies. A review of the literature suggests that NAM does not alter skeletal facial growth when compared with the samples that did not receive PSIO. Nevertheless, the published studies on NAM show evidence of benefits to the patient, caregivers, the surgeon, and society. These benefits include documented reduction in severity of the cleft deformity prior to surgery and as a consequence improved surgical outcomes, reduced burden of care on the care givers, reduction in the need for revision surgery, and consequent reduced overall cost of care to the patient and society.

Objective: To quantify 3-dimensional (3D) nasal changes in infants with unilateral cleft lip with or without cleft palate (UCL±P) treated by nasoalveolar molding (NAM) and cheilorhinoplasty and compare to noncleft controls. Design: Retrospective case series of infants treated with NAM and primary cheilorhinoplasty between September, 2012 and July, 2016. Infants were included if they had digital stereophotogrammetric records at initial presentation (T1), completion of NAM (T2), and following primary cheilorhinoplasty (T3). Images were oriented in 3dMD Vultus software, and 16 nasolabial points identified. Patients: Twenty consecutively treated infants with UCL±P. Interventions: Nasoalveolar molding and primary cheilorhinoplasty. Main Outcome Measures: Anthropometric measures of nasal symmetry and morphology were compared in the treatment group between time points using paired Student t tests. Postsurgical nasal morphology was compared to noncleft controls. Results: Nasal tip protrusion increased, and at T3 was 2.64 mm greater than noncleft controls. Nasal base width decreased on the cleft side by 4.01 mm after NAM and by 6.73 mm after cheilorhinoplasty. Columellar length of the noncleft to cleft side decreased from 2:1 to 1:1 following NAM. Significant improvements in subnasale, columella, and nasal tip deviations from midsagittal plane were observed. Treatment improved symmetry of the alar morphology angle and the nasal base–columella angle between cleft and noncleft sides. Conclusions: Three-dimensional analysis of UCL±P patients demonstrated significant improvements in nasal projection, columella length, nasal symmetry, and nasal width. Compared to noncleft controls, nasal form was generally corrected, with overcorrection of nasal tip projection, columella angle, and outer nasal widths.

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.

Abstract Le Fort III distraction osteogenesis may be indicated in the treatment of syndromic craniosynostosis with severe midface retrusion and proptosis. This study assesses the stability of proptosis correction over 10-years. A retrospective review identified 15 patients with syndromic craniosynostosis treated by Le Fort III distraction prior to age 10 (9 males, 6 females; age 4.9 ± 1.5 years). Untreated, non-craniosynostotic age- and gender-matched controls were obtained from historical growth records. Lateral cephalometric tracings at pre-surgery (T1), immediate (T2), 1 year (T3), 5 years (T4), and 10 years (T5) (n = 11) post-distraction were superimposed using the best-fit of cranial base. Proptosis severity was defined as the horizontal distance between the Ant. Globe cephalometric point and orbital rim landmarks Orbitale and Lat. Orbit. The orbital rim advanced 10.54 ± 3.78 mm (P < 0.001) at Orbitale and 9.73 ± 4.54 mm (P > 0.001) at Lat. Orbit from T1 to T2; Ant. Globe advanced 3.13 ± 3.02 mm (p 0.001). Proptosis decreased 7.41 ± 5.29 mm (P < .001) from Orbitale and 6.60 ± 6.50 mm (p 0.002) from Lat. Orbit. Comparison to controls demonstrated phenotypic correction. In craniosynostotic patients from T2 to T5, the bony orbital rim demonstrated non-significant remodeling posteriorly and inferiorly. Anterior Globe moved 3.79 ± 1.47 mm anteriorly (P < .001), which did not differ significantly from controls. Proptosis increased by 4.18 ± 2.94 mm in craniosynostotic patients from T2 to T5. Le Fort III distraction was stable, with no significant anteroposterior relapse of the maxilla or bony orbit. Phenotypic relapse of proptosis to pre-treatment levels occurred through deficient growth of the midface, surface resorption at the orbital rim, and preservation of normal forward movement of Ant. Globe.

BACKGROUND:Gingivoperiosteoplasty can avoid secondary alveolar bone grafting in up to 60 percent of patients with a cleft. However, preoperative predictors of success have not been characterized. This study reports on the preoperative alveolar segment position most favorable for successful gingivoperiosteoplasty. METHODS:The authors performed a single-institution, retrospective review of patients with a unilateral cleft who underwent nasoalveolar molding. Alveolar segment morphology was directly measured from maxillary dental models created before and after nasoalveolar molding. Statistical analysis was performed to identify parameters associated with the decision to perform gingivoperiosteoplasty and its success, defined as the absence of an eventual need for alveolar bone grafting. RESULTS:Fifty patients with a unilateral cleft who received nasoalveolar molding therapy were included in this study (40 underwent gingivoperiosteoplasty and 10 did not). Eighteen alveolar morphology and position characteristics were tested, including cleft gap width, horizontal and vertical positions of the alveolar segments, alveolar stepoff, and degree of alveolar segment apposition. Post-nasoalveolar molding vertical rotation of the greater segment and the percentage of segment alignment in the correct anatomical zone were statistically significant predictors of the decision to perform gingivoperiosteoplasty (86 percent predictive power). Cleft gap, greater/lesser segment overlap, alveolar segment alignment, greater segment horizontal rotation, and alveolar segment width following nasoalveolar molding were significant predictors of gingivoperiosteoplasty success (86.5 percent predictive power). CONCLUSIONS:Greater segment vertical rotation and proper alveolar segment anatomical alignment are positive predictors of the decision to perform gingivoperiosteoplasty. Post-nasoalveolar molding evidence of proper alignment and direct contact between the alveolar segments were significant predictors of successful gingivoperiosteoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, III.

Cleft lip and palate is a complex craniofacial anomaly typically requiring treatment from a range of specialists to produce excellent outcomes. Due to the challenges of coordinating this extensive range of specialists, treatment is best provided by a centralized cleft lip and palate treatment team. This article outlines the members of a modern treatment team, their contributions and responsibilities in patient care, and the benefits to both patient and practitioner when treatment is provided by an experienced multidisciplinary team. (C) 2017 Elsevier Inc. All rights reserved.