Faculty Bibliography

ABSTRACT: The incidence of postoperative complications in cleft care is low. In this 19-year retrospective analysis of cleft lip and palate patients treated with preoperative nasoalveolar molding, we examine the incidence of postoperative oronasal fistulae. The charts of 178 patients who underwent preoperative nasoalveolar molding by the same orthodontist/prosthodontist team and primary cleft lip/palate repair by the same surgeon over a 19-year period were reviewed. Millard, Mohler, Cutting, or Mulliken-type techniques were used for cleft lip repairs. Oxford-, Bardach-, or von Langenbeck-type techniques were used for cleft palate repairs. One nasolabial fistula occurred after primary cleft lip repair (0.56% incidence) and was repaired surgically. Four palatal fistulae (3 at the junction between soft and hard palate and 1 at the right anterior palate near the incisive foramen) occurred, but 3 healed spontaneously. Only 1 palatal fistula (0.71%) required surgical repair. All 5 fistulae occurred within the first 8 years of the study period, with 4 (80%) of 5 occurring within the first 3 years. Although fistula rate may be related to surgeon experience and the evolution of presurgical techniques, nasoalveolar molding in conjunction with nasal floor closure contributes to a low incidence of oronasal fistulae.

BACKGROUND: Face transplantation allows the reconstruction of the previously nonreconstructible injury. Anthropometric landmarks are fixated to corresponding cephalometric landmarks to restore function and appearance, with emphasis on phonation, mastication, and functional upper airway. Currently, only a few face transplantations have been performed worldwide. A portion of these reconstructions involves combinations of hard and soft tissues of the midface. METHODS: Craniofacial and orthognathic considerations should be emphasized for functional effect in the planning and execution of face transplants that include both bone and soft tissue elements. These steps are taken to restore normal anatomy by fixating the midface into proper relationship with the skull base. Traditional orthognathic planning, using cephalometric parameters, often involves a line through sella and nasion as a reference for the skull base. Intraoperatively though, without a cephalograph, the sella-nasion plane is not accessible as a reference point. RESULTS: Postoperative analysis of our first face transplant recipient revealed that the Frankfort horizontal plane can alternatively serve as an accessible skull base reference point to guide the positioning of the midface. We have developed a technique to ensure fixation of the midface donor allograft in a proper functional relationship with the skull base, within 1 SD of Bolton normative data. CONCLUSIONS: "Reverse craniofacial planning" allows for precise fixation of the hard tissue components of the face transplant in relation to the skull base, as opposed to a "best fit" approach. We believe that this relationship results in the most anatomical restoration of occlusion, speech, and airway function.

BACKGROUND: : Patients with syndromic craniosynostosis and midface hypoplasia are often treated with Le Fort III advancement. The authors present four patients with extraordinarily long-term follow-up (in excess of 20 years). METHODS: : An institutional review board-approved retrospective chart review was performed on all patients with syndromic craniofacial synostosis who underwent Le Fort III advancement. Patients with greater than 20 years of cephalometric and photographic records were identified. Lateral cephalograms were obtained preoperatively, immediately postoperatively, at 1-year follow-up, and at long-term follow-up. Cephalograms were traced, digitized, and averaged. Fifty cephalometric landmarks were identified for serial measurements. RESULTS: : Of the four patients identified, one had Apert syndrome and three had Crouzon syndrome. Average age at the time of Le Fort III advancements was 11 years (range, 4 to 20 years). Average length of postoperative follow-up was 25 years (+/-5 years). No patient had significant anterior midfacial growth following Le Fort III advancement. Both young patients (<10 years) had substantial vertical inferior midfacial growth after advancement. CONCLUSIONS: : These data demonstrate that the Le Fort III segment of children with syndromic craniosynostosis does not grow significantly forward. Moreover, the traditional Le Fort III osteotomy does not provide the amount of midface advancement necessary to avoid phenotypic recidivism in these syndromic patients. This study also suggests that patients undergoing Le Fort III advancement appear to have zygomatic effacement and ptosis of the overlying soft tissue with deepening of the facial folds; collectively, it is suggested that these changes give the appearance of accelerated facial aging. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V

ABSTRACT: This article focuses on current practices and controversy in the area of presurgical infant orthopedics in patients born with cleft lip and palate.

BACKGROUND: Mandibular distraction has evolved from the use of external to the use of intraoral and semiburied devices. The authors highlight the evolution of the semiburied technique. The authors evaluate advantages and limitations, and report perioperative events for external and semiburied techniques to establish the indications for selection of the different devices. METHODS: A retrospective review was conducted of patients undergoing mandibular distraction at the New York University Langone Medical Center from the authors' introduction of mandibular distraction in May of 1989 to June 30, 2009. Perioperative events were stratified into three groups: minor incidents, moderate incidents, and major incidents. RESULTS: A total of 211 mandibular distraction procedures were performed: 129 external procedures on native bone, 37 external procedures on grafted bone, and 45 semiburied procedures on native bone. Minor incidents were more common with the semiburied device (62 percent) compared with external devices on native (26 percent) and grafted (38 percent) bone. There were fewer moderate incidents with the semiburied device (18 percent) than with the external device on native (22 percent) and grafted (30 percent) bone. In contrast to the external technique, no major incidents were seen with semiburied distraction. CONCLUSIONS: The semiburied device reduces scarring and has the mechanical advantages of being applied directly to the bone, less vulnerable to dislodgment, and more favorable for a vertical vector. However, its use requires more bone stock and it has the disadvantage of requiring a second operation for removal. Semiburied distraction is safe, reliable, and indicated for lengthening of the hypoplastic mandible where there is adequate bone stock for its attachment

BACKGROUND: Patients with Apert, Crouzon, and Pfeiffer syndromes who have severe midfacial hypoplasia are treated by Le Fort III midface advancement. The purpose of this study was to examine long-term (10-year) midface skeletal stability and growth following Le Fort III midface advancement in growing children. METHODS: A review of 192 patients with syndromic craniosynostosis treated by classic (nondistracted) Le Fort III advancement osteotomy between 1973 and 1998 was performed. Twenty-five patients met the inclusion criteria (age at surgery < 11 years and availability of cephalograms of diagnostic quality before treatment, after surgery, and at 1-, 5-, and 10-year follow-up). The mean age at the time of surgery was 5.8 years and the diagnosis was either Crouzon (n = 10), Apert (n = 9), or Pfeiffer (n = 6) syndrome. RESULTS: After surgery, point A advanced sagittally 10.72 mm and moved downward 3.77 mm. At 1 year, point A moved forward 0.10 mm and downward 0.47 mm. At 5 years, point A moved back 0.18 mm, whereas at 10 years it advanced 0.12 mm. During the same periods, however, pogonion came forward 5.72 mm and 7.32 mm, respectively. CONCLUSIONS: Le Fort III midface advancement in growing children with syndromic craniosynostosis is stable after the first year postoperatively. There is minimal horizontal growth of the midface between postoperative years 5 and 10, although the mandible continues to grow. Due to the differential growth rate of the midface and mandible, the facial profile becomes concave, thereby necessitating secondary midface surgery at the completion of skeletal growth

BACKGROUND:: The purpose of this study was to compare clinical outcomes and 1-year postsurgical stability with three different techniques of Le Fort III midface advancement. METHODS:: The records of 212 syndromic craniosynostosis patients were reviewed from the period 1973 to 2006. A total of 60 patients satisfied the inclusion criteria, and the mean age of the sample at surgery was 6.2 years. In group I (1977 to 1987), fixation was performed by interosseous wiring and intermaxillary fixation; in group II (1987 to 1996), fixation was achieved by only rigid plate fixation; and in group III (2000 to 2005), the patients underwent midface distraction with the rigid external distraction device. Cephalometric landmarks were identified and digitized at each of the time intervals (preoperatively, postoperatively, and 1 year postoperatively). RESULTS:: The mean advancement measured at point A in group I averaged 9.7 mm; in group II, it was 10.6 mm; and in group 3, it was 16.1 mm. There was no statistically significant difference in the amount of advancement between groups I and II. However, when groups I and II were compared with group III, there was a statistically significant difference (p < 0.05). No statistical significance was noted within and between all three groups at 1-year follow-up. CONCLUSIONS:: Significantly larger midface advancement was achieved with rigid external distraction (group III) compared with classic Le Fort III midface advancement with wire (group I) or plate (group III) fixation. At 1 year after surgery, the three groups showed relative stability of the advanced midface segment

BACKGROUND: Precise control of the position of the midface through distraction with the rigid external distraction (RED) device has been a challenge. The present RED device with wire attachments to the intraoral dental splint and to the skeletal bone plates allows for flexibility in the vertical plane of the osteotomized Le Fort III segment. This tends to rotate the midface in a counterclockwise direction with inferior movement of the posterior nasal spine. OBJECTIVES: To report the development of a rigid distraction splint attachment to the RED device that permits precise control of the position of the midface during the latency period and through the activation and consolidation phases. METHODS: This paper describes the appliance design and the clinical application of a new device in controlling the position of the midface during distraction. Placement of the device and application of the desired force vectors are discussed. Patients treated by this modified device are illustrated to document the planned midface position after Le Fort III midface advancement. RESULTS: Examination of predistraction and postdistraction cephalograms of 2 patients treated with the new device showed advancement with minimum inferior displacement of the midface during all phases of the distraction process. CONCLUSIONS: The new device prevents undesired inferior movement of the posterior midface immediately after osteotomy and helps to stabilize the midface during the latency period. The device enables directional control of the distraction vectors, resulting in more predictable midface position at the end of treatment

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, 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 yrs. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair

BACKGROUND: The purpose of this investigation was to determine the response of the osteotomized Le Fort III midface bony segment to variations in the location and direction, or vector, of force application on using the rigid external distraction device. METHODS: This retrospective study involved 18 consecutive syndromic craniosynostotic patients (average age, 5.7 years) who underwent Le Fort III midface advancement distraction. Various cephalometric and novel landmarks, located on the mobilized Le Fort III segment and on the components of the distraction device, were identified before activation and at mid-activation. The direction and magnitude of change for these points were recorded. RESULTS: Based on the observed change in the position of the midface during distraction, the sample was divided into the following groups. In group 1 (n = 5), the Le Fort III segment translated forward and no rotation was noted. In group 2 (n = 3), the Le Fort III segment rotated clockwise and showed downward displacement. In group 3 (n = 6), the Le Fort III segment showed forward displacement and rotated counterclockwise. In group 4 (n = 4), the Le Fort III segment translated forward and downward. CONCLUSIONS: Direction of movement and resultant change in position of the Le Fort III segment during distraction are directly related to the location and direction of force application. Translation forward, with minimal rotation, was achieved when the force was applied at a location 55 percent above the occlusal plane (between the occlusal plane and the nasion) and in a direction parallel to the maxillary occlusal plane