[Maxillary advancement osteotomy with sequelae cleft lip and palate: Dilemma between occlusion and aesthetic profile]. / Ostéotomie d'avancée maxillaire dans les séquelles de fente labio-maxillo-palatine: dilemme entre l'occlusion et l'esthétique du profil.

INTRODUCTION: Maxillary hypoplasia is a common sequela of cleft lip and palate. Its surgical treatment consists in a maxillary advancement by distraction or by conventional orthognathic surgery but morphological results are unpredictable. Our goal in this study was to see if the esthetical results (on the lip and the nose) of maxillary advancement were correlated to the preservation of lateral incisor space of the cleft side. PATIENTS AND METHOD: This retrospective study included 38 patients operated between 2002 and 2013. Unilateral clefts were studied independently from bilateral clefts. Profile aesthetics was evaluated independently and subjectively by two surgeons and scored on an 8-point scale. The result was classified as "good" if the score was superior or equal to 6. The score was correlated to the following parameters: amount of maxillary advancement, upper incisor axis, preservation of the missing lateral incisor space. RESULTS: In the "good result" group, the space of the lateral incisor was less often preserved. The nasolabial angle was more open and the upper central incisor axis more vertical. These results were more pronounced in bilateral clefts, but also found in unilateral clefts. DISCUSSION: Under reservation of the subjective evaluation and of the small number of patients, it seemed that lateral incisor space closure improved the profile of patients treated by maxillary advancement for cleft lip and palate sequelae.

[The orthodontist and the child with a cleft palate]. / L'orthodontiste et l'enfant porteur de fente.

Dealing with this type of malformation, the orthodontist is confronted with a three-level problem: inter-personal, social, and technical. Because families consider the birth of a cleft palate child to be a disaster, orthodontists who undertake their treatment should understand the genesis of the turbulence that families will have to endure. Most parents learn to deal with these difficulties, but the affected children are going to have to submit to the stares of those they encounter. Adolescence is a critical period for them and it is also the time when they will visit their orthodontist most frequently. Problems that accompany treatment of these patients are numerous and the treating orthodontists must point them out and explain them tactfully. The treating team must also establish a therapeutic alliance to envelop the cleft palate patients, ensuring maintenance of expert cooperation between specialists responsible for different aspects of their treatment.

[Bilateral labio-maxillo-palatal clefts. Therapeutic evaluation]. / La fente labio-maxillo-palatine bilatérale. Mise au point thérapeutique.

The wide diversity of bilateral facial clefts makes it most difficult to assess surgical success, particularly in terms of long-term outcome. The aim of this work was to examine the rationale for the current protocol used for cleft surgery at the Grenoble University Hospital. In a first group of 28 children, a 3-step surgical protocol was applied. The first two steps were performed between 4 and 8 months with at least 3 months between each procedure. Skoog's unilateral cheilo-rhino-uranoplasty was used, associated with a periosteal tibial graft. The third step, performed between 10 and 12 months, was for staphylorraphy. Outcome was analyzed at 15 years and evidenced the deleterious effect of excessive and asymmetrical premaxillary scars, of the 2-step cheiloplasty and of columella lengthenings from the lip. The frequency of secondary revision of the superior labial vestibule and the medial labial tubercule (43%) was considered to be high; this procedure should be re-examined as should be osteotomy (32% revision). Palatine closure, acquired in 82% of the cases and premaxillary stability, achieved in 86%, would appear to favor use of the periosteal tibial graft. The osteogenic capacity of this graft tissue was less satisfactory after a second harvesting (from the same tibia three months later). These results have led us to modify our protocol, favoring early and total closure of the bony palate and continued use of the periosteal tibial graft. We now use the following operative protocol: premaxillary alignment using an active orthopedic plate at 2 months, lip adhesion associated with staphylorraphy and passive palatine contention plate at 3 months, definitive bilateral cheilo-uranoplasty associated with a single periosteal graft at 7 months. The preliminary results with this protocol in a group of 12 children have shown better quality scars, more harmonious maxillary arches, an excellent occlusion of the deciduous dentition, and preservation of the positive results obtained with the periosteal tibial graft.

[Alveolar and hard palate repair by tibial periosteal graft in complete unilateral cleft lip and palate. Long-term follow-up of 51 cases]. / Evaluation à long terme de l'uranoplastie par greffe de périoste tibial dans la fente labio-maxillo-palatine totale unilatérale. A propos de 51 cas cliniques.

PURPOSE OF THE STUDY: The purpose of this study was double: appreciate the osteogenic and growth capacities of the free tibial periosteal graft concerning the alveolar and hard palate repair in the complete unilateral cleft lip and palate, and evaluate long-term follow-up concerning maxillo-mandibular morphology and palatal air-tight. MATERIAL AND METHOD: This retrospective study concerns 51 patients, of more than 13 years of age, treated for complete unilateral cleft lip and palate. The treatment included a Skoog type cheiloplasty, a tibial periosteal graft between 4 and 6 months (as described by M. Stricker) and a staphyloraphy between 8 and 18 months. Our documentation was: figures, pictures and precise description of the initial cleft, dental casts, teleradiographies, dental panorams performed at different stages of treatment, orthodontic, orthophonic and otologic follow-up. Growth was evaluated using casts during the first 6 years then by profil teleradiographies after puberty. Ossification was evaluated quantitatively by CT scan in 18 patients. RESULTS: Results confirm an ossification of the periosteal graft in 72% of cases and the advantage of periosteal graft in palatal air-tight. 85% of cases show equilibrated squeletal growth with good occlusion, and 13.7% of cases needed deferral osteotomy. CONCLUSION: We propose a method for long-term cleft results evaluation, with the use of periosteal graft.