Faculty Bibliography

OBJECTIVES/OBJECTIVE:To compare 3-dimensional nasal symmetry in patients with UCLP who had either rotation advancement alone or nasoalveolar molding (NAM) followed by rotation advancement in conjunction with primary nasal repair. DESIGN/METHODS:Pilot retrospective cohort study. MATERIALS AND METHODS/METHODS:Nasal casts of 23 patients with UCLP from 2 institutions were analyzed; 12 in the rotation advancement only group (Iowa) and 11 in the NAM, rotation advancement with primary nasal repair group (New York). Casts from patients aged 6 to 18 years were scanned using the 3Shape scanner and 3-dimensional analysis of nasal symmetry performed using 3dMD Vultus software, Version 2507, 3dMD, Atlanta, GA. Cleft and noncleft side columellar height, nasal dome height, alar base width, and nasal projection were linearly measured. Inter- and intragroup analyses were performed using t tests and paired t tests as appropriate. RESULTS:; P = .02). Intergroup analysis performed on the most sensitive linear measure, alar base width, revealed significantly less asymmetry on average in group 2 than in group 1 ( P = .013). CONCLUSION/CONCLUSIONS:This study suggests the NAM followed by rotation advancement in conjunction with primary nasal repair approach may result in less nasal asymmetry compared to rotation advancement alone.

OBJECTIVE:To determine the effects of nasoalveolar molding (NAM) on nasal airway architecture. DESIGN/METHODS:Retrospective case-control study of patients with unilateral cleft lip treated with NAM vs without NAM. SETTING/METHODS:Tertiary referral center specializing in cleft and craniofacial care. Patients, Participants, and Interventions: Thirty-six patients with complete unilateral cleft lip and alveolus: 19 with NAM therapy and 17 without NAM therapy. MAIN OUTCOME MEASURES/METHODS:Cone beam computed tomography (CBCT) scans were compared in multiple coronal sections and were evaluated for linear and angular septal deviation, inferior turbinate hypertrophy, and linear and 2-dimensional airway area. RESULTS:There were no significant differences in linear or angular septal deviation, inferior turbinate area, linear stenosis, or airway area between NAM- and non-NAM-treated patients. CONCLUSIONS:NAM effectively molds the external nasal cartilage and structures but may have limited effects on internal nasal structures.

The orthodontic treatment of adolescents with cleft lip and palate is complex and highly individualized. For such patients, there is a great need for thorough and comprehensive diagnosis as well as attention to multi-disciplinary aspects of orthodontic care. A framework for categorizing patients with varying forms and degrees cleft lip and palate into three levels of skeletal discrepancy from least to most severe is presented, and the specific treatment objectives of phase II orthodontic treatment for each of the three categories is then outlined. Moreover, due to specific challenges of a cleft-related dentition, the various aspects of the management of missing teeth are reviewed. Finally, the importance and most pertinent methods of retention are emphasized. (C) 2017 Elsevier Inc. All rights reserved.

Maxillary hypoplasia is a common finding in patients with cleft lip and palate (CLP). This study evaluated the skeletal and dentoalveolar changes in patients with CLP treated with an occlusally bonded maxillary protraction headgear (PHG) appliance. A total of 267 consecutive patients (1995-2012) treated with a PHG appliance were reviewed. In all, 40 patients with CLP (mean age 7.70 years) met the inclusion criteria. Mean treatment duration was 7.5 months with a mean force of 405 g per side. X- and Y-axis displacement for 38 lateral cephalometric landmarks was recorded at pretreatment (T-0), following removal of PHG (T-1), and at 1.5 years follow-up (T-2). From T-0 to T-1, A-point advanced by +2.48 mm (p < 0.01), UIE advanced by +4.91 mm (p < 0.01) and B-point moved posteriorly by -2.03 mm (p < 0.01) and inferiorly by -3.86 mm (p < 0.01). During the same time interval, the ANB angle changed from 0.08 to 3.77 (p < 0.01). At 1.5 year follow-up, A-point moved posteriorly by -0.28 mm (p > 0.05), B-point moved anteriorly by 3.69 mm (p < 0.01) and the ANB angle decreased to 0.51 (p < 0.01). A PHG appliance with a mean 810 g of force resulted in 54.60% skeletal and 45.40% dentoalveolar advancement. At 1.5 years (T2), the maxillary position was stable with minimal anterior growth; however, the mandible showed significant anterior growth contributing to reduction of the ANB angle. (C) 2017 Elsevier Inc. All rights reserved.

Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with bilateral cleft. The NasolAveolar molding (NAM) technique, a new approach to presurgical infant orthopedics, developed by Grayson reduces the severity of the initial cleft alveolar and nasal deformity. This enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This paper will discuss the appliance design, clinical management, and biomechanical principles of nasolaveolar molding therapy. Long-term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, and 60% reduction in the need for secondary alveolar bone grafting. No effect on growth of midface in sagittal and vertical plane has been recorded up to the age of 18 years. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair. (C) 2017 Elsevier Inc. All rights reserved.

Cleft lip and palate is a complex craniofacial anomaly typically requiring treatment from a range of specialists to produce excellent outcomes. Due to the challenges of coordinating this extensive range of specialists, treatment is best provided by a centralized cleft lip and palate treatment team. This article outlines the members of a modern treatment team, their contributions and responsibilities in patient care, and the benefits to both patient and practitioner when treatment is provided by an experienced multidisciplinary team. (C) 2017 Elsevier Inc. All rights reserved.

Background/Purpose: Distraction osteogenesis is indicated in patients with syndromic craniosynostosis with severe midface hypoplasia and proptosis. Pre-adolescent intervention is indicated when eye closure is limited, to prevent long-term ocular damage. The long-term stability of proptosis correction by Le Fort III distraction in this population has not been previously reported. Methods/Description: A retrospective review was conducted to identify patients with syndromic craniosynostosis treated by Le Fort III distraction prior to age 10, with cephalometric films available at least 3 years after treatment. 15 patients were identified (9 male, 6 female; age 4.9+/-1.5 years) with diagnoses of Crouzon(7), Apert(6), and Pfeiffer(2) syndromes. Lateral cephalometric radiographs at pre-surgery(T1), immediate post-distraction(T2), short-term post-distrac-tion(T3), and long-term(T4) were traced manually to identify the most inferior point on the orbital rim (orbitale), and the most anterior point on the globe. Tracings were superimposed on sella-ethmoid using the best-fit of cranial base details. Changes were measured using an x,y coordinate system with sella as the origin, and 7degree below the T1 sella-nasion line as the horizontal plane. Proptosis severity was defined as the horizontal distance between globe and orbitale. All measurements were corrected to a magnification factor of 0%. Changes in landmark location and proptosis severity were assessed by paired t-tests. Results: Orbitale advanced 10.2+/-3.8mm (p<0.001) horizontally from T1 to T2, with a superior movement of 2.1+/-3.5mm (p 0.02). The globe advanced 3.0+/-3.2mm (p 0.03) with no significant change in vertical position (p 0.539), resulting in a significant decrease in proptosis (-7.265.1mm, p<0.001). From T2 to T3 (1.160.7 years), orbitale remained stable horizontally (p 0.595), with minor inferior movement (-1.661.8mm, p 0.05). Globe position was stable horizontally (p 0.363) and vertically (p 0.436), as was proptosis correction (p 0.721). At long-term follow-up (T2 to T4, 4.87+/-0.93 years), orbitale remained stable horizontally (p 0.522) with no significant vertical change compared to T3 (p 0.113). Globe position was stable vertically (p 0.350); however, significant anterior globe movement occurred (+2.2+/-2.6mm, p 0.003) with an associated increase in proptosis (+1.9+/-2.7mm, p 0.015). Despite this, proptosis remained decreased by 5.3mm (95% CI 2.9mm, 7.6mm) at T4 compared to T1. Conclusions: Bony advancement of the orbital rim by Le Fort III distraction osteogenesis in pre-adolescent patients was stable 5 years post-distraction. Initial advancement of the orbit was associated with minor advancement of the globe, though considerable individual variation was noted. While proptosis was improved by treatment at all time-points, phenotypic relapse of 2mm was observed 5 years post-treatment, reinforcing the need for over-correction. At 5 year follow-up, 2.9 to 7.6 mm of proptosis correction remained