Impact of Orthodontic Gap Closure versus Prosthetic Replacement of Missing Maxillary Lateral Incisor on Dental Arch Relationships and Symmetry in 212 Patients with Cleft Palate: Retrospective Study.

BACKGROUND: Maxillary lateral incisors are frequently missing in patients with cleft lip and/or palate. The aim of this study was to assess how orthodontic gap closure or prosthetic rehabilitation of the missing maxillary lateral incisor affected dental arch relationships and symmetry at the end of treatment. The authors also aimed to determine the effect of the level of oral hygiene on the decision made to manage the missing maxillary lateral incisor gap. METHODS: A descriptive, retrospective cohort study including all patients with cleft lip and/or palate born between 1980 and 1999 and treated at Nantes Cleft Center was performed. Patients presenting unilateral or bilateral missing maxillary lateral incisors were reviewed. Data on management of the missing incisor gap, dental arch relationships, symmetry, and level of oral hygiene were collected. RESULTS: A total of 486 patients with cleft lip and/or palate were reviewed, including 212 patients with unilateral or bilateral missing maxillary lateral incisors. When compared with orthodontic gap closure, prosthetic replacement of the gap was associated with better final dental arch relationships (59.8 percent versus 10.3 percent; p < 0.01) and better dental arch symmetry (88.1 percent versus 44.0 percent; p < 0.01) for patients with unilateral missing incisors but not for patients with bilateral missing incisors. A higher level of oral hygiene was associated with more cases of prosthetic replacement for patients with unilateral missing incisors ( p = 0.03) but had no effect for patients with bilateral missing incisors. CONCLUSION: Prosthetic replacement of the missing maxillary lateral incisor gap provided better functional and aesthetic results for patients with cleft lip and/or palate presenting with unilateral missing maxillary lateral incisor.

Aesthetic and psychosocial impact of dentofacial appearance after primary rhinoplasty for cleft lip and palate.

The primary aim of this study was to demonstrate whether primary rhinoplasty shows aesthetic and psychosocial advantages for children with a complete unilateral cleft lip and palate. The second aim was to determine the satisfaction levels concerning the dentofacial appearance. Group A corresponded to patients from a center specialised in primary cheilo-rhinoplasty with 20 years' experience and Group B to patients who did not benefit from primary rhinoplasty. Children and their parents filled in a custom-designed satisfaction questionnaire on dentofacial appearance and its psychosocial impact. The variables studied were the main criterion (the nose) and secondary criteria (the upper lip, the smile, the profile and the face as a whole). 56 families consented to be involved in the study. The children did not rate statistically differently their social relationships if they had primary rhinoplasty or not. Parents however expressed very different views. They considered the nasal appearance of the children who had primary rhinoplasty as statistically more attractive and evaluated their psychosocial experience as significantly better. For the other parts of the face, in both groups, satisfaction levels of dentofacial appearance and psychosocial comfort were good (scores above 80/100). Yet, 44% of the families would go for further interventions, especially concerning the nose (13% of whom were in Group A and 42% in Group B). Within the limitations of this study, primary rhinoplasty seems to improve the patient's well-being and social life and, therefore, should be considered whenever appropriate.

[Etiological treatment of Obstructive Sleep Apnea]. / Du traitement étiologique des apnées obstructives du sommeil.

Research in the field of Obstructive Sleep Apnea (OSA) has been organized, and has profoundly transformed the quality of life of apneic patients, while even inviting dentofacial orthopedists to contribute to their symptomatic treatment. However, among the points still to be elucidated, the initial cause of the snoring that destabilizes the pharynx occupies a place apart. The objective of this article was to develop the proposal by Jacques Talmant regarding a mechanism capable of explaining the onset of OSA and for a therapy to treat pharyngeal destabilization during sleep. Based on published data, the etiopathogenesis of snoring and its consequences are described. Structural changes secondary to the vibratory trauma caused by snoring can affect each component of the pharyngeal structures and contribute to the collapsibility of this airway segment. By directly optimizing the development of ventilatory capabilities in their patients, orthodontists contribute, indirectly, to optimizing their cardiovascular and neuropsychological functions.

[Cleft rhinoplasty, from primary to secondary surgery]. / Rhinoplastie de fente primaire et secondaire.

Despite fifty years of statistics, congresses, publications, the cleft nose remains an enigma to the great majority of cleft specialists. Most of the published papers give recipes to camouflage the cleft deformity, very few are concerned by the functional anatomy and its relation with facial growth. The complexity of the matter, the results frequently disappointing, the lack of awareness of the necessity of early nasal breathing, and the academic condemnation of any imperfect attempt to correct the nose at the time of the first operation have led to resignation. For the last forty years, we have been involved in a careful and obstinate research about the early correction of the cleft nose deformity. We wish to present our conclusions in this chapter with at least 17 years of follow-up. They are as following: in cleft patients the nasal cartilages are only deformed. We can achieve sub periosteal and sub perichondrial dissections by 6 months of age without being harmful for facial and nasal growth. Repositioning accurately the nasal structures is enough if we are able to control the healing process and prevent endonasal wound contraction. We have not to do any compromise and favor one function with regard to the others, nasal ventilation being the most important for a good facial growth. In a word, nasal pediatric surgery is necessary at the time of the first operation from 6 months of age and should be carried on with a double demand, aesthetic and functional. To achieve this goal, we must have a sound knowledge of the cleft nose deformity, of the adequate surgical techniques and of the logic chronology to reach the best result. The nose repair cannot be limited to the nasal cartilages. The whole nasal structure is concerned especially its bony framework, the width of which at the level of the piriform orifice and the nasal floor depends on the outcomes of any surgical step that it would relate to the lip, palate or alveolar closure. Interaction of all these factors calls for an appropriate answer in adequation with the diagnosis of the deformity and a coherent answer as we know that any local action may induce an unfavorable chain reaction and should integrate a global and logic project. After the primary surgery, additional correction for aesthetic or functional purpose as well, may be useful during the period of growth. For cleft teenagers or adults, the rhinoplasty can simply be indicated for harmonization after a good primary nasal correction and optimal facial growth. On the contrary, the rhinoplasty may be more or less a complex operation for the usual and severe deformities. In the last case, the diagnosis must take into account all the residual deformities, even the labial and alveolar ones, and the treatment plan integrate all the principles and techniques of the primary surgery. What has not been done at the time of the primary surgery, should be done secondarily: all the structures are present, only deformed and embedded in scarred tissues. Primary or secondary cleft rhinoplasty must be undertaken by surgeons accustomed to cleft patients, but also trained in the other fields of nasal surgery, aesthetic and reconstructive.