- Email: [email protected]
Repair of bilateral clefts of lip, alveolus and palate Part 1: A refined method for the lip-adhesion in bilateral cleft lip and palate patients
Journal of Cranio-Maxillofacial Surgery (2001) 29, 39–43 # 2001 European Association for Cranio-Maxillofacial Surgery doi:10.1054/jcms.2000.0187, available online at http://www.idealibrary.com on
Repair of bilateral clefts of lip, alveolus and palate Part 1: A refined method for the lip-adhesion in bilateral cleft lip and palate patients Klaus Bitter Department of Maxillo-Facial Plastic Surgery (Head: Prof. Dr. Dr. K. Bitter), University Hospital Frankfurt, Germany SUMMARY. The protruding premaxilla represents the most severe problem in the surgical closure of a bilateral cleft lip, alveolus and palate (BCLP). In principle there are two methods to overcome this obstacle: (1) preliminary lip adhesion and (2) presurgical repositioning with intraoral devices. According to the various degrees of premaxillary protrusion, sometimes adhesion alone is sufficient, if the surgical technique is unlikely to break down. In this paper a refined adhesion method is presented, withstanding traction to the wound margins and concomitantly enables lip and nose repairs in a single second operation. For patients with severe premaxillary protrusion, presurgical use of a Latham appliance achieves conditions for safe lip adhesion as above. Both treatment methods are outlined. # 2001 European Association for Cranio-Maxillofacial Surgery
(Latham, 1980; Millard, 1980; Millard and Latham, 1990). The adhesion principle has not been abandoned, as it delivers natural forces and the focus of the repositioning effect can be adjusted exactly to the anterior nasal spine. The severely protruded premaxilla, however, often inhibits lip adhesion due to a very high risk of wound break down. Although many modifications of the adhesion technique have been developed, no progress regarding its reliability has yet been achieved. Whenever several methods have been suggested to solve a problem, they raise the suspicion of being inadequate. It seems therefore prudent, to find a rationale for any combination of different procedures. The purpose of this paper is, to outline the cooperation between the Latham device and a newly modified lip adhesion for repairing the bilaterally cleft lip and lengthening the columella in a one stage operation.
INTRODUCTION The protruding premaxilla still remains the most severe obstacle in closure of bilateral clefts of lip, alveolus and palate (BCLP). No wonder, that in early generations it was simply cut away which was followed by a disastrous midfacial hypoplasia. The efforts, to move the premaxilla backwards into the gap between the lateral maxillary segments, can be traced back to the seventeenth century. More recently McNeil was the first to apply a device to achieve proper alveolar alignment and alleviate the need for subsequent surgical procedures (McNeil, 1950). Burston refined the method and demonstrated marvellous results following repositioning of the maxillary segments, albeit under in-patient conditions, which today are not affordable (Burston, 1958 and 1965) Hotz and Gnoinski popularized the method, which is now in wide-spread use and is known by some as the ‘feeding plate’ (Hotz, 1964 and 1973; Hotz and Gnoinski, 1976). Burston’s procedure however, is of limited effect, because no real active forces can be exerted to reposition the deviated maxillary segments, which is particularly necessary in the case of a protruding premaxilla. Even Burston’s active plates have the inherent disadvantage of being applied to the alveolar surface instead of at the key level of displacement, which is in the plane of nasal spine and nasal floor. For that reason the plate intrudes the premaxilla and does not move it posteriorly together with the septal strut. Pinned intraoral appliances respect this essential factor. Latham offers currently the most advanced device, which has been used in Frankfurt for 11 years in 71 cases of bilateral cleft lip, alveolus and palate
MATERIAL AND METHODS One hundred and seventy two patients with bilateral cleft of lip alveols and palate have been reviewed under the following time schedule since 1988. In an otherwise healthy newborn baby with an average birth weight, the Latham-appliance is inserted at 3 months of age. The indication for this device depends on the amount of premaxillary protrusion and on the consistency of the tissue. This sounds difficult, because there is no definite parameter for the decision. The degree of protrusion alone is not sufficient, although more than one centimetre threatens wound disruption. On the other hand, 39
40 Journal of Cranio-Maxillofacial Surgery
a protrusion of less than one centimetre can also cause wound breakdown, when the cartilage and bone of the nasal septum is very resistant due to its inherent stiffness. Nevertheless, the threshold of one centimetre may be incorrect; it does not exclude personal experience of greater protrusion, but still includes the possibility of failure. Two to three weeks later the appliance can be removed and the first operation is performed. It consists of (1) intravelar veloplasty, (2) lip adhesion and (3) insertion of grommets (Goode type). Four months after the first operation the second one is undertaken consisting of (1) gingivo-periosteoplasty and (2) one-stage lip closure plus columella lengthening. Approximately 1 year later, the hard palate is closed. At this time the cleft is so narrow depending on normal function of the lip and the soft palate, that the closure can be done with minimal surgery. Concomitantly the grommets are exchanged for Shepard-Eartubes, which fall out after several months and can then be reinserted according to individual requirements. The GoodeTubes do not fall out by themselves and usually remain in situ too long, producing a risk of middle ear complications.
SURGICAL TECHNIQUE OF LIP ADHESION In Figure 1, two different patients are presented. One with moderate premaxillary protrusion and very stiff tissues before (Fig. 1A) and after (Fig. 1B) using the Latham-appliance. Retropositioning of the premaxilla is clearly recognizable after two weeks.
Fig. 1 – Two patients with BCLP presurgically. (A) Moderate – severe protrusion of the premaxilla, requiring the LathamAppliance. (B) Two weeks after Latham-repositioning. The appliance has just been removed; the mucosal impressions of the device are still visible; the nasal septum is thickened by tissue inflow. (C) Slight – moderate protrusion of the premaxilla with no need for presurgical retropositioning.
The nasal septum is thickened because of the tissue inflow. The same patients will be shown in Parts 2 and 3 of this paper demonstrating normal growth and reshaping of the septum during the postoperative phase. This is important regarding the arguments which blame tissue damage on the use of the Latham device. The second patient (Fig. 1C) presented with minor protrusion, which easily can be overcome by lip adhesion alone and does not demand presurgical alignment. Figure 2 outlines stepwise the adhesion procedure in a patient with moderate premaxillary protrusion and soft tissue consistency. The diagram is for the purpose of clarifying something that cannot be clearly recognized from the clinical photographs. Figures 2D and 2E outline the marking of the incision-lines. Within the prolabial island, the C-flaps are designed laterally leaving a philtrum of nearly normal shape and dimension. The latter is not essential, because it will grow extensively when under traction from the lateral lip elements and usually has to be reduced later, when the definite lip closure is performed. The prolabial vermilion remains untouched. The lateral lip incision can be best described as a tiny advancement flap (which also leaves the vermilion intact) so that it can be sewn to its prolabial counterpart, to close the deep aspect of the lip. The extension of the incision has to be limited to the SBAL-point and the medial end of the white roll. (SBAL-point is an anthropological landmark, defined as that point of the nasal ala, that definitely meets the upper lip). Arrow 1 point at these in Figure 2D and 2E. There is no trespassing allowed beyond these land-marks otherwise the definitive lip closure cannot be achieved with fresh tissue. Sometimes, especially in patients with a very wide premaxilla, it is necessary, to extend the incision into the nasal vestibulum along the piriform aperture, to mobilize the ala base, which has to be positioned on top of the premaxilla and to be fixed to the anterior nasal spine. To cover the raw area within the nasal vestibulum, a Muir-flap offers a safe procedure. Arrow 3 points to this type of flap from the cleft vermilion in Figure 2E. In Figure 2F the arrow runs along the axis of the Muir flap, which is attached to the gaping vestibular defect. It has to be emphasized that this manoeuvre is necessary only in rare and extraordinary situations. When all edges and all flaps are cut and mobilized, the first stage of the repair is to fix the alar bases onto the premaxilla at the anterior nasal spine. This in principle is an alar cinch suture and the nasal and paranasal muscles remain untouched, because the distance between the muscle ends and the anterior nasal spine is too great to attach them safely, which of course would be desirable to establish the normal anatomy. By pulling together the alar bases (to the midline) the cleft margins close in to the prolabium, so that the vermilion edges can be closed and form the back of the preliminary lip repair (Figs 2H, I).
Repair of bilateral clefts of lip, alveolus and palate 41
Fig. 2 – Adhesion technique step by step. See text.
The third step is to insert the C-flaps into the subalar gap. This corresponds perfectly with Millard’s banking procedure and offers the great advantage of closing the lip definitively together with the columellar lengthening in one session during the second operation. This is done when the premaxilla has been retropositioned into the space between the lateral maxillary segments. (See Part 2 of this paper.) Finally the skin of the lateral lip elements is sutured together with two or three mattress sutures, which run across the prolabial island. This has to be done very smoothly because the lateral traction is considerable and the closure sometimes becomes a type of intraoperative tissue expansion. The most cranial crosssuture has to be slung around the anterior nasal spine and consequently exerts a key function in repositioning the deviated cleft segments. A superficial wound closure usually is not essential but can be performed with 6–0 resorbable suture material. There is no need for suture removal because the quality of the scar is irrelevant. It is better to leave the sutures, to avoid the slightest risk of wound break down.
RESULTS In Figure 3 a patient is seen with a bilateral cleft and only a slight premaxillary protrusion, not requiring any presurgical repositioning a and b show the situation at the time of the first operation at age 3 months. Figure 3C and D show the same patient 4 months later, when the second operation for closure of the alveolar clefts together with concomitant lip-and cloumellar reconstruction is performed. In c, the incision lines for the lip repair are outlined. (See Part 2 of this paper.) In Fig. 3D the premaxilla forms a butt joint with the lateral alveolar segments. A gingivo-periosteoplasty can be performed easily and will facilitate spontaneous bone formation. In Figure 4 a patient is depicted with a moderate premaxillary protrusion but very stiff and resistant septal tissue which would have threatened the lipadhesion with break down. Therefore the Latham appliance was inserted for two weeks and succeeded in moving the premaxilla symmetrically into the gap between the lateral segments. The result of the adhesion procedure is shown in Figs 4D and E.
42 Journal of Cranio-Maxillofacial Surgery
periosteoplasty more difficult, but creates a greater likelihood of spontaneous bone formation within the alveolar cleft. To date only one patient has shown a complete unilateral breakdown because the mother was careless and dropped the baby. There was another patient with bilateral wound break down from the vermilion border. The C-flaps, however, remained in situ so that moulding of the alveolar process was only compromised but not inhibited. The reason for this partial breakdown was probably due to not using the Latham appliance because of misjudging the degree of protrusion and tissue resistance. Fig. 3 – (A–D) A patient with BCLP and only slight premaxillary protrusion, which does not require any presurgical repositioning. (A) and (B) at age 3 months, when the adhesion-procedure is to be done (C) and (D) same patient 4 months later, when the definite lipnose-repair is to be performed.
DISCUSSION If one supposes that repositioning its dislocated maxillary segments in a cleft maxilla would assist in the definitive repair, the question would then be how, best to achieve it. A precondition for any therapy is knowledge of the pathogenesis. In the case of maxillary segment dislocation, the muscular malfunction is of basic importance and to date has been widely analysed. Although many details are lacking we still have no experimental models. If we are able to restore normal muscular function, this will then reposition the segments by natural forces. In bilateral clefts of lip, alveolus and palate, however, the protruding premaxilla often prevents restoration of the anterior muscular ring. Traction on the wound edges after preliminary lip closure (adhesion) is so great, that breakdown is probable and subsequent procedures become progressively more difficult and may finally lead to disastrous results. The literature is full of different methods and recommendations to overcome this problem. Rationally there is no alternative to presurgical retropositioning the premaxilla. Then the preliminary adhesion with muscle forces at the key level of the nose-lip junction will mould the alveolar process into proper alignment. Latham’s appliance undoubtedly fulfills this task ideally. Tissue damage, however, is blamed on it and cannot be overlooked, hence careful follow-up investigations are obligatory. The application of Latham’s device in 71 patients with bilateral clefts during the last 11 years has not caused more growth inhibition than non-Latham cases. (See Part 3 of this paper.)
Fig. 4 – (A) Asymmetrical moderate premaxillary protrusion with very resistent septal tissue consistency, (B) 2 weeks later after using the Latham appliance, (C) same patient, when lip-adhesion is commenced, (D) 4 months later at the time of the second operation. The C-flaps are situated high in the nasal floor and not visible here, (E) proper alignment and strong butt joint of the maxillary segments caused by the natural forces resulting from lip-adhesion.
References
Some times the C-flaps get into a high intranasal position and cannot be seen in the frontal view D. The maxillary segments moved into proper alignment and butt joint, which of course renders gingivo-
Burston WR: The early orthodontic treatment of cleft palate conditions. Dent Pract 9: 41–56, 1958 Burston WR: The early orthodontic treatment of alveolar clefts. Proc R Soc Med 58: 767–774, 1965 Hotz M: Early treatment of cleft lip and palate. Bern, Huber, 1964 Hotz M: Aims and possibilities of pre- and post-surgical orthopedic treatment in uni- and bilateral clefts Third International Congress, London 553–558, 1973
Repair of bilateral clefts of lip, alveolus and palate 43 Hotz M, Gnoinski W: Comprehensive care of cleft lip and palate children at Zurich University: A preliminary report. Am J Orthod 70: 481–504, 1976 Latham RA: Orthopedic advancement of the cleft maxillary segment: A preliminary report. Cleft Palate J 17: 227–241, 1980 McNeil CK: Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec 79: 126–137, 1950 Millard DR Jr: Cleft Craft, Vol. 3. Boston: Little, Brown and Company, 1980 Millard DR Jr, Latham RA: Improved primary surgical and dental treatment of clefts. Plast Reconstr Surg 86: 856–871, 1990
Prof. Dr. Dr. Klaus Bitter Department of Maxillo-Facial Plastic Surgery University of Frankfurt Theodor-Stern-Kai 7 D-60590 Frankfurt Germany Tel: +49 69 6301 5643 Fax: +49 69 6301 5644 E-mail: [email protected] Paper received 4 February 2000 Accepted 20 December 2000
Repair of bilateral clefts of lip, alveolus and palate Part 1: A refined method for the lip-adhesion in bilateral cleft lip and palate patients Klaus Bitter Department of Maxillo-Facial Plastic Surgery (Head: Prof. Dr. Dr. K. Bitter), University Hospital Frankfurt, Germany SUMMARY. The protruding premaxilla represents the most severe problem in the surgical closure of a bilateral cleft lip, alveolus and palate (BCLP). In principle there are two methods to overcome this obstacle: (1) preliminary lip adhesion and (2) presurgical repositioning with intraoral devices. According to the various degrees of premaxillary protrusion, sometimes adhesion alone is sufficient, if the surgical technique is unlikely to break down. In this paper a refined adhesion method is presented, withstanding traction to the wound margins and concomitantly enables lip and nose repairs in a single second operation. For patients with severe premaxillary protrusion, presurgical use of a Latham appliance achieves conditions for safe lip adhesion as above. Both treatment methods are outlined. # 2001 European Association for Cranio-Maxillofacial Surgery
(Latham, 1980; Millard, 1980; Millard and Latham, 1990). The adhesion principle has not been abandoned, as it delivers natural forces and the focus of the repositioning effect can be adjusted exactly to the anterior nasal spine. The severely protruded premaxilla, however, often inhibits lip adhesion due to a very high risk of wound break down. Although many modifications of the adhesion technique have been developed, no progress regarding its reliability has yet been achieved. Whenever several methods have been suggested to solve a problem, they raise the suspicion of being inadequate. It seems therefore prudent, to find a rationale for any combination of different procedures. The purpose of this paper is, to outline the cooperation between the Latham device and a newly modified lip adhesion for repairing the bilaterally cleft lip and lengthening the columella in a one stage operation.
INTRODUCTION The protruding premaxilla still remains the most severe obstacle in closure of bilateral clefts of lip, alveolus and palate (BCLP). No wonder, that in early generations it was simply cut away which was followed by a disastrous midfacial hypoplasia. The efforts, to move the premaxilla backwards into the gap between the lateral maxillary segments, can be traced back to the seventeenth century. More recently McNeil was the first to apply a device to achieve proper alveolar alignment and alleviate the need for subsequent surgical procedures (McNeil, 1950). Burston refined the method and demonstrated marvellous results following repositioning of the maxillary segments, albeit under in-patient conditions, which today are not affordable (Burston, 1958 and 1965) Hotz and Gnoinski popularized the method, which is now in wide-spread use and is known by some as the ‘feeding plate’ (Hotz, 1964 and 1973; Hotz and Gnoinski, 1976). Burston’s procedure however, is of limited effect, because no real active forces can be exerted to reposition the deviated maxillary segments, which is particularly necessary in the case of a protruding premaxilla. Even Burston’s active plates have the inherent disadvantage of being applied to the alveolar surface instead of at the key level of displacement, which is in the plane of nasal spine and nasal floor. For that reason the plate intrudes the premaxilla and does not move it posteriorly together with the septal strut. Pinned intraoral appliances respect this essential factor. Latham offers currently the most advanced device, which has been used in Frankfurt for 11 years in 71 cases of bilateral cleft lip, alveolus and palate
MATERIAL AND METHODS One hundred and seventy two patients with bilateral cleft of lip alveols and palate have been reviewed under the following time schedule since 1988. In an otherwise healthy newborn baby with an average birth weight, the Latham-appliance is inserted at 3 months of age. The indication for this device depends on the amount of premaxillary protrusion and on the consistency of the tissue. This sounds difficult, because there is no definite parameter for the decision. The degree of protrusion alone is not sufficient, although more than one centimetre threatens wound disruption. On the other hand, 39
40 Journal of Cranio-Maxillofacial Surgery
a protrusion of less than one centimetre can also cause wound breakdown, when the cartilage and bone of the nasal septum is very resistant due to its inherent stiffness. Nevertheless, the threshold of one centimetre may be incorrect; it does not exclude personal experience of greater protrusion, but still includes the possibility of failure. Two to three weeks later the appliance can be removed and the first operation is performed. It consists of (1) intravelar veloplasty, (2) lip adhesion and (3) insertion of grommets (Goode type). Four months after the first operation the second one is undertaken consisting of (1) gingivo-periosteoplasty and (2) one-stage lip closure plus columella lengthening. Approximately 1 year later, the hard palate is closed. At this time the cleft is so narrow depending on normal function of the lip and the soft palate, that the closure can be done with minimal surgery. Concomitantly the grommets are exchanged for Shepard-Eartubes, which fall out after several months and can then be reinserted according to individual requirements. The GoodeTubes do not fall out by themselves and usually remain in situ too long, producing a risk of middle ear complications.
SURGICAL TECHNIQUE OF LIP ADHESION In Figure 1, two different patients are presented. One with moderate premaxillary protrusion and very stiff tissues before (Fig. 1A) and after (Fig. 1B) using the Latham-appliance. Retropositioning of the premaxilla is clearly recognizable after two weeks.
Fig. 1 – Two patients with BCLP presurgically. (A) Moderate – severe protrusion of the premaxilla, requiring the LathamAppliance. (B) Two weeks after Latham-repositioning. The appliance has just been removed; the mucosal impressions of the device are still visible; the nasal septum is thickened by tissue inflow. (C) Slight – moderate protrusion of the premaxilla with no need for presurgical retropositioning.
The nasal septum is thickened because of the tissue inflow. The same patients will be shown in Parts 2 and 3 of this paper demonstrating normal growth and reshaping of the septum during the postoperative phase. This is important regarding the arguments which blame tissue damage on the use of the Latham device. The second patient (Fig. 1C) presented with minor protrusion, which easily can be overcome by lip adhesion alone and does not demand presurgical alignment. Figure 2 outlines stepwise the adhesion procedure in a patient with moderate premaxillary protrusion and soft tissue consistency. The diagram is for the purpose of clarifying something that cannot be clearly recognized from the clinical photographs. Figures 2D and 2E outline the marking of the incision-lines. Within the prolabial island, the C-flaps are designed laterally leaving a philtrum of nearly normal shape and dimension. The latter is not essential, because it will grow extensively when under traction from the lateral lip elements and usually has to be reduced later, when the definite lip closure is performed. The prolabial vermilion remains untouched. The lateral lip incision can be best described as a tiny advancement flap (which also leaves the vermilion intact) so that it can be sewn to its prolabial counterpart, to close the deep aspect of the lip. The extension of the incision has to be limited to the SBAL-point and the medial end of the white roll. (SBAL-point is an anthropological landmark, defined as that point of the nasal ala, that definitely meets the upper lip). Arrow 1 point at these in Figure 2D and 2E. There is no trespassing allowed beyond these land-marks otherwise the definitive lip closure cannot be achieved with fresh tissue. Sometimes, especially in patients with a very wide premaxilla, it is necessary, to extend the incision into the nasal vestibulum along the piriform aperture, to mobilize the ala base, which has to be positioned on top of the premaxilla and to be fixed to the anterior nasal spine. To cover the raw area within the nasal vestibulum, a Muir-flap offers a safe procedure. Arrow 3 points to this type of flap from the cleft vermilion in Figure 2E. In Figure 2F the arrow runs along the axis of the Muir flap, which is attached to the gaping vestibular defect. It has to be emphasized that this manoeuvre is necessary only in rare and extraordinary situations. When all edges and all flaps are cut and mobilized, the first stage of the repair is to fix the alar bases onto the premaxilla at the anterior nasal spine. This in principle is an alar cinch suture and the nasal and paranasal muscles remain untouched, because the distance between the muscle ends and the anterior nasal spine is too great to attach them safely, which of course would be desirable to establish the normal anatomy. By pulling together the alar bases (to the midline) the cleft margins close in to the prolabium, so that the vermilion edges can be closed and form the back of the preliminary lip repair (Figs 2H, I).
Repair of bilateral clefts of lip, alveolus and palate 41
Fig. 2 – Adhesion technique step by step. See text.
The third step is to insert the C-flaps into the subalar gap. This corresponds perfectly with Millard’s banking procedure and offers the great advantage of closing the lip definitively together with the columellar lengthening in one session during the second operation. This is done when the premaxilla has been retropositioned into the space between the lateral maxillary segments. (See Part 2 of this paper.) Finally the skin of the lateral lip elements is sutured together with two or three mattress sutures, which run across the prolabial island. This has to be done very smoothly because the lateral traction is considerable and the closure sometimes becomes a type of intraoperative tissue expansion. The most cranial crosssuture has to be slung around the anterior nasal spine and consequently exerts a key function in repositioning the deviated cleft segments. A superficial wound closure usually is not essential but can be performed with 6–0 resorbable suture material. There is no need for suture removal because the quality of the scar is irrelevant. It is better to leave the sutures, to avoid the slightest risk of wound break down.
RESULTS In Figure 3 a patient is seen with a bilateral cleft and only a slight premaxillary protrusion, not requiring any presurgical repositioning a and b show the situation at the time of the first operation at age 3 months. Figure 3C and D show the same patient 4 months later, when the second operation for closure of the alveolar clefts together with concomitant lip-and cloumellar reconstruction is performed. In c, the incision lines for the lip repair are outlined. (See Part 2 of this paper.) In Fig. 3D the premaxilla forms a butt joint with the lateral alveolar segments. A gingivo-periosteoplasty can be performed easily and will facilitate spontaneous bone formation. In Figure 4 a patient is depicted with a moderate premaxillary protrusion but very stiff and resistant septal tissue which would have threatened the lipadhesion with break down. Therefore the Latham appliance was inserted for two weeks and succeeded in moving the premaxilla symmetrically into the gap between the lateral segments. The result of the adhesion procedure is shown in Figs 4D and E.
42 Journal of Cranio-Maxillofacial Surgery
periosteoplasty more difficult, but creates a greater likelihood of spontaneous bone formation within the alveolar cleft. To date only one patient has shown a complete unilateral breakdown because the mother was careless and dropped the baby. There was another patient with bilateral wound break down from the vermilion border. The C-flaps, however, remained in situ so that moulding of the alveolar process was only compromised but not inhibited. The reason for this partial breakdown was probably due to not using the Latham appliance because of misjudging the degree of protrusion and tissue resistance. Fig. 3 – (A–D) A patient with BCLP and only slight premaxillary protrusion, which does not require any presurgical repositioning. (A) and (B) at age 3 months, when the adhesion-procedure is to be done (C) and (D) same patient 4 months later, when the definite lipnose-repair is to be performed.
DISCUSSION If one supposes that repositioning its dislocated maxillary segments in a cleft maxilla would assist in the definitive repair, the question would then be how, best to achieve it. A precondition for any therapy is knowledge of the pathogenesis. In the case of maxillary segment dislocation, the muscular malfunction is of basic importance and to date has been widely analysed. Although many details are lacking we still have no experimental models. If we are able to restore normal muscular function, this will then reposition the segments by natural forces. In bilateral clefts of lip, alveolus and palate, however, the protruding premaxilla often prevents restoration of the anterior muscular ring. Traction on the wound edges after preliminary lip closure (adhesion) is so great, that breakdown is probable and subsequent procedures become progressively more difficult and may finally lead to disastrous results. The literature is full of different methods and recommendations to overcome this problem. Rationally there is no alternative to presurgical retropositioning the premaxilla. Then the preliminary adhesion with muscle forces at the key level of the nose-lip junction will mould the alveolar process into proper alignment. Latham’s appliance undoubtedly fulfills this task ideally. Tissue damage, however, is blamed on it and cannot be overlooked, hence careful follow-up investigations are obligatory. The application of Latham’s device in 71 patients with bilateral clefts during the last 11 years has not caused more growth inhibition than non-Latham cases. (See Part 3 of this paper.)
Fig. 4 – (A) Asymmetrical moderate premaxillary protrusion with very resistent septal tissue consistency, (B) 2 weeks later after using the Latham appliance, (C) same patient, when lip-adhesion is commenced, (D) 4 months later at the time of the second operation. The C-flaps are situated high in the nasal floor and not visible here, (E) proper alignment and strong butt joint of the maxillary segments caused by the natural forces resulting from lip-adhesion.
References
Some times the C-flaps get into a high intranasal position and cannot be seen in the frontal view D. The maxillary segments moved into proper alignment and butt joint, which of course renders gingivo-
Burston WR: The early orthodontic treatment of cleft palate conditions. Dent Pract 9: 41–56, 1958 Burston WR: The early orthodontic treatment of alveolar clefts. Proc R Soc Med 58: 767–774, 1965 Hotz M: Early treatment of cleft lip and palate. Bern, Huber, 1964 Hotz M: Aims and possibilities of pre- and post-surgical orthopedic treatment in uni- and bilateral clefts Third International Congress, London 553–558, 1973
Repair of bilateral clefts of lip, alveolus and palate 43 Hotz M, Gnoinski W: Comprehensive care of cleft lip and palate children at Zurich University: A preliminary report. Am J Orthod 70: 481–504, 1976 Latham RA: Orthopedic advancement of the cleft maxillary segment: A preliminary report. Cleft Palate J 17: 227–241, 1980 McNeil CK: Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec 79: 126–137, 1950 Millard DR Jr: Cleft Craft, Vol. 3. Boston: Little, Brown and Company, 1980 Millard DR Jr, Latham RA: Improved primary surgical and dental treatment of clefts. Plast Reconstr Surg 86: 856–871, 1990
Prof. Dr. Dr. Klaus Bitter Department of Maxillo-Facial Plastic Surgery University of Frankfurt Theodor-Stern-Kai 7 D-60590 Frankfurt Germany Tel: +49 69 6301 5643 Fax: +49 69 6301 5644 E-mail: [email protected] Paper received 4 February 2000 Accepted 20 December 2000