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A retrospective Institutional Review Board-approved review was performed at the Institute of Reconstructive Plastic Surgery, NYU Langone Medical Center, of patients undergoing craniofacial distraction osteogenesis procedures using the rigid external distractor device between 2000 and 2010. Three particularly challenging cases were identified and are presented here.

Background/Purpose: LeFort III distraction osteogenesis is commonly recommended for children with syndromic craniosynostosis to reduce exorbitism, improve airway function, and decrease dysmorphism. This purpose of this study is to report on the long-term clinical outcomes of patients with syndromic craniosynostosis patients who have undergone early primary subcranial LeFort III distraction osteogenesis and who have been followed longitudinally through skeletal maturity. Methods/Description: Retrospective review of all patients who underwent LeFort III distraction osteogenesis between the ages of 3 and 11 years and were followed throughout development with longitudinal dental, medical, radiographic, and photographic evaluations conducted through skeletal maturity and beyond. Inclusion criteria entailed having preoperative medical photographs and cephalometric studies at 6 months and 1, 5, and 10 years postoperatively after the primary LeFort III distraction osteogenesis as well as cephalometric documentation 6 months and 1 year after the secondary midface advancement after skeletal maturity.
Result(s): Seventeen patients fulfilled inclusion criteria, with a mean age of 5.7 years at the time of initial LeFort III distraction. The mean advancement of point A was 14.9 mm anteriorly and 2.7 mm inferiorly along the x- and y-axis, respectively. Orbitale moved 10.5 mm anteriorly and 2.2 mm inferiorly along the x- and y-axis, respectively. At 10 years postoperatively, point A moved 3.4 mm anterior along the xaxis and 4.7 mm inferiorly along the y-axis, while orbitale moved 0.4 mm posteriorly and 3 mm inferiorly along the x- and y-axis, respectively. At the time of skeletal maturity, there was a return of occlusal disharmony from normal mandibular growth and a return of proptosis owing to remodeling of orbitale inferiorly, and the lateral orbital rim posteriorly, while the globe continued to grow in the anterior vector. All but 1 study patient underwent or is scheduled to undergo a secondary midface advancement at the LeFort III and LeFort I level after skeletal maturity was attained.
Conclusion(s): The data demonstrate that patients who undergo early LeFort III distraction osteogenesis before the age of mixed dentition will still most likely need a secondary midface advancement after skeletal maturity is reached given that there is a small degree of anterior growth at the level of the maxilla and no anterior growth at orbitale over time

Background/Purpose: Gingivoperiosteoplasty (GPP) performed concurrent with lip repair is an option for treating bony alveolar deficiency in patients with orofacial clefts. GPP has been demonstrated to produce bony continuity, eliminating the need for alveolar bone grafting (ABG) in two-thirds of treated cleft sites. The purpose of this study was to assess if early bone formation as produced by successful GPP influences maxillary canine eruption. Methods/Description: A retrospective chart review was conducted to identify patients born between January 1, 2000, and December 31, 2007, with unilateral complete cleft lip and alveolus, with or without cleft palate. Patients were included if they had successful GPP or ABG, and had panoramic or maxillary CBCT radiographs available at age 5 to 9 (T1) and 9 to 12 (T2) years, with a minimum of 6 months between radiographs. Panoramic images were excluded if a head positioning error produced an occlusal plane greater than 15degree from perpendicular to midline. Panoramic images were used to assess maxillary canine sector, angulation relative to midline and ipsilateral occlusal plane, and cusp tip height from ipsilateral occlusal plane. CBCT images were used to assess the horizontal distance between the canine cusp tip and the maxillary arch form. Clinical charts were reviewed to determine if canines erupted successfully or required intervention. Finally, canine mesial-distal and labio-lingual position after eruption was assessed using occlusal photographs. Outcomes in GPP and ABG groups were compared, and results were stratified by ipsilateral lateral incisor presence or absence.
Result(s): Seventy-nine patients met inclusion; 24 had successful bone fill after GPP, and 55 after ABG. In patients with cleft-side lateral incisors present, no significant differences were found between GPP and ABG groups in canine angulation, height, sector, eruptive outcome, or timing of eruption. When spontaneous canine eruption occurred, there was a statistically nonsignificant trend to more mesial eruptive position in patients who were treated with GPP. In patients with cleft-side lateral incisor agenesis, initial canine angulation did not differ. Patients who were treated with GPP demonstrated 10.8degree +/- 11.1degree spontaneous canine uprighting from T1 to T2, while canine angulation was maintained in the ABG group; this difference was statistically significant (P = .001). The GPP group demonstrated greater canine descent from T1 to T2, resulting in significantly less distance from the occlusal plane (5.8 +/- 4.8 mm) compared to the ABG group (9.4+/-4.2 mm). Horizontal distance to arch did not differ between the groups. In the GPP group, 75% of patients demonstrated successful spontaneous canine eruption, compared to 41% in the ABG group, though this did not reach statistical significance (P = .146).
Conclusion(s): Gingivoperiosteoplasty favorably influenced the angulation, height, and eruptive success of cleft-side canines in patients. These benefits were predominantly noted in patients with congenital absence of lateral incisors

BACKGROUND:Gingivoperiosteoplasty can avoid secondary alveolar bone grafting in up to 60 percent of patients with a cleft. However, preoperative predictors of success have not been characterized. This study reports on the preoperative alveolar segment position most favorable for successful gingivoperiosteoplasty. METHODS:The authors performed a single-institution, retrospective review of patients with a unilateral cleft who underwent nasoalveolar molding. Alveolar segment morphology was directly measured from maxillary dental models created before and after nasoalveolar molding. Statistical analysis was performed to identify parameters associated with the decision to perform gingivoperiosteoplasty and its success, defined as the absence of an eventual need for alveolar bone grafting. RESULTS:Fifty patients with a unilateral cleft who received nasoalveolar molding therapy were included in this study (40 underwent gingivoperiosteoplasty and 10 did not). Eighteen alveolar morphology and position characteristics were tested, including cleft gap width, horizontal and vertical positions of the alveolar segments, alveolar stepoff, and degree of alveolar segment apposition. Post-nasoalveolar molding vertical rotation of the greater segment and the percentage of segment alignment in the correct anatomical zone were statistically significant predictors of the decision to perform gingivoperiosteoplasty (86 percent predictive power). Cleft gap, greater/lesser segment overlap, alveolar segment alignment, greater segment horizontal rotation, and alveolar segment width following nasoalveolar molding were significant predictors of gingivoperiosteoplasty success (86.5 percent predictive power). CONCLUSIONS:Greater segment vertical rotation and proper alveolar segment anatomical alignment are positive predictors of the decision to perform gingivoperiosteoplasty. Post-nasoalveolar molding evidence of proper alignment and direct contact between the alveolar segments were significant predictors of successful gingivoperiosteoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, III.

Background/Purpose: The aim of this study was to investigate the effect of infant orthopedics on transversal, sagittal and vertical dimensions of maxillary and mandibular dentoalveolar measurements in patients with unilateral cleft lip and palate (UCLP) and to compare them to patients without cleft at the age of 5. Methods/Description: Forty-five dental casts of nonsyndromic patients with completeUCLP were assessed for this retrospective study (age range: 4.5-6.5 years). These patientswere divided into 2 groups based onwhether infant orthopedics were applied (IO) or not (NIO). Maxillary andmandibular dental casts were available for 25 patients in the IOgroup and 20 in the NIO group 20. These 2 cleft groups were compared to a control group of age-matched patients with class I occlusion and without a cleft (n = 48). Maxillary and mandibular anterior and posterior arch widths, arch lengths, and palatal depths were measured with a ruler and digital caliper. Lesser segment canine position and the amount of cleft gap were evaluated as well. For statistical analysis, ANOVA was used for comparisons between groups.
Result(s): Maxillary anterior (III-III) and posterior arch widths (V-V) were similar in the subgroups of patientswith clefts, whereas they were narrower than the noncleft control group (P < .01). There was no significant difference in mandibular arch dimensions between samples from patients with and without a cleft (P >= .05). Lesser segment arch perimeter did not differ between groups (P <= .336), while greater segment arch perimeter was found to be higher in the control group when compared to the groups with a cleft (P <= .01). Posterior palatal depth, measured from the occlusal surfaces of the second primary molars, was found to be higher in noncleft samples (P <= .001) and the difference between patients in the IO and NIO groups were not significant. However, measurement of anterior palatal depth revealed no significant difference between patients with a cleft and the control group (P >= .05). The maxillary deciduous canine at the lesser segmentwas located more palatinally in theNIO group than in the IOgroup (P < .05). Regarding the amount of cleft gap, the NIO group exhibited a bigger cleft width (3.98 +/- 2.65 mm) and depth (2.12 +/- 2.63 mm) than those of the IO group (2.36 +/- 2.48 mm, 0.78 +/- 1.14 mm, respectively) significantly (P <= .05).
Conclusion(s): Maxillary transverse measurements were decreased in groups of patients with a cleft both with/without IO when compared to a noncleft control group. The IO and NIO groups exhibited similar arch widths. Cleft depth and width were found to be higher in the NIO group

Background/Purpose: Gingivoperiosteoplasty (GPP) performed with lip repair has been shown to eliminate the need for alveolar bone grafting in two-thirds of treated cleft sites. In patients who have received GPP and subsequently require alveolar bone grafting (ABG), bone fill may be more favorable than in patients treated by ABG alone. However, some reports have suggested that GPP increases the risk of dental anomalies. This study aimed to assess the prevalence of dental anomalies in patients who were treated by GPP compared to those treated by ABG without GPP. Methods/Description: A retrospective chart review was conducted to identify patients born January 1, 2000, to December 31, 2007, with unilateral complete cleft lip and alveolus, with or without cleft palate. Patients were included if they received GPP or ABG at our center, and had adequate panoramic radiographs and clinical images at ages 5 to 9 and 10 to 12 years. Clinical records were assessed for missing or malformed teeth by a blinded examiner. Cleft side lateral incisors were classified as absent, present, extracted, and supernumerary; cleft side lateral incisor morphology was classified as normal, undersized/ peg shaped, or severely malformed; cleft side central incisors were classified as absent, normal, or anomalous; and the number of cleft side premolars was recorded. Dental anomalies were compared between the GPP and no-GPP groups using the chi-square test.
Result(s): Ninety-four patients met inclusion criteria: 46 treated with GPP, and 48 patients who did not receive GPP. Among patients who received GPP, cleft-side lateral incisors were absent in 54% of patients, compared to 50% of patients who did not receive GPP. Two patients in the GPP group and 4 in the no-GPP group required lateral incisor extraction. Two patients in the GPP group and one in the no- GPP group had supernumerary lateral incisors. These differences were statistically nonsignificant (P = .919). The majority of lateral incisors were undersized or peg shaped in both the no-GPP (20, 83.3%) and GPP (15, 71.4%) groups. One patient in the GPP group had a severely malformed lateral incisor. These differences were not statistically significant (P = .442). Cleft side central incisors were present in the majority of patients. In the GPP group, 5 patients (10.9%) exhibited central incisor agenesis, and a further 3 had significant hypoplasia. In the no-GPP group, 4 patients (8.3%) exhibited central incisor agenesis, and 5 (10.5%) significant hypoplasia. There were no intergroup differences (P = .937). Eight patients in the GPP group and 14 in the no- GPP group were missing cleft side premolars; the difference was not statistically significant (P = .937).
Conclusion(s): In this sample, gingivoperiostoplasty was not associated with increased prevalence of agenesis or malformation of cleft side incisors or premolars. When performed appropriately, gingivoperiosteoplasty is a safe treatment technique that does not increase the risk of dental anomalies

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.

Background/Purpose: Early LeFort III (LFIII) surgery or LFIII distraction involve osteotomies and disjunction in the region of the maxillary tuberosity in proximity to the maxillary posterior tooth buds. The purpose of this study was to determine the effect of early LFIII advancement and/or distraction on survival of the maxillary posterior permanent dentition. Methods/Description: A retrospective review of patients with syndromic craniosynostosis treated by early LFIII surgery and distraction was conducted. Of 225 syndromic craniosynostosis patients enrolled between 1973 and 2006, a total of 50 patients satisfied the inclusion criteria: 1) surgical intervention prior to age 8 years; 2) two panoramic radiographs, one prior to surgery and one in adolescence; 3) no apparent abnormalities in the position of permanent tooth buds. Of the 50 patients, 25 underwent LFIII surgery and 25 underwent midface distraction (M = 21, F = 29, average age at time of surgery = 5 +/- 1.1 years with diagnoses of Crouzon (20), Apert (17) and Pfeiffer (13), syndromes). Panoramic radiographs presurgically (T1) and postsurgically (T2) were inspected by a trained observer. The tooth buds were classified as being present (P), displaced (D), impacted (I), ankylosed (ANK), extracted (E), or absent (A). SPSS software was used to carry out chi-squared analysis and Fisher exact test.
Result(s): In the LFIII surgery group, 94% of maxillary second molars (D = 16%, I = 8%, E = 6%, A = 64%) and 28% of maxillary first molars (D = 18%, I = 4%, ANK = 2%, E = 2%, A = 2%) experienced a disturbance in eruption. Of the displaced second molars, 75% were located in the maxillary sinus and 25% in the maxillary tuberosity. Of the displaced first molars, 78% were located in the maxillary sinus and 22% in the maxillary tuberosity. In the distraction group, 80% of maxillary second molars (D = 38%, ANK = 4%, E = 14%, A = 24%) and 18% of maxillary first molars (D = 10%, I = 2%, E = 2%, A = 4%) experienced a disturbance in eruption. Of the displaced second molars, 37% were located in the maxillary sinus and 63% in the maxillary tuberosity. Of the displaced first molars, 100% were located in the maxillary tuberosity. Traditional LFIII osteotomy was significantly more likely to result in an adverse event for maxillary second molars compared to distraction (chi² = 4.33, P = .037).
Conclusion(s): The eruption of maxillary second molars had a high incidence of disruption following early LFIII intervention, with traditional LFIII surgery having greater negative consequences for the maxillary second molars compared to distraction. The maxillary first molars show significantly less disruption during early LFIII intervention with no significant differences noted between surgical procedures. Furthermore, a common disruption seen postsurgically is the displacement of the maxillary second molar tooth buds into the maxillary sinus, leading to the question if presurgical planning should include extraction/enucleation of the second molar tooth buds to avoid this sequela

OBJECTIVE:To quantify 3-dimensional (3D) nasal changes in infants with unilateral cleft lip with or without cleft palate (UCL±P) treated by nasoalveolar molding (NAM) and cheilorhinoplasty and compare to noncleft controls. DESIGN/METHODS:Retrospective case series of infants treated with NAM and primary cheilorhinoplasty between September, 2012 and July, 2016. Infants were included if they had digital stereophotogrammetric records at initial presentation (T1), completion of NAM (T2), and following primary cheilorhinoplasty (T3). Images were oriented in 3dMD Vultus software, and 16 nasolabial points identified. PATIENTS/METHODS:Twenty consecutively treated infants with UCL±P. INTERVENTIONS/METHODS:Nasoalveolar molding and primary cheilorhinoplasty. MAIN OUTCOME MEASURES/METHODS:Anthropometric measures of nasal symmetry and morphology were compared in the treatment group between time points using paired Student t tests. Postsurgical nasal morphology was compared to noncleft controls. RESULTS:Nasal tip protrusion increased, and at T3 was 2.64 mm greater than noncleft controls. Nasal base width decreased on the cleft side by 4.01 mm after NAM and by 6.73 mm after cheilorhinoplasty. Columellar length of the noncleft to cleft side decreased from 2:1 to 1:1 following NAM. Significant improvements in subnasale, columella, and nasal tip deviations from midsagittal plane were observed. Treatment improved symmetry of the alar morphology angle and the nasal base-columella angle between cleft and noncleft sides. CONCLUSIONS:Three-dimensional analysis of UCL±P patients demonstrated significant improvements in nasal projection, columella length, nasal symmetry, and nasal width. Compared to noncleft controls, nasal form was generally corrected, with overcorrection of nasal tip projection, columella angle, and outer nasal widths.

OBJECTIVE/UNASSIGNED:To investigate intrinsic palatal and alveolar tissue deficiency in patients with unilateral cleft lip and palate (UCLP) as compared to age-matched individuals without UCLP using surface area measurements on 3D scans of plaster casts. METHODS/UNASSIGNED:22 maxillary casts of infants with UCLP from the Wyss Department of Plastic Surgery of NYU Langone Medical Center and 37 maxillary casts from infants without clefts from Sillman's longitudinal study were scanned by Ortho Insight 3D by Motion View Software, LLC (Chattanooga, TN) and measured using Checkpoint software (Stratovan, Davis, CA). The palatal and alveolar surface areas of each cast were measured. The most superior point of the alveolar ridge in front of the incisive papilla and the most superior point of each maxillary tuberosity were connected by a line that ran along the highest part of the alveolar ridge. This line was used to set boundaries for the palatal surface area measurements. The surface areas of greater and lesser segments were measured independently on UCLP casts. A total palatal surface area for the UCLP sample including width of the cleft gap was also measured. RESULTS/UNASSIGNED:< .0001). CONCLUSION/UNASSIGNED:An intrinsic palatal and alveolar tissue deficiency exists in patients born with UCLP. The amount of tissue deficiency for a patient with UCLP should be considered when developing and executing a patient-specific treatment plan.