Active Presurgical Infant Orthopedics for Unilateral Cleft Lip and Palate: Intercenter Outcome Comparison of Latham, Modified McNeil, and Nasoalveolar Molding.

OBJECTIVE: To compare dental arch relationship, craniofacial form, and nasolabial aesthetic outcomes among cleft centers using distinct methods of presurgical infant orthopedics (PSIO). DESIGN: Retrospective cohort study. SETTING: Four cleft centers in North America. PATIENTS: One hundred ninety-one children with repaired complete unilateral cleft lip and palate (CUCLP). MAIN OUTCOME MEASURES: Dental arch relationship was assessed using the GOSLON Yardstick. Craniofacial form was assessed by 12 cephalometric measurements. Nasolabial aesthetics were assessed using the Asher-McDade system. Assessments were performed between 6 and 12 years of age. RESULTS: The center that used no PSIO achieved the most favorable dental arch relationship and maxillomandibular relationship, with a median GOSLON score of 2.3 ( P < .01) and an ANB angle of 5.1° ( P < .05). The proportion of children assigned a GOSLON score of 4 or 5, predictive of the need for orthognathic surgery in adolescence, was 16% at the center that used no PSIO and no secondary surgery, compared to 76% at the centers that used the Latham appliance and early secondary lip and nose surgery ( P < .01). The center that used no PSIO and no secondary surgery achieved significantly less favorable nasolabial aesthetic outcomes than the centers using Latham appliance or nasoalveolar molding (NAM) ( P < .01). CONCLUSIONS: Effects of active PSIO are multifaceted and intertwined with use of revision surgery. In our study, centers using either the Latham appliance combined with early revision surgery or the NAM appliance without revision surgery achieved better nasolabial aesthetic outcomes but worse maxillary growth, compared to a center using no PSIO and secondary surgery.

Mandibular deformities: single-vector distraction techniques for a multivector problem.

Single-vector distraction devices have been criticized for creating a malocclusion in an attempt to correct a three-dimensional mandibular deficiency, resulting in the evolution of a multiplanar device. Although there are indications for the use of a multiplanar device, a vast number of patients with mandibular hypoplasia can be effectively treated with a single-vector device, producing a normal occlusion and an aesthetic result while minimizing facial scarring and simplifying postoperative care. The purpose of this review was to describe surgical techniques whereby a single-vector device is effectively used in treating a multivector mandibular deficiency.A retrospective analysis of all patients who underwent mandibular distraction at the Children's Hospital of Philadelphia between 1996 and 2005 with a semiburied, uniplanar device was conducted. Charts, photographs, graphs, operative reports, computed tomography scans, and cephalometrograms were reviewed for those patients undergoing uniplanar mandibular distraction.Ten unilateral and 4 bilateral distractions were performed. In these 14 patients, causes included hemifacial microsomia, Treacher Collins syndrome, posttraumatic hypoplasia, and temporomandibular joint ankylosis with hypoplasia. The average device distraction was 29 mm (range, 18-34 mm). The average age at distraction was 8.4 years (range, 4-15 years). Surgical techniques for these patients will be described in detail. The single-vector, semiburied device can be effectively used to aesthetically correct a three-dimensional problem and to produce or maintain a class I occlusion while simplifying postoperative management and minimizing facial scarring.