Long-term solutions for the delivery of craniofacial care in India and the developing world.

An international group of craniofacial surgeons was consulted to identify means of providing care of consistent quality to children with craniofacial anomalies in India and subsequently use this as a model for delivering craniofacial care to children in need throughout the developing world. Three senior craniofacial surgeons were selected from the Medical Advisory Board of the World Craniofacial Foundation to evaluate eligible centers in India. A subcommittee of 10 surgeons from the World Craniofacial Foundation Medical Advisory Board was formed to help develop summary recommendations based on this site visit. These centers were selected after contacting plastic surgeons and orthodontists involved in craniofacial and cleft care throughout India and asking the director of each center to complete a questionnaire documenting their current level of activity. Based on these responses, 3 potential craniofacial centers in India were identified. These sites were selected as potential locations for the development of craniofacial centers that could provide free care to indigent patients who otherwise could not receive treatment. The sites chosen consisted of a private hospital (southern India), a state-run government hospital (central India), and a federal government hospital (northern India). After the site visits, the directors of each of the 3 potential craniofacial centers in India were asked to complete a questionnaire helping to further identify their specific needs. The subcommittee of the World Craniofacial Foundation Medical Advisory Board then developed a set of summary recommendations to help guide the development of regional craniofacial centers in India. We feel that this process will facilitate access to care to indigent children with craniofacial anomalies who would not otherwise be eligible to receive appropriate care.

Characterization of the maxillary complex in unilateral cleft lip and palate using cone-beam computed tomography: a preliminary study.

Deficiencies in maxillary growth have often been implicated in suboptimal results of cleft lip and palate therapy. Cone-beam computed tomography provides an opportunity to look at the dimensions of the maxillary complex in three dimensions in a way that is not possible with lateral cephalograms or dental models. The purposes of this preliminary study were to outline a new set of 18 cone-beam computed tomographic measurements, apply them to 6 patients with unilateral cleft lip and palate (UCLP), and contrast them to a comparable sample of 7 normal young adults. The patients with UCLP were treated with a single protocol by a single surgeon and orthodontist. The 18 measurements had a mean intrarater reliability of 0.95 and ranged from 0.40 to 2.23 for the individual measurements. The mean interrater reliability was 1.01 and ranged from 0.40 to 2.45 for the individual measurements. Significant differences between the patients with UCLP and control subjects (combined sex samples) were found in palate length, anterior palate thickness, overall sagittal maxillary length, and premaxillary height (Mann-Whitney U tests, P

Primary bilateral two-stage cleft lip/nose repair: part II.

The Dallas surgical protocol for primary bilateral cleft lip/nose repair depends on the anatomy of the deformity. In cases of asymmetric bilateral clefts, an extremely small prolabium (<6 mm in vertical high) or a displaced premaxilla, a 2-stage lip repair was performed. At the same time, assessment of the tissue available for the columella determined the approach to the nose. In this part, the technique of 2-stage lip/nose repair of the bilateral cleft lip and palate is reviewed, and the long-term outcomes are presented.

Primary bilateral one-stage cleft lip/nose repair: 40-year Dallas experience: part I.

A 40-year experience with a proven protocol of repair for primary bilateral cleft lip/nose is presented. The Dallas surgical protocol for primary bilateral cleft lip/nose repair depends on the anatomy of the deformity. In cases of complete and partial bilaterally symmetric cleft lip, alveolus, and palate, 1-stage lip closure was performed at 3 months of age. In cases of asymmetric or incomplete bilateral clefts, an extremely small prolabium (<6 mm in vertical height), or a displaced or severely projected premaxilla, a 2-stage lip closure is more feasible ("Primary Bilateral Cleft Lip/Nose Repair Part II"). Primary nasal reconstruction was at 1 year of age. Early nasal reconstruction eliminates severe secondary deformity and the need for major early surgery. Orthognathic surgery was performed in approximately 40% of the senior surgeon's bilateral cleft patients to achieve optimal facial balance and aesthetics. Ten completed cases are presented with their long-term outcomes. The long-term outcomes of speech, occlusion, and facial balance are good to excellent in most of our bilateral patients. But in many cases, outcome of the lip/nose is still unsatisfying in the senior author's opinion compared with the results of unilateral cleft patients. These long-term outcomes are determined by the severity of the cleft deformity, primary repair technique, secondary surgery, and, most important, a protocol performed by a multidisciplinary experienced team until growth is complete. This technique should be considered in the treatment of all bilateral clefts, depending on the anatomy and team availability.

Unilateral cleft lip and nose repair; closed approach Dallas protocol completed patients.

Unilateral primary lip/nose repair, closed approach using the Dallas protocol presents step-by-step technique with 10 completed cases. Adjustments and corrections frequently used in the lip/nose repair are presented. A discussion of various techniques used today with their advantages and disadvantages is reviewed. Ten completed cases are presented with their long-term outcomes. Recommendations for developing countries regarding this and other techniques are made for the care of the unilateral primary cleft lip, nose, alveolus, and palate.

Reviewing the orthognathic surgical care of the patient with cleft lip and palate: the single surgeon experience.

Patients with cleft lip and palate are best treated in a multidisciplinary setting and benefit from being treated by experienced surgeons in high-volume centers. We present the evaluation of 103 consecutive patients with cleft lip and palate treated by a senior craniofacial surgeon. The results of orthognathic surgery in respect to function, stability, cosmesis, and complications are audited.

Current status of cleft lip and palate management in China.

Several million individuals with cleft lip and palate (CLP) exist in China, and it is estimated that at least 30,000 newborns with CLP are born every year. How to give them an optimal treatment with excellence is still a problem in most areas. The treatment of cleft patients presents various situations around world that are different from those in the United States and Europe. In this article, we reviewed the current status of CLP management in our country and shared our experience from one of the biggest CLP centers in China. We hope the management of cleft can be improved, and more patients can be treated by dedicated teams and dedicated centers in China.

Sequential treatment of speech disorders in velocardiofacial syndrome patients: an 8-year retrospective evaluation.

BACKGROUND: Speech disorders are the most common presentations of patients with velocardiofacial syndrome (VCFS) and are difficult to be treated with very good treatment outcome. The purpose of this study was to evaluate the clinical diagnosis and outcomes of sequential treatment of therapy for VCFS. METHODS: A retrospective study of 120 patients (ages ranged from 4.3 to 38 years old, with a mean age of 10.2 years) was conducted and thoroughly reviewed retrospectively oral speech evaluation, oral examinations, and lateral cephalometry of 33 patients. Comparison was made in 33 patients (age range, 4-17 years; mean age, 7.24 years); patients were compared with and age-matched controls, using IQ scores and speech intelligibility tests. A Chinese speech intelligibility test and blowing test were also used to evaluate the outcomes of modified pharyngeal flap surgery, behavioral therapy, and speech therapy. RESULTS: The average age of the primary diagnosis for VCFS was 13.9 years. No cleft palate and reduced mobility in pharyngeal function were found by oral examination. Speech intelligibility in the 33 patients with VCFS was 33%, with an average IQ test score of 67. Chinese speech intelligibility of 33 patients who underwent pharyngoplasty and speech therapy was improved from 47% to 98%, and the duration of blowing test increased from 17 to 38 seconds. The average length of therapy period was estimated to be 8 months. CONCLUSIONS: Hypernasality and reduced mobility in palate and pharyngeal structures of VCFS patients could be measured with Chinese speech intelligibility test and blowing tests. The pharyngeal flap surgery and the behavioral therapy are proved to be an effective protocol for VCFS.

Utilization of three-dimensional computed tomography for craniofacial phenotypic analysis in children with velocardiofacial syndrome.

OBJECTIVES: To analyze variants of the craniofacial phenotypes in children with velocardiofacial syndrome (VCFS) and children with cleft palates with a new protocol of landmarks using a three-dimensional computed tomography (CT)-reconstructed model in a cross-sectional group experimental design. MATERIALS AND METHODS: We present a retrospectively reviewed case series of 21 patients with VCFS, verified by short-tandem repeat techniques, and 20 children with cleft palate with age- and sex-matched controls from the Craniofacial Cleft Department of Oral and Maxillofacial Surgery of the 9th Shanghai People's Hospital. The records during the period between January 2005 and December 2008 were analyzed. The sample population of 41 children in this study was scanned with spiral CT. These images were reconstructed into three-dimensional models by SimPlant 11.2 and were analyzed with a new protocol of landmarks to test the variants of craniofacial phenotypes. RESULTS: All of the children with VCFS demonstrated velopharyngeal incompetence and craniofacial deformities. Measurements in the standard coordinate system demonstrated significant shorter cranial base, cervical vertebrae, longer maxilla height, and palatal angle. For the velopharyngeal variants, greater depth but lesser width of the pharyngeal cavity was shown in the VCFS group. CONCLUSIONS: Three-dimensional CT can provide precise data on craniofacial variants in children with distinctive morphologic features of VCFS.

Recombinant human BMP-2 enhances the effects of materials used for reconstruction of large cranial defects.

PURPOSE: Cranial defect reconstruction presents 2 challenges: induction of new bone formation, and providing structural support during the healing process. This study compares quantity and quality of new bone formation based on various materials and support frameworks. MATERIALS AND METHODS: Eighteen dogs underwent surgical removal of a significant portion of their cranial vault. Demineralized bone matrix was used to fill the defect in all animals. In 9 dogs, recombinant human bone morphogenetic protein-2 (rhBMP-2) was added, while the other 9 served as the non-rhBMP-2 group. In each group, 3 animals were fixed with cobalt chrome plates, 3 with adding platelet-rich plasma, and 3 fixed with a Lactosorb (Walter Lorenz Surgical, Inc, Jacksonville, FL) resorbable mesh. Necropsy was done at 12 weeks postoperative. Histomorphometry, density, and mechanical properties of the regenerate were analyzed. RESULTS: The non-rhBMP-2 groups showed minimal substitution of demineralized bone matrix with new bone, while only sporadic remnants of demineralized bone matrix were present in the rhBMP-2 groups. The defect showed more new bone formation (P < .001) and density (P < .001) in the rhBMP-2 groups by Kruskal-Wallis test. The area of new bone was not significantly different among the rhBMP-2 subgroups. The resorbable mesh struts showed no sign of bone invasion or substitution. In the non-rhBMP-2 resorbable mesh group, demineralized bone matrix almost totally disintegrated without replacement by new bone. CONCLUSIONS: The addition of rhBMP-2 to demineralized bone matrix accelerated new bone formation in large cranial defects, regardless of the supporting framework or the addition of platelet-rich plasma. The use of a resorbable mesh in such defects is advisable only if rhBMP-2 is added.

Bone generation in the reconstruction of a critical size calvarial defect in an experimental model.

OBJECTIVE: This study was designed to investigate the optimal combination of known osteogenic biomaterials with shape conforming struts to achieve calvarial vault reconstruction, using a canine model. METHODS: Eighteen adolescent beagles were divided equally into 6 groups. A critical size defect of 6 x 2 cm traversed the sagittal suture. The biomaterials used for calvarial reconstruction were demineralised perforated bone matrix (DBM), recombinant human bone morphogenetic protein-2 (rhBMP2) and autogenous platelet-rich plasma (PRP). The struts used were cobalt chrome (metal) or resorbable plate. The groupings were as follows: 1) DBM + metal, 2) DBM + PRP + metal, 3) DBM + PRP + resorbable plate, 4) DBM + rhBMP2 + metal, 5) DBM + rhBMP2 + PRP + metal, and 6) DBM + rhBMP2 + resorbable plate. Animals were euthanised at 3 months post-surgery. There was no mortality or major complications. Analysis was performed macroscopically, histologically, and with computed tomography (CT). RESULTS: There was complete bony regeneration in the rhBMP2 groups only. Non-rhBMP2 groups had minimal bony ingrowth from the defect edges and on the dural surface, a finding confirmed by CT scan and histology. PRP did not enhance bone regeneration. Shape conformation was good with both metal and resorbable plate. CONCLUSION: rhBMP2 but not PRP accelerated calvarial regeneration in 3 months. The DBM in the rhBMP2 groups were substituted by new trabecular bone. Shape molding was good with both metal and resorbable plate.

Unilateral cleft lip-nose repair--long-term outcome.

Good to excellent results have consistently been achieved by the authors in primary unilateral cleft lip-nose repair. Modifications and improvements in their original technique have led to better symmetry and balance, with less scarring. This technique, when performed by experienced surgeons, yields consistent, predictable, and achievable outcomes for all patients with unilateral cleft lip and nose, where normal appearance and function at conversational distance is the standard of care. The achievement of excellence in soft tissue and skeletal restoration optimizing each patient's growth potential depends on a surgical-orthodontic-speech-oriented treatment plan. Long-term outcomes demonstrating consistently good to excellent results can be achieved using this primary technique if it is backed up with a dedicated, multidisciplinary ongoing treatment protocol.

Skeletal facial balance and harmony in the cleft patient: Principles and techniques in orthognathic surgery.

The management of the palatal cleft, dental arch, and subsequent maxillary form is a challenge for the craniomaxillofacial surgeon. The purpose of this paper is to present the experience of a senior surgeon (KES) who has treated over 2000 patients with cleft lip and palate. This paper focuses on the experience of a recent series of 103 consecutive orthognathic cases treated by one surgeon with a surgical-orthodontic, speech-oriented approach. It will concentrate on not only correcting the occlusion, as others have described, but also on how a surgeon who was trying to achieve optimal aesthetic balance, harmony, and beauty, approached this problem.