Dual midfacial distraction osteogenesis: Le Fort III minus I and Le Fort I for syndromic craniosynostosis

Midfacial hypoplasia has been corrected by Le Fort III or monobloc forward advancement in one stage in syndromic craniosynostosis, but recently developed distraction osteogenesis has been in use. Whereas the amount of forward mobilization in Le Fort III conventional osteotomy is determined by the preplanned fabricated interdental splint, that in Le Fort III distraction is determined by the positions of the inferior orbital rim, malar complex, and nose. Therefore, the forward mobilization of the upper part of the midface may sometimes be insufficient when one focuses on the final occlusion, and the occlusion might not be satisfied when the forward mobilization is sufficient. Correction of the midfacial hypoplasia should be considered differently in the upper and lower portions of the midface. The upper portion contains the inferior orbit and nose, and the lower portion contains the occlusal structure of the maxillary dentoalveolar portion with the mandible. Separating the midface into two portions and conducting the distraction osteogenesis in both portions separately in different amounts and vectors of distraction is described in this article. Although distraction of the upper portion of the midface can be conducted in one direction with an internal device, distraction of the lower portion of the midface is preferred for conduction by a controllable device because of the need to obtain the preferred occlusion. To obtain better functional and aesthetic results in midfacial distraction in adults and adolescents with syndromic craniosynostosis, dual Le Fort III minus I and Le Fort I midfacial distraction osteogenesis was performed in four cases (in two patients with Crouzon syndrome and in two patients with Apert syndrome). Two females and two males are described (age range, 13 to 26 years). An internal device was used for the upper portion of the midface and an external device was used for the lower portion. The amount of distraction ranged from 14 to 21 mm in the upper portion of the midface and from 11 to 18 mm in the lower portion. No particular complications were noticed over a follow-up period of 10 to 38 months (average follow-up, 19.8 months).     

Le Fort fractures without mobility

The Le Fort fracture without maxillary mobility constitutes 9 percent of maxillary fractures observed over a 3-year period. A high Le Fort (level II or III) injury exists as a one- or two-piece incomplete fracture. The degree of fracture is insufficient to permit mobility of the maxillary alveolus. Frequently, an obvious unilateral zygomatic fracture is present. Physical findings consist of bilateral eyelid ecchymosis and malocclusion. The occlusal disturbance may consist of either crossbite, open bite, maxillary rotation, or lack of proper dental intercuspation. On CT scan, fractures are best demonstrated in the posterior and medial maxillary walls at the Le Fort I level; they are most obvious unilaterally with contralateral fractures that may be subtle. Bilateral maxillary sinus fluid is consistently present on CT. Treatment usually consists of observation and traction elastics but may require mobilization of the fragments followed by open reduction and rigid fixation.     

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified.Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records.Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent).When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms.The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance.Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.     

The Le Fort III osteotomy: to distract or not to distract?

Treatment of the craniofacial dysostoses (e.g., Crouzon, Apert, Pfeiffer, Saethre-Chotzen syndromes) is critically dependent on the successful advancement of the midface with a Le Fort III procedure. The purpose of this retrospective clinical outcome study was to evaluate a new technique for distracting the Le Fort III procedure and to compare its results in growing children with those of the standard Le Fort III osteotomy. The records of 22 children were reviewed; 10 patients (mean age, 6.5 years) underwent a standard Le Fort III procedure, and 12 patients (mean age, 7.5 years) underwent a Le Fort III distraction procedure. The distraction group included two separate techniques, bilateral buried distraction (n = 2) and halo distraction (n = 10). Preoperative and 2- to 3-month postoperative cephalograms were analyzed. The average horizontal advancement achieved in the standard Le Fort III group was 6 mm, compared with 19 mm of advancement in the distraction group (p 相似文献   

Craniofacial distraction with a modular internal distraction system: evolution of design and surgical techniques.

The present report summarizes the evolution of design for a modular internal distraction system that is applicable throughout the craniofacial region. Eleven patients (5 boys, 6 girls), whose ages ranged from 4 months to 10 years at the time of distraction, constitute the basis for this study. The clinical indications for distraction were exorbitism with corneal exposure (n = 1), obstructive sleep apnea (n = 4), tracheostomy decannulation (n = 1), severe maxillary hypoplasia with class III malocclusion (n = 3), severe vertical and sagittal maxillary deficiency with anophthalmia (n = 1), and relapse following frontoorbital advancement in a case of rare craniofacial clefting (n = 1). Twenty-two distraction devices were used in these 11 patients. Two initial prototypes were tested (prototype 1 = 8 devices; prototype 2 = 2 devices) until the modular internal distraction system (MIDS, Howmedica-Leibinger, Inc.) was developed (n = 12 devices). The craniofacial osteotomies used were Le Fort III (n = 4), monobloc (n = 3), mandibular (n = 3), Le Fort I (n = 2), and cranial (n = 1). The distraction distances ranged from 11 to 28 mm. One patient undergoing mandibular distraction developed transient swelling in the left mandibular region, which responded to antibiotics. There were no other complications. Depending on the age of the patient and the length of distraction, the distraction gap was allowed to consolidate from 6 weeks to 3 months. The devices were then removed on either an outpatient or a 23-hour-stay basis. The modular internal distraction system permits widespread application of easily customizable, buried distraction devices throughout the craniofacial region.     

Exposure through a coronal incision for initial treatment of facial fractures.

The coronal incision approach to Le Fort III fractures gives excellent exposure for anatomical reduction and internal fixation of the fracture sites. Either an extracranial, or a combined intracranial procedure, is feasible. The exposure obtained not only facilitates the reduction and the fixation but, with the addition of transconjunctival incisions, the patient benefits by not having multiple surgical scars in the face.     

Blindness as a complication of Le Fort I osteotomy for maxillary distraction

High Le Fort I osteotomy and maxillary distraction has become an accepted method for the treatment of maxillary retrusion in children and teenagers with cleft lip and palate or craniofacial anomalies. This procedure effectively corrects the dentofacial deformity in these patients. No major surgical morbidity has been reported. During the past 4 years, 94 cleft patients with maxillary hypoplasia received Le Fort I osteotomy and distraction osteogenesis at the authors' center. Two of them developed blindness after this operation. The first case was a girl with bilateral cleft lip and palate with median facial dysplasia. She received high Le Fort I osteotomy at age 12 years 4 months to correct maxillary retrusion. Right eye swelling and ecchymosis was found after surgery. The patient complained of vision loss in that eye 2 days later. Computed tomography showed subarachnoid hemorrhage and skull base hematoma. There were no atypical fractures in the orbit, pterygoid plates, sphenoid bone, and skull base. Angiogram revealed left ophthalmic and basilar artery aneurysm. The second case was a 12-year-old boy with left cleft lip and palate. He received Le Fort I osteotomy to correct maxillary retrusion. During surgery, abnormal pupil dilatation was found after the osteotomy and down-fracture of maxilla. Emergent computed tomography found no hemorrhage or atypical fractures. Examination revealed complete left optic neuropathy and partial right abducens nerve palsy with mydriasis. Magnetic resonance imaging, magnetic resonance angiography, and repeated computed tomography revealed no sign of orbital injury, vascular problem, or abnormal fractures. The cause of blindness was unknown. In both cases, a steroid was used. Maxillary distraction was continued. Recovery of meaningful visual sense did not occur after 3 and 2 years' follow-up, respectively. A review of the literature revealed five other patients who suffered from visual loss after Le Fort I osteotomy. Inadvertent skull base fractures were identified in two cases, but a cause for the blindness was not known in the others. Induced hypotension and indirect trauma may be responsible for the optic nerve injury. In none of the cases was meaningful visual sense recovered, although high-dose steroids were given. In conclusion, a total of seven cases developed blindness after Le Fort I osteotomy. Once blindness develops, the prognosis is poor. High Le Fort I osteotomy should be performed with extreme care, and perhaps the informed consent should include visual loss as a complication of the procedure.     

Rotation advancement of the midface by distraction osteogenesis

A wide variety of disease processes produce alteration of midfacial skeletal growth, resulting in moderate-to-severe midface deficiency presenting as retrusion associated with Angle's class III malocclusion. Le Fort III osteotomies with advancement can provide an excellent tool for correction of this deformity. Recently, the corrective procedure of choice for advancement of midfacial segments has been distraction osteogenesis after osteotomy. Straight linear advancement is the most common choice for corrective movement of the midfacial segment, whether accomplished through acute surgical advancement or through the progressive distraction technique. Unfortunately, linear advancement can produce abnormal configurations, both at the nasal root and lateral orbits, regardless of the technique used. Enophthalmos, caused by orbital enlargement, may limit the advancement necessary to achieve class I occlusion.The authors have extended the utility of the Le Fort III procedure and have improved the final outcome by creating a controlled rotation advancement of the midfacial segment using distraction. The application of an existing internal distraction device is modified to control the movement of the midfacial segment in a rotation advancement path. Included in the series were 10 patients with severe midface retrusion secondary to multiple congenital syndromes, along with cleft lip and palate. The ages of the patients ranged from 6 to 14 years. An internal distraction system was used in all cases. Application of the distractor was substantially modified to simplify both fixation and removal and to produce controlled rotation advancement. The team orthodontist determined the final occlusal relationship. Percutaneous distractor drive rods were removed 4 to 6 weeks after active distraction to increase patient comfort. The distractors and all associated hardware were removed after 12 to 16 weeks of consolidation; follow-up periods ranged from 1 to 3 years.By using the modified distractor application to produce rotation advancement, the contour abnormalities at the nasal root and lateral orbit and the enophthalmos produced by linear advancement were eliminated. Significant improvement in facial contour and class I occlusion was obtained in all cases. Complications consisted of near exposure of the device in one patient. Stability has been excellent, with no relapse reported by the orthodontist.Rotational advancement of facial segments by distraction allows successful early intervention in patients with significant midface retrusion. The abnormal nasal root and lateral orbital configurations produced by direct linear advancement are avoided, and a stable and normalized facial configuration is produced.     

Immediate versus delayed midface distraction in a primate model using a new intraoral internal device

The theoretic advantage of distraction osteogenesis of the craniofacial skeleton, especially in cases of severe midface retrusion and in the presence of maxillary scarring, is prevention of relapse following significant advancements. The purpose of this study is to demonstrate the utility of a new low-profile, intraoral, internal device for midface distraction at the conventional or high Le Fort I level. In addition, the present study compares the efficacy of immediate versus delayed distraction on subsequent maxillary relapse. Four adult rhesus Macaca mulatta monkeys were divided into two groups. Group 1 underwent immediate midface distraction; group 2 underwent delayed distraction. All four monkeys underwent a modified Le Fort I osteotomy through an upper buccal sulcus incision and bilateral application of the intraoral midface distraction devices. No other osteotomies or incisions were necessary. Immediate distraction, performed in group 1, entailed intraoperative activation of the devices and distraction of 10 mm followed by a 5-day lag period before postoperative activation and distraction of an additional 10 mm at the rate of 1 mm/day. Delayed distraction, performed in group 2, entailed a 5-day postoperative lag period before device activation and distraction of 20 mm at the rate of 1 mm/day. Both groups thus underwent 20 mm of midface distraction. All devices were removed 6 weeks after completion of distraction. All monkeys tolerated the devices and daily distraction uneventfully. On the basis of serial cephalograms and dental models obtained throughout the experimental period, there was no evidence of relapse in either the immediate or delayed groups 6 months after distraction. In addition, on the basis of histologic, ultrastructural, and dry skull analysis, no significant differences were observed in the quality of regenerate bone obtained when comparing the immediate and delayed distraction groups. Significant midface advancement is thus feasible using this new internal, intraoral distraction device, which presents several advantages over other internal devices that require coronal incisions and additional osteotomies to achieve midface advancement. In addition, immediate distraction may abbreviate the distraction period without adverse sequelae.     

Le Fort I型截骨术定位平面的应用解剖学研究

目的：研究Le Fort I型截骨术与上颌牙根尖的关系,为临床合理制订截骨平面提供解剖学依据。方法：选择上颌牙槽清晰或出土后仍有牙保留的颅骨,在颅骨梨状孔下缘至上颌结节作一连线作为模拟Le Fort I型术式截骨水平,以上颌牙槽缘为标志,用游标卡尺测量每侧上颌各牙的牙槽缘至上述模拟截骨水平的距离及牙槽缘至各牙根尖端的长度,然后计算出上颌各牙根尖至Le Fort I型术式截骨线的距离。结果：上颌各牙相对的牙槽缘至Le FortI型术式截骨线的距离,从中切牙至第二磨牙逐渐缩小,右侧中切牙为21．09±1．53mm,左侧中切牙为20．96±1．64mm,右侧第二磨牙为14．94±1．52mm,左侧第二磨牙为14．95±1．59mm;上颌各牙根尖至Le Fort I型术式截骨水平的距离,从中切牙至第二磨牙也逐渐缩小,而两侧尖牙牙根尖距离Le Fort I型术式截骨线的距离右侧为4．49±1．74mm,左侧为4．69±2．14mm,第二磨牙牙根尖距离Le Fort I型术式截骨线的距离右侧为4．65±1．63mm,左侧为4．49±1．89,两侧尖牙牙根尖和第二磨牙牙根尖至Le Fort I型术式截骨水平的距离均比较接近。结论：上颌各牙根尖至LeFortI型术式截骨线的距离均在4mm以上,根据前牙中尖牙牙根尖的位置和后牙中第二磨牙牙根尖的位置,Le Fort I型术式截骨线水平在13、23（3｜3）根尖及27、27（7｜7）根尖上方4mm以上,按此平面作截骨水平较为安全,不易损伤牙根。     

Acute otitis media: a new treatment strategy.

The incidence of acute otitis media and its response to treatment only with nose drops and analgesics (but without antibiotics or myringotomy) were assessed over three months by 45 doctors in and around Tilburg. In addition, over 17 months 60 general practitioners assessed the effects of this limited treatment in children aged 2 to 12 years and referred all those in whom the condition took an unsatisfactory course (either a severe course--illness continuing beyond three to four days with high temperature or pain, or both--or persistent discharge after 14 days) to an ear, nose, and throat specialist. Those referred because of appreciable illness continuing beyond three or four days were entered into a further study, comparing the effects of myringotomy alone, antibiotics alone, and myringotomy and antibiotics combined. Bacteriology was assessed in all children in whom the course of the condition was unsatisfactory. More than 90% of an estimated 4860 children seen over 17 months (estimation based on incidence of severe course in the three month study) recovered within a few days. The course of the condition was severe in only 126 (2.7%) patients; haemolytic streptococci group A were identified in 30 of these 126 patients but Haemophilus influenzae in only one. One hundred of these patients with a severe course entered the trial of treatment, which showed antimicrobial treatment either alone or in combination to be more effective than myringotomy alone. Whether combined treatment was more effective than antibiotics alone remained unconfirmed. Acute otitis media in children can be treated with nose drops and analgesics alone for the first three to four days. Patients in whom this regimen is not accompanied by satisfactory recovery can be recognised within a short time and treated by the general practitioner.     

Midface fractures: advantages of immediate extended open reduction and bone grafting

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.     

Correction of severe facial deformity.

A craniofacial team has been developed to corrdinate the treatment of patients with severe facial deformity and to minimize the surgical risks. Two hundred patients have been evaluated in the last 4 years and more than 100 treated by this team to correct orbital hypertelorism, oxycephaly and plagiocephaly with exophthalmos, features of Crouzon''s disease and Apert''s and Treacher Collins syndromes, hemifacial microsomia, and severe lower facial deformity and malocclusion. Surgical principles include extensive subperiosteal stripping of bone, osteotomy as necessary, and repositioning maintained by bone grafts. Postoperative evaluation is being maintained for 5 years or to maturity in younger children. Although many of the results are less than perfect, there has been sufficient improvement, especially psychologic and functional, to warrant continuation of the surgical program under closely controlled conditions.     

The effect of an early Le Fort III surgery on permanent molar eruption

The purpose of this retrospective study was to evaluate the extent to which an early Le Fort III osteotomy affects the position and eruption of the permanent maxillary first and second molars. To test the null hypothesis that there are no changes in eruption patterns, 31 patients diagnosed with craniosynostoses (13 with Crouzon's syndrome, nine with Apert's syndrome, eight with Pfeiffer's syndrome, and one with Carpenter's syndrome) with a mean age at the time of surgery of 5.3 +/- 1.3 years were studied. All patients underwent a Le Fort III osteotomy performed by a single surgeon to correct the anatomical deformity for functional and psychosocial reasons. Eighteen patients with craniosynostoses who had not been operated on (11 with Crouzon's syndrome, four with Apert's syndrome, and three with Pfeiffer's syndrome) served as controls; they had a mean age of 21.2 +/- 9.5 years. First and second molar positions and eruption patterns were assessed separately on panoramic radiographs by three observers. For the patients who underwent surgery, long-term evaluation showed that although 79 percent of all first molars erupted compared with 100 percent for the control group (p < 0.001), only 18 percent of all second permanent molars erupted compared with 89 percent for the control group (p < 0.0001). The authors conclude that in a significant minority of cases, early Le Fort III osteotomy affects first molar eruption, whereas the probability of second molar eruption is significantly decreased in the majority of cases. Therefore, Le Fort III osteotomy sites should be positioned distal to the second molar tooth buds. If this is not possible, patients, parents, and dental professionals should be made aware of these early postosteotomy sequelae so that later treatment planning can be enhanced.     

Total reconstruction of the "end-stage" cleft lip and palate deformity

The purpose of this paper is to present a 5-year experience using a comprehensive surgical approach to reconstruct what we have chosen to call the "end-stage cleft lip and palate deformity." The deformity consists of varying degrees of midface retrusion, malocclusion, nasal deformity, and lip deformity. Most of the patients afflicted had unacceptable upper lip anatomy characterized by tightness and lack of cupid's bow and bulk. All had severe palatal scarring with resulting arch collapse and severe malocclusion. Most had had multiple surgical attempts to improve nasal aesthetics using standard rhinoplasty techniques with little or no improvement. The procedure involves splitting the upper lip with incisions extending into the upper buccal sulcus and rim of the nose allowing wide skeletalization of the maxilla and osteocartilagenous nasal skeleton. LeFort I or II maxillary advancement, nasal reconstruction, and upper lip modification (with Abbé flap if indicated) are done. The jaws are placed in intermaxillary fixation for 6 to 8 weeks. This comprehensive approach has been used in 16 patients, aged 15 to 29 years, with follow-up of up to 5 years. Excellent functional and aesthetic improvement has occurred in all patients, and complications have been minimal.     

Maxillary hypoplasia secondary to midfacial trauma in childhood

Three normal children who suffered midfacial trauma and developed midfacial retrusion that would require Le Fort III advancements for correction of the deformity are described. The common denominator in these three cases seems to be an injury to the medial facial structure including the nasal septum. It is concluded that midfacial fractures in childhood may be a cause of subsequent midfacial hypoplasia.     

The use of miniplates in craniomaxillofacial surgery

Miniplates were used in craniomaxillofacial surgery for fixation in the skull, maxilla, and/or mandible in 74 patients with minimal or no intermaxillary wiring. Procedures included forehead and orbital repositioning, frontofacial advancement, Le Fort III and particularly Le Fort I osteotomies, as well as mandibular osteotomies and fracture repair. The miniplates provided stable fixation and, compared with other techniques, improved airway safety. The complication rate was low: there were no infections, but two plates (1 percent) became exposed in the buccal sulcus. Although application of miniplates lengthened surgery and increased the cost of the procedure, the savings in intensive care monitoring more than offset these costs. The stability of fixation minimizes the opportunity to reposition the fragments postoperatively with training elastics. Therefore, meticulous technique is mandatory, with particular emphasis on passive fitting of the plates and precise drilling of screw holes.     

不同类型的下颌骨骨折的手术治疗

目的：评估不同类型的下颌骨骨折的手术入路及固定方法。方法：对于52例不同类型下颌骨骨折患者采用不同的口外或口内切口及相应的固定方法。结果：52例患者伤口全部一期愈合,51例咬合关系恢复到伤前咬合关系,1例出现咬合关系不良,X线检查骨折线队位良好。结论：对于不同部位的下颌骨骨折应采用相应的手术切口及固定方法,以获得最好的疗效。     

Predictors of velopharyngeal insufficiency in cleft palate orthognathic surgery

The purpose of this study was to appraise the value of preoperative speech assessments, nasopharyngoscopy, and surgical models as predictors of velopharyngeal deterioration after a Le Fort I maxillary advancement in cleft patients. This retrospective study involved a series of 26 cleft patients (16 unilateral complete and nine bilateral complete cleft lips and palates, and one isolated complete cleft palate) who had Le Fort I maxillary advancements between March 1, 1993, and February 7, 1996. The 13 male patients and 13 female patients ranged in age from 15.3 to 46 years (mean age, 19.5 years). Four of these patients had previously undergone pharyngeal flap surgery. Eleven patients had palatal fistulas and one had a bifid uvula that was repaired at the time of orthognathic surgery. Patients with perceived hypernasal speech preoperatively all had hypernasality after advancement (nine of nine). Velopharyngeal insufficiency was observed in two of the 16 whose resonance preoperatively was within normal limits. Speech assessment, therefore, predicted accurately the postoperative status in 23 of 26 patients. Twelve patients had preoperative nasopharyngoscopy that indicated a high risk for velopharyngeal insufficiency (borderline or inadequate closure). Nine of these patients had postoperative velopharyngeal insufficiency. Two of the 14 patients not judged at risk by nasopharyngoscopy developed velopharyngeal insufficiency. Therefore, 21 of the 26 patients were accurately predicted by nasopharyngoscopy. Scoping detected borderline velopharyngeal insufficiency in one patient who was not detected by speech alone. The combined predictive value of speech and scope identified all but one patient who would develop postoperative velopharyngeal insufficiency. The degree of anteroposterior movement determined from surgical models was not predictive of the outcome. Patients with hypernasal speech preoperatively continue to have hypernasal speech after Le Fort I advancement. Preoperative perceptual speech assessment by specially trained speech-language pathologists is an excellent test for predicting postoperative velopharyngeal insufficiency status. Nasopharyngoscopy is an invasive and resource-dependent test that should be assessed with respect to cost effectiveness. In this series, only one patient's risk was more accurately predicted using nasopharyngoscopy than by speech assessment alone.     

Skeletal stability after Le Fort I maxillary advancement in patients with unilateral cleft lip and palate

Outcomes in 30 adults and adolescents judged skeletally mature who had unilateral cleft lip and palate and underwent Le Fort I advancement were investigated to determine amount and timing of relapse, correlation between advancement and relapse, effect of performing multiple jaw procedures, effect of different types of bone grafts, effect of pharyngoplasty in place at the time of osteotomy, and effectiveness of various methods of internal fixation. Tracings of preoperative and serial postoperative lateral cephalograms were digitized to calculate horizontal and vertical maxillary changes. No significant differences in outcome was seen between patients who had maxillary surgery alone and those who had operations on both jaws, nor did the outcome vary significantly with the type of autogenous bone graft used or the segmentalization of the Le Fort osteotomy. Mean "effective" advancement was greater immediately and 2 years after surgery in those patients who did not have a pharyngoplasty in place before the operation. Advancement also was greater immediately and after 2 years in the miniplate fixation group than in patients with direct-wire fixation. Mean downward (vertical) displacement was 2.6 mm with a relapse of 1.4 mm after 2 years. Amounts of relapse and of advancement or displacement did not correlate significantly.