The Effects of Secondary Cleft Procedures on Alar Base Position and Nostril Morphology in Patients with Unilateral Clefts.

OBJECTIVE: To compare effects of secondary cleft procedures on alar base position and nostril morphology. DESIGN: Retrospective review. SETTING: Multidisciplinary cleft clinic at tertiary center. PATIENTS, PARTICIPANTS: Seventy consecutive patients with unilateral clefts were grouped according to secondary procedure. INTERVENTIONS: Alveolar bone graft versus total lip takedown with anatomic muscle repair versus single-stage total lip with cleft septorhinoplasty (nose-lip) versus rhinoplasty alone. MAIN OUTCOME MEASURES: Anthropometric measurements were recorded from pre- and postoperative photographs. Ratios of cleft to noncleft side were compared within and across groups pre- and postoperatively using parametric and nonparametric tests. RESULTS: Within the bone graft group, no differences were seen postoperatively in alar base position in long-term follow-up. The total lip group demonstrated greater symmetry at the alar base (P < .001), increased vertical lip dimension (P < .001), and decreased nostril height (P = .004) postoperatively. Within the nose-lip group, increased vertical dimension and alar base support (P < .001) were also seen postoperatively. Across groups, the single-stage nose-lip group demonstrated greatest alar base symmetry on worm's-eye view (P < .04). CONCLUSIONS: Alar base asymmetry in patients with unilateral clefts may be related to soft tissue deficiency and was not affected by alveolar bone grafting. Total lip takedown with anatomic muscle reapproximation was associated with increased alar base symmetry and vertical lip dimension on cleft to noncleft side. Greatest symmetry at the alar base was seen following single-stage nose-lip reconstruction, which may be an effective technique for correcting the secondary cleft lip nasal deformity.

The effects of nonvascularized versus vascularized bone grafting on calvarial defect healing.

It remains unknown whether bone graft vascularity influences calvarial healing. The purposes of this study were (1) to develop a model to study nonvascularized and vascularized calvarial grafts as well as (2) to compare effects of bone graft vascularity on calvarial healing. Bilateral calvarial defects were created in 26 Wistar rats. The defects were left empty within 1 parietal region. On the contralateral side, the defects were partially closed with native parietal bone (control group, n = 6), nonvascularized (N-V, n = 10), or vascularized bone grafts (VAS, n = 10). The vascularized grafts were supplied by perforating dural arterioles. Bone mineralization and healing patterns from serial microcomputed tomographic scans were compared within and across the groups using parametric and nonparametric tests. Differences in bone mineral content across sides were significant between the groups at weeks 6 (P = 0.016) and 12 (P = 0.025). Bone formation was greater within both the control and VAS groups versus the N-V group at weeks 6 and 12 (P < 0.05). Healing patterns differed between the groups (P < 0.05), progressing through islands of new bone formation within the control and VAS groups while limited to defect margins on the N-V graft side. In conclusion, a bilateral calvarial defect model was established to study bone graft vascularity. Bone quantity and healing patterns differed in the presence of the nonvascularized versus vascularized grafts. Although the calvarial defect model is often applied within the plastic surgery literature to study bone substitutes, greater understanding of basic mechanisms influencing calvarial healing is first needed to avoid confounding results.

Accounting for cranial vault growth in experimental design.

OBJECTIVE: Earlier studies have not accounted for continued growth when using the rat calvarial defect model to evaluate bone healing in vivo. The purpose of this study was: 1) to calculate rat cranial vault growth over time; and 2) to determine the effects of accounting for growth on defect healing. STUDY DESIGN: Bilateral parietal defects were created in 10 adult Wistar rats. Serial microscopic computerized tomography scans were performed. Bone mineral content (BMC) measured according to standard technique and repeated accounting for cranial growth over time was compared with the use of parametric and nonparametric tests. RESULTS: Cranial vault growth continued through 22 weeks of age, increasing 7.5% in width and 9.1% in length, and calvarial defects expanded proportionately. BMC was greater within defects accounting for growth 2-12 weeks postoperatively (P < .003). CONCLUSIONS: BMC was underestimated through standard analysis, which demonstrates the importance of accounting for cranial growth given advances in serial imaging techniques.

Critical analysis of consecutive unilateral cleft lip repairs: determining ideal sample size.

Objective : Cleft surgeons often show 10 consecutive lip repairs to reduce presentation bias, however the validity remains unknown. The purpose of this study is to determine the number of consecutive cases that represent average outcomes. Secondary objectives are to determine if outcomes correlate with cleft severity and to calculate interrater reliability. Design : Consecutive preoperative and 2-year postoperative photographs of the unilateral cleft lip-nose complex were randomized and evaluated by cleft surgeons. Parametric analysis was performed according to chronologic, consecutive order. The mean standard deviation over all raters enabled calculation of expected 95% confidence intervals around a mean tested for various sample sizes. Setting : Meeting of the American Cleft Palate-Craniofacial Association in 2009. Patients, Participants : Ten senior cleft surgeons evaluated 39 consecutive lip repairs. Main Outcome Measures : Preoperative severity and postoperative outcomes were evaluated using descriptive and quantitative scales. Results : Intraclass correlation coefficients for cleft severity and postoperative evaluations were 0.65 and 0.21, respectively. Outcomes did not correlate with cleft severity (P  =  .28). Calculations for 10 consecutive cases demonstrated wide 95% confidence intervals, spanning two points on both postoperative grading scales. Ninety-five percent confidence intervals narrowed within one qualitative grade (±0.30) and one point (±0.50) on the 10-point scale for 27 consecutive cases. Conclusions : Larger numbers of consecutive cases (n > 27) are increasingly representative of average results, but less practical in presentation format. Ten consecutive cases lack statistical support. Cleft surgeons showed low interrater reliability for postoperative assessments, which may reflect personal bias when evaluating another surgeon's results.

Correction of the cleft lip lateral bulge deformity using anatomic muscle repair.

BACKGROUND: The lateral bulge deformity may result after primary cleft lip repair. In a pilot study, greater orbicularis oris thickness and levator width underlying the lateral bulge were identified using ultrasound. The purpose of this study was to evaluate postoperative results of anatomic muscle repair for lateral bulge correction. METHODS: Patients with a lateral bulge after primary unilateral cleft lip repair were prospectively recruited. Oronasal musculature and connective tissue dimensions were measured using ultrasound, preoperatively and postoperatively. Guided by preoperative ultrasound findings in each patient, lateral bulge correction consisted of total lip takedown and anatomic orbicularis oris reapproximation. Within each group, measurements between sides at corresponding landmarks were compared using t-tests. Ratios between sides at corresponding landmarks preoperatively and postoperatively were compared using parametric and nonparametric tests. Repeat measurements were performed to calculate intrarater reliability. Standardized video assessments of dynamic lip function were recorded preoperatively and postoperatively. RESULTS: Average patient age was 17.4 years. Patients were evaluated preoperatively and postoperatively (n=14) at 7.8 months' mean follow-up. Cleft-side orbicularis thickness and levator width were greater preoperatively versus postoperatively (P=0.003 and P=0.018, respectively). Postoperatively, no differences were seen between sides for both orbicularis thickness (P=0.763) and levator width (P=0.626). All patients demonstrated improved lip contour and symmetry, both static and dynamically, on video assessments. CONCLUSIONS: Lip contour, function, and aesthetics improved clinically, and lip muscle anatomy normalized postoperatively as assessed using ultrasound. Complete orbicularis oris takedown and anatomic reapproximation effectively addressed the lateral bulge deformity.

Definition of the lateral bulge deformity after primary cleft lip repair using real-time high-resolution ultrasound.

The lateral bulge is a common secondary deformity after primary cleft lip repair; however, its underlying anatomy remains undefined. The purpose of this study was to use real-time high-resolution ultrasound to better understand the anatomy underlying the lateral bulge deformity. Twenty-three patients with a lateral bulge were included in addition to 12 patients without clefts to validate ultrasound measurements. Muscle and connective tissue dimensions were recorded at standardized landmarks using ultrasound, both at rest and with movement. The cleft and noncleft sides (right and left in noncleft patients) were compared within groups, and ratios between sides were compared across groups using parametric and nonparametric tests. Repeat measurements were recorded to calculate intrarater reliability. Orbicularis oris thickness was greater on the cleft side in the lateral bulge group at rest, both at the philtral column and alar crease (P < 0.001), and with facial movement at the corresponding landmarks (alar crease: smile P < 0.001 and pucker P = 0.003; philtral column: smile P < 0.001 and pucker P = 0.001). The ratio for levator width was also greater in the lateral bulge group (P < 0.001). No differences were identified between sides at the corresponding landmarks in the noncleft group. Ultrasound enabled real-time high-resolution evaluation of anatomic differences underlying the lateral bulge deformity. It was associated with greater orbicularis oris thickness and levator width on the cleft side. Findings from this study may guide future surgical correction of the lateral lip bulge.

Gingivoperiosteoplasty following alveolar molding with a Latham appliance versus secondary bone grafting: the effects on bone production and midfacial growth in patients with bilateral clefts.

BACKGROUND: The role of gingivoperiosteoplasty in closure of bilateral alveolar clefts remains unclear. The purpose of this study was to evaluate bone production and midfacial growth in patients with bilateral clefts treated with gingivoperiosteoplasty following alveolar molding with a pin-retained Latham appliance versus secondary bone grafting. METHODS: Patients with complete bilateral clefts past permanent canine eruption were included. Ethics approval and informed consent were obtained. Periapical films and lateral cephalograms were analyzed by one blinded rater based on three radiographic grading scales--Bergland, Witherow et al., and Long et al.--and standard cephalometric landmarks, respectively. Repeated measurements were recorded to assess intrarater reliability. Measurements were grouped according to gingivoperiosteoplasty versus secondary bone grafting and compared using parametric and nonparametric tests. RESULTS: Fifty-three patients (gingivoperiosteoplasty, n = 43; secondary bone grafting, 10) met inclusion criteria. Average age was 15 years and 66 percent were male patients. Thirty-five patients had adequate radiographs for evaluation (gingivoperiosteoplasty, n = 25; secondary bone grafting, n = 10). Gingivoperiosteoplasty was clinically less successful than secondary bone grafting, 58 percent versus 90 percent, respectively. The quantitative radiographic success rate of gingivoperiosteoplasty, however, was 28 percent. Secondary bone grafting demonstrated higher Bergland, eight-point, and location grading (p < 0.002), and less alveolar notching (p = 0.008). Anteroposterior maxillary and mandibular dimensions were significantly decreased for the gingivoperiosteoplasty group versus the secondary bone grafting group. CONCLUSIONS: Bone quantity and location were inferior following bilateral gingivoperiosteoplasty versus secondary bone grafting, and the majority of patients required subsequent bone grafting. The gingivoperiosteoplasty group had decreased maxillary growth with mandibular compensation. Secondary bone grafting therefore remains our first choice for repair of bilateral alveolar clefts.

The effects of gingivoperiosteoplasty following alveolar molding with a pin-retained Latham appliance versus secondary bone grafting on midfacial growth in patients with unilateral clefts.

BACKGROUND: Gingivoperiosteoplasty is used for early closure of the alveolar cleft in patients with complete clefts of the primary palate. However, its impact on long-term facial development remains unclear. The purpose of this study was to evaluate the effects of gingivoperiosteoplasty following alveolar molding with a pin-retained Latham appliance on long-term midfacial growth and compare it with secondary bone grafting. METHODS: A retrospective review identified patients born with unilateral complete clefts of the primary and secondary palate. All patients were past the age of permanent canine tooth eruption. Standard cephalometric landmarks were plotted and analyzed by a blinded rater. Patients were divided into two groups based on type of alveolar closure: secondary bone grafting-only or gingivoperiosteoplasty-total. The gingivoperiosteoplasty-total group was further subdivided based on gingivoperiosteoplasty clinical outcomes. Statistical analyses first controlled for age and then for age and palate repair. RESULTS: The average age of the patients was 14.7 years. Radiographs were obtained for 54 patients (gingivoperiosteoplasty-total, n = 38; secondary bone grafting-only, n = 16). The gingivoperiosteoplasty-total group demonstrated decreased maxillary height (p = 0.005) and protrusion (p = 0.001) versus secondary bone grafting only. Dentoalveolar occlusion was not statistically different between groups. CONCLUSIONS: Gingivoperiosteoplasty following alveolar molding with a pin-retained Latham appliance resulted in decreased maxillary protrusion and height compared with secondary bone grafting only. These differences were found irrespective of the technique of palatoplasty. This technique resulted in similar growth patterns as documented following primary bone grafting. Secondary bone grafting therefore remains the authors' surgical approach to the cleft alveolus.

Evaluating the success of gingivoperiosteoplasty versus secondary bone grafting in patients with unilateral clefts.

BACKGROUND: The role of gingivoperiosteoplasty in closure of the cleft alveolus remains controversial. Few studies have documented long-term results of gingivoperiosteoplasty and how it compares to secondary bone grafting. The purpose of this study was to compare gingivoperiosteoplasty with secondary bone grafting by evaluating the amount of bone produced at the alveolar cleft site in patients with unilateral clefts. This comparison should help delineate the role of gingivoperiosteoplasty in the management of patients with clefts. METHODS: Eighty-six unilateral patients past the age of permanent canine tooth eruption with repaired alveolar clefts were identified. Clinical evaluations of the alveolar cleft site were performed. Grading for 73 periapical and occlusal films was recorded using the scales of Bergland, Long et al., and Witherow et al. and grouped according to gingivoperiosteoplasty (n = 64) or secondary bone grafting (n = 9). RESULTS: The average patient age was 17 years. The clinical success rate of gingivoperiosteoplasty was lower than that of secondary bone grafting, 41 percent versus 88 percent, respectively. Radiologic evaluations showed that the gingivoperiosteoplasty group had a greater than 90 percent failure rate. In addition, patients in the gingivoperiosteoplasty group that had salvage bone grafting after failed gingivoperiosteoplasty (n = 19) still had less bone at the alveolar cleft compared with patients in the secondary bone grafting group. CONCLUSIONS: Gingivoperiosteoplasty resulted in bone of less quantity and poorer location within the alveolar cleft. Most unilateral clefts repaired with a gingivoperiosteoplasty will require additional bone grafting. Secondary bone grafting should continue to be considered the standard treatment.