CAUSALITY OF CLEFT LIP & PALATE
TAJAMMAL AHMED CH.
Cleft lip & Palate represent the commonest congenital craniofacial abnormality affecting mankind. It is a problem of immense international proportion affecting more than 10 million people across the globe. Historically clefts have known to occur before the time of Christ.

The incidence varies by race, geographic location, sex and nationality. Pakistan is known to have the 4th largest number of CL&P patients after China, India and Indonesia.
Although the subject of a great deal of investigation, etiological factors remain largely unknown. The anomaly is considered to be due to multifactorial inheritance of a threshold character in that several genes act in concert with environmental agents to cause a failure of mesodermal penetration of the two epithelial membranes destined for upper lip and jaw development. These unsupported epithelial membranes rupture in the face of rapid facial growth resulting in the cleft.

This presentation shall focus on the latest developments in detection of the causality of Cleft Lip & Palate. It is extremely important to thoroughly investigate its etiology and pathogenesis so that preventive measures could be adopted in the high risk population. Owing to its high incidence, even a slightest reduction in risk could result in a significant public health benefit.

SURGICAL APPROACH IN CLEFT LIP REPAIR
FAKHR ALKHAIRY
In unilateral cleft lip repair the main aim is to achieve symmetry, lengthening of the lip to correspond to the length of the lip on noncleft side and correction of nose deformity at the same time. The triangular flap techniques ensure the closure of wide clefts with an error of too short or too long lip in case of wrong planning. The Cupid bow is also invaded by the surgical scar which makes the revision difficult. The rotation and advancement flap ensure the integrity of Cupid’s bow but provide no solution to cleft lip nose deformity in one goal unless modified with columella split using hemifork flap. In this technique revision is easy but shortening of lip on cleft side may occur.

In bilateral cleft lip repair the main issues are to achieve external scar along reasonable anatomic line, to provide good muscular capability, to provide properly lined sulcus and to preserve normal existing surface i.e. Vermilion & vermilion-cutaneous margin. The Millard’s repair meets all the requirements except lengthening of columella at the same time. Borrowing excessive nostril floor tissue for lengthening columella as V-Y advancement on later stage remains a good option. Borrowing tissue for lengthening of columella on later stage from constructed lip jeopardizes the external scar along reasonable anatomic line.

This paper presents the review of literature regarding unilateral & bilateral cleft lip repair.

UNILATERAL COMPLETE CLEFT LIP AND PALATE REPAIR USING LIP ADHESION COMBINED WITH A PASSIVE INTRAORAL ALVEOLAR MOLDING APPLIANCE: SURGICAL RESULTS AND THE EFFECT ON THE MAXILLAR ALVEOLARARCH
BYUNG CHAE CHO, M.D.
A number of combined maxillary orthopedic and surgical treatment protocols have been proposed for the initial therapeutic phase of infants with a complete cleft lip and palate. Lip adhesion was used in combination with a passive intraoral molding appliance to treat a unilateral complete cleft lip and palate. Lip adhesion, along with the positioning of a passive alveolar molding appliance, was performed in infants 4 to 6 weeks of age. Definitive cheiloplasty was then performed at 4 to 5 months of age and palatoplasty at 12 months of age. Twenty-five patients with a unilateral complete cleft lip and palate were treated using this protocol between April 1994 and December 2003. There were fifteen male patients and ten female patients. The follow-up period was between 6 months and ten years. Maxillary dental study model analysis were performed regarding lip adhesion, definitive cheiloplasty, palatoplasty, and for 3 to 10 year old patients.
The alveolar gap, the length of maxillary alveolar cleft, the width of maxillary alveolar cleft and the palatal gap were 10.1 ± 4.2 mm, 6.1± 0.9 mm, 10.2 ± 4.8 mm, 13.4 ±2.9 mm for lip adhesion, 3.1 ± 1.4 mm, 2.6 ± 0.8 mm, 2.7 ± 1.6 mm, 9.6 ± 1.5 mm for definitive cheiloplasty, and 0.2 ± 0.1 mm, 1.5 ± 0.7 mm, 0.2 ± 0.1 mm, 8.3 ± 1.1 mm for palatoplasty, respectively.

The measurements for palatoplasty decreased with statistical significance (p<0.05). For the following maxillary dental cast for 3 to 10 year olds, the intercanine width and canine arch lengths were within the normal value. The intermolar width and the molar arch length, however, decreased slightly compared to the control normal values with a statistical significance (p<0.005). For cephalometric analysis, two patients were within the normal range, seven patients over the range, and one patient was below the range in SNA. Two patients were within the normal range and eight patients were over the SNB range. One patient was within the normal range, seven patients were over the range, and two were below the ANB range. In the two patients below the ANB range, retrusion of the maxilla was presented with an anterior and buccal crossbite. The resulting lip scar was aesthetically acceptable in most patients.
 
In conclusion, lip adhesion and a passive alveolar molding appliance achieved a normal position and stabilized the arch in a symmetrical platform. A longer follow-up period, however, is necessary until 15 years of age in order to establish a permanent dental arch.

UNILATERAL CLEFT LIP REPAIR
PHILIP KT CHEN
Over a period of 20 years, refinements and changes in the rotation advancement technique for repairing unilateral cleft lip have evolved in Chang Gung Craniofacial Center. These changes have resulted in a more consistent and better result and are presented as our current method of unilateral cheiloplasty. These changes are based on a large cleft lip series in our center of over 200 new clefts each year. An adhesion cheiloplasty is still used whenever the alveolar cleft is greater than 10mm or in the presence of tissue deficiency. Most of the clefts are done in one stage with the help of presurgical nasoalveolar molding using various appliance. The essential aspects of the unilateral cheiloplasty include the following important points:
1. Rotation of the Cupid's bow down with a Mohler’s rotation incision, adequate release of the muscle under ANS to lengthen the lip.
2. Release of the C-flap from the premaxilla and develop of a C- mucosal flap which will be used for lining across the cleft.
3. Release of the lateral lip with minimal dissection over the maxilla and an attached inferior turbinate mucosal flap and L-mucosal flap for lining the piriform area and closure of all operative incisions without tension.
4. Dissection of lateral lip musculature from ala and skin without a preliminary horizontal incision on the lateral lip.
5. Triangular lateral lip vermilion flap to correct central prolabial vermilion deficiencies.
6. Reconstruction of the philtral column using mattress muscle sutures.
7. Redraping the lateral lip skin over the muscle without incisions extending around the alar base to minimize scars in this area and also give a better contour of the ala-facial groove.
8. Advancement and release of the lower lateral cartilages from asymmetric incisions (Tajima on cleft side and rim incision on non-cleft side). The lower lateral cartilages are advanced and fixed by mattress sutures over the dome area and alar transfixion sutures. The cleft side nostril is over-corrected in its height and width. Postoperative nasal stenting to maintain the nostril and scar care are helpful in achieving a satisfactory result. The changes made have evolved over a long period of time with continual evaluation of the results.

CORRECTION OF UNILATERAL CLEFT LIP NASAL DEFORMITY DURING PRESCHOOL,
SCHOOL YEARS AND ADULTS USING REFINED REVERSE-U INCISION AND V-Y PLASTY: LONG-TERM FOLLOW-UP RESULTS
BYUNG CHAE CHO,
INTRODUCTION: 
Repair of nasal deformities in unilateral cleft lip patients may be done at the time of primary lip repair, in the preschool years (age 4 to 6 years), during puberty (age 10 to 12 years), or as an adult. There is now less credence given to the concept of disturbance of nasal growth by surgery. The current author has modified and refined the reverse-U incision technique for ten years to avoid unsatisfactory results. This technique has been applied to patients with unilateral cleft lip nasal deformity and presents long-term results.

MATERIALS AND METHODS:  In the case of a mild or moderate malposition of the lower lateral cartilage and alar-columella web, a reverse-U incision is used on the cleft side. A V-shaped incision is then made continuous with the lateral end of the reverse-U incision. Through this incision, the cleft lower lateral cartilage is exposed. The cleft lower lateral cartilage is dissected completely to its junction with the medial crus including its mucosal lining. The normal noncleft lower lateral cartilage is dissected through a 1 cm long alar rim incision on the noncleft side. The abnormal cleft lateral crus is severed from its lateral attachment. The soft tissue in the alar-columella web adjacent to the nasal mucosa of the reverse-U flap is trimmed to facilitate redarping into the nasal cavity. Two to three fine scores using a no. 15 blade were made in the soft tissue in the alar-columella web adjacent to the nasal mucosa of the reverse-U flap. One horizontal mattress suture using 6-0 Vicryl is performed on the scored area of the reverse-U flap to create a concave shape for easy redraping into the concave nasal surface. The cleft lower lateral cartilage is fixed to the noncleft lower lateral cartilage using 5-0 white Nylon through incisions. The mucoperichondrial flap is then advanced medially and superiorly into a more favorable position. The defect left in the mucosa is repaired with a V-Y closure after the advancement of the lateral crus. The alar transfixion sutures are made in the vestibular skin area.  In the case of a severe flattening of the lower lateral cartilage or a buckled lateral crus, a reverse-U incision and V-Y plasty are combined with an open rhinoplasty incision. The columella flap is raised and the lower and upper lateral cartilages are both exposed. Any loose fatty and connective tissue is preserved as far as possible. The mucochondrial flap is advanced and the cleft lower lateral cartilage is fixed to the normal lower lateral cartilage and upper lateral cartilage, respectively. A V-shaped incision is made at the base of the cleft alar. The alar base is then freed from the piriform aperture and transposed medially to create a symmetry of the nasal floor and nostril. Alar base advancement or a cancellous iliac bone graft for alveolar cleft can also be performed if needed.
A self-made nasal retainer is then applied for 6 months to maintain the corrected nostril contour and to prevent the nostril from reconstructing.

RESULTS:  A reverse-U incision and V-Y plasty were used in 60 patients of preschool and school years, 58 patients of adults with mild to moderate unilateral cleft lip nasal deformity during last 10 years. An open rhinoplasty incision combined with a reverse-U incision and V-Y plasty were used in 45 patients with severe unilateral cleft lip nasal deformity. A cancellous iliac bone graft for an alveolar cleft was performed in 21 cases. Alar base advancement was performed in 62 cases. The follow-up period ranged from 1 to 10 years, with an average of 4.5 years. The final results were evaluated based on the degree of symmetry of both nostrils. The length of the longitudinal axis of the nostril and the width at the midcolumella level were long term and were measured with calipers.  An excellent result was defined as a deviation of less that 10 % between the measured lengths of the longitudinal axis and widths of both nostrils, a good result was a deviation between 11 to 20 %, a fair result was between 21 to 30 %, and a poor result was above 31 %. Excellent results were achieved in 76 patients, with minimal or no alar-columella web deformity and a satisfactory symmetry of the nostrils. Twenty-six patients showed good results, twelve fair, and 4 poor. Sixteen patients in the fair and poor category experienced a drooping and overhanging of the corrected alar-columella web. Possible causes of redrooping of the corrected alar-columella web deformity were incomplete fixation of the cleft lower lateral cartilage, undercorrection of the vestibular web. In patients of preschool and school years, postoperative nostril symmetry was maintained within one to two years follow-up. However, in cases of long-term follow-up over than 4 to 5 years, mild changes of the corrected alar-columella web occurred. The exact cause is unclear. The possible cause was believed to be change of anatomic structure by growth. In addition, in 10 cases performed cancellous iliac bone graft for alveolar cleft, there were mild changes of the corrected cleft nasal deformity with long-term follow-up. The possible cause was partial absorption of previous iliac bone graft and growth change. In adults, there were no changes after the operation.

CONCLUSION: 
The reverse-U incision with V-Y plasty was effective in correcting the unilateral cleft lip nasal deformity during the preschool, school years and adults. However, there were slight changes of the corrected alar-columella web at four to five years after the operation in patients of preschool and school years. The proposed procedure is recommended for a slight overcorrection of the cleft lip nasal deformity during the preschool and school years. In addition, this technique provides ample advancement and repositioning of the mucochondrial flaps and simultaneous correction of the nasal vestibular web.

NEW TECHNIQUE FOR CORRECTION OF THE MICROFORMCLEFT LIP USING VERTICAL INTERDIGITATION OF THEORBICULARIS ORIS MUSCLE THROUGH THEINTRAORAL INCISION
BYUNG CHAE CHO, M.D
A microform cleft lip has three major components:
(1) a minor defect of the upper vermilion border with loss of the mucocutaneous ridge,
(2) a narrow ridge of tissue, resembling an exaggerated philtral column extending to the nostril sill, and
(3) a deformity of the nostril. To attain the muscle continuity without external scar on the upper lip, the current author introduced a new method for the correction of a microform cleft lip
deformity using vertical interdigitation of the orbicularis oris muscle through the intraoral incision to create philtrum.

Through the intraoral incision, a full thickness incision is made down to the mucosa and the posterior portion of the muscle. Then, the remaining portion of the muscle is dissected. The medial and lateral muscle flaps are also detatched from the oral mucosa and completely exposed and split into two leaves. The upper leaf of the lateral muscle flap is sutured to the dermis on the philtral dimple and base of the upper leaf of the medial muscle flap. Two leaves of each muscle flap are sutured together to create a vertical interdigitation to increase the thickness of the philtral column and to provide the continuity of the muscle.

A total of 22 patients with microform cleft lip were treated between August of 2001 and October of 2005. Fifteen of the patients were male and seven were female with an age range of 1 to 43 years old. The follow-up period ranged from 6 months to 36 months, with an average of 12 months. The results of vertical interdigitation of the muscle were examined. All patients were satisfied with their results. The orbicularis oris muscle presented continuity and preserved a good function. In all cases, the operation scar was not visible on the depressed philtral groove on the cleft side. Correction of cleft lip nasal deformity in four patients and alar base advancement in two patients was performed.

In conclusion, the advantages of the proposed procedure include the creation of an anatomically natural philtrum without an external visible scar through the  intraoral incision, preservation of the continuity and function of the muscle, and sufficient augmentation of the philtral column by the vertical interdigitation of the muscle.

 
BILATERAL CLEFT LIP REPAIR
PHILIP KT CHEN
The bilateral cleft lip repair is the most challenging problem in the whole spectrum of cleft surgery. Deficiency and distortion of the oral structures makes the problem more difficult than the unilateral cleft lip repair. The asymmetry of the pathology further complicates the reconstructive procedure. Here in this unit, our technique is based on the evolution during the last twenty years. Presurgical nasoalveolar molding is performed in most cases to align and approximate the dental arch and lengthen the columella. The central prolabial flap is designed in a width about 4mm in the lower part and 3mm on the upper part. Part of the residual vermilion and mucosa are used for lining of the premaxilla. The nasal floor is reconstructed by mucosal flaps including the L-flap, the turbinate flap and mucosa from the prolabium. The lateral lip segments are incised along the cleft margin just above the white skin roll to develop a white skin roll-free border flap. The orbicularis muscles are dissected extensively and approximated in the midline. The prolabial flap is redraped back and sutured to the lateral lips. Special attention is given to the width of the nasal floor to avoid a wide nostril. The nose is corrected by bilateral Tajima incisions, releasing of LLC’s and advancing LLC’s by vertical mattress sutures. Alar-transfixion sutures are placed for further fixation. The result of the nasal reconstruction is much better compared to those of our previous techniques. Case presentations will be given.

FORMATION OF THE PHILTRAL COLUMN USING VERTICAL INTERDIGITATION OF THE ORBICULARIS ORIS MUSCLE FLAPS IN THE SECONDARY CLEFT LIP
BYUNG CHAE CHO, M.D
For patients who have undergone cleft lip surgery, the construction of the philtrum is crucial for restoring a normal appearance to the upper lip. Previously, the current author presented a new method for creating a more natural philtral column through the vertical interdigitation of the split orbicularis oris muscle flaps in the secondary cleft lip. A total of 38 patients with cleft lip nasal deformities were treated for the creation of a philtral column between January 1998 and December 2003.

The scar on the philtral column is excised and a full-thickness incision is made down to the orbicuralis oris muscle and mucosa. The medial and lateral muscle flaps are then exposed and split into two leaves. The two leaves of each muscle flap are sutured together to create a vertical interdigitation. Any excess skin is not excised but rather closed with 7-0 nylon.
The follow-up period ranged from 11 to 60 months, with an average of 28 months. Thirty-four out of 38 patients were satisfied with their good surgical results. Three patients were fair results. One patient experienced a widening of the scar and no improvement in the philtral column.

In conclusion, the advantages of our procedure include the creation of an anatomically natural philtrum by preserving the continuity and function of the muscle, sufficient augmentation of the philtral column by the vertical interdigitation of the muscle, relief of skin tension, and no donor site morbidity.

SECONDARY REPAIR OF UNILATERAL & BILATERAL CLEFT LIP
PHILIP KT CHEN
The revision of the secondary cleft lip/nasal deformity should be planned in an individual basis according to the different pathology in each patient. Any asymmetry in lip or nose should be evaluated in 3-dimension including vertical, horizontal and sagittal planes including both the soft tissue and skeleton.
A significant bony discrepancy should be corrected by bone grafting or an orthognathic surgery before soft tissue revision. Mild to moderate bony discrepancy should still be bone-grafted during soft tissue revision.

A vertically or horizontally short lip, a lip without good philtral column, a lip with bad scarring or mismatching of the landmarks are best revised by “Re-repair” with reopening the lip, re-dissection or releasing of the muscle with re-approximating and realigning of the anatomical layers and landmarks. This concept can be applied to both unilateral and bilateral secondary deformities.

The nasal deformity is best corrected by an open rhinoplasty with unilateral or bilateral Tajima incisions, well-exposure of the frameworks, correction of lining deficiency and increasing of the supportive strength by adding cartilage graft in columella and cleft side alar rim. The dorsum usually needs some straightening or augmentation. The speaker’s preference is using diced cartilage graft. Any significant nasal obstruction should be corrected at the same time by a SMR or SMT procedure.

These concepts have evolved in Chang Gung Craniofacial Center over the past 20 years and now can give a better and more consistent result.

ABBE FLAP: INDICATIONS AND TECHNIQUES
BYUNG CHAE CHO, M.D
Repair of defects of upper lip contour and position is dependent on correction of the following elements:
1) the maxilla, which is often retruded;
2) the alveolus, which is deficient through the nasal floor defects;
3) the columella, which is particularly short in bilateral clefts; and 4) the lower lip, which tends to compensate to achieve lip seal. Correction of marked horizontal deficiencies (tight lip) with gross lip disproportion in the secondary cleft lip may require an Abbe flap.

The flap is basically a composite transfer of skin, muscle, and mucosa based on a pedicle containing the inferior labial vessels. The 180 degree transposition of the lower lip flap and its insertion into the upper lip is facilitated by minimizing the bulk of the pedicle. The flap should always be placed in the midline of the upper lip, regardless of the type or location of the previous repair. In this position, it recreates the philtrum, the Cupid’s bow, and the philtral tubercle. The flap is divided and insert under local anesthesia after ten days. Reinnervation may occur in Abbe flaps in one year or less. Triangular flap has the advantage of closer apposition to the upper lip orbicularis oris muscle superiorly. In addition, various modifications of the flap such as shelving muscle flap, sandwich Abbe flap have been described.

However, the Abbe flap skin is of a different texture and color from that of the upper lip; moreover, hair is scanty and grows in a different direction from upper lip hair. The lower lip scar may become hypertrophic and obvious. Therefore, the Abbe flap procedure should be used in selected indications.

PALATE REPAIR:-RECONSTRUCTION OF DYNAMIC VELOPHARYNGEAL MECHANISM
GHULAM QADIR FAYYAZ
TAJAMMAL AHMED CH
TAHIR AYUB
The goals of Palate repair are threefold:
Static separation of Oral and Nasal cavities,
Dynamic separation of Naso-Pharynx from Oro-Pharynx,
Minimization of secondary dentoskeletal deformation,
Prime Purpose is:  Adequate Speech Outcome
In Cleft Palate, Levator veli Palatini is discontinuous across the cleft and run more or less longitudinally along the cleft margin before its aberrant insertion into the posterior border of the hard palate. This leads to ineffective contraction and inability to close the Palate against the Posterior Pharyngeal wall. Air escape through the nose during speech results in Hypernasality. The Palatal Repair Procedures which fail to reunite the palatal muscular sling by changing the orientation of contraction, will lead to impaired velopharyngeal function.

Intravelar veloplasty needs an extensive dissection of Levator muscle, to be freed from Oral and nasal mucosa. There is a natural plane between the oral mucosal layer of the soft Palate(containing minor salivary glands) and Levator muscle. One simple stroke of tip of suction cannula can separate the levator from oral mucosa. However, the separation of nasal mucosa from Levator requires delicate dissection with proper instrument.

We describe a simple technique to separate the muscle from Oral and Nasal mucosa and releasing the muscle from posterior border of hard palate; so to bring the muscle from both sides posteriorly and unite these in midline. We do not use any microscope or even loupes to separate the muscle. 

The greater palatine artery is released from the oral mucoperiosteal flap as much as needed by using knife and palatal dissector. This maneuver effectively lengthens the palate in the hard palate area so as to bring the tips of both flaps to the most anterior parts of the maxillary segments.

We use continuous sutures for the repair of nasal mucosa. After the muscle is repaired in more posterior position, the oral layer is repaired starting from uvula to the junction of soft & hard palate. Then one gutter suture is used to obliterate the dead space between the oral and nasal layers. The tips of both flaps (anterior-most portion) are then approximated to the anterior most parts of the maxillary segments so preventing any fistula or closing the palate as up to the most anterior part as possible.

MANAGEMENT OF PALATAL FISTULA
BYUNG CHAE CHO, M.D
Palatal fistula is the most common defect in the hard palate after repair. It may be located anterior or posterior to the alveolar ridge. True fistulas are caused by infection, hematoma formation between the oral and nasal layers, excess tension on the repair, flap necrosis, inadequate attachment of the oral to the nasal layer, and a technically insecure anterior closure.
When the fistula is small and of no functional significance, closure can be delayed for several years. The local blood supply is usually sufficiently robust to allow safe mobilization of local tissue despite the presence of scarring.

The hard palate mucoperiosteum rapidly regenerates over denuded areas.Oronasal or anterior alveolar palatal fistulas are generally repaired when secondary lip revision is undertaken or are repaired in conjunction with bone grafting of the alveolar cleft.

Palatal fistulas located posterior to the alveolus may vary in size from 2mm to greater than 10 mm. In the majority of cases closure can be obtained by using local palatal flaps. When designing a mucoperiosteal flap for fistula closure, the flap must be made significantly larger than the defect, and the design must allow sufficient mobility of the flap to cover the defect without tension. Mucoperiosteum is stiff, and does not adapt to transposition or suturing particularly well. The rule is always to use large palatal flaps; closure with small flaps is almost doomed to failure.

In rare cases, distant flaps (gingival flap, buccal flap, tongue flap or radial forearm flap) are indicated. Large fistulas in association with a short palate may necessitate a concomitant pharyngeal flap procedure. The use of an obturator is an alternative solution in defects that cannot be closed by local tissue because of size, previous unsuccessful surgical procedures, or patient request.

MANAGEMENT OF VELOPHARYNGEAL INSUFFICIENCY
PHILIP KT CHEN
Many surgeons have favored using the pharyngeal flap as the treatment for the velopharyngeal insufficiency (VPI) after cleft palate repair. However, the increasing number of reports of sleep apnea and airway compromise as a result of pharyngeal flap surgery support the need to eliminate any unnecessary pharyngeal flap surgery.
In Chang Gung Craniofacial Center, patients with velopharyngeal insufficiency were selected after a thorough study including intraoral examination, perceptual speech assessment and nasopharyngoscopy. The criteria for selection included age, intraoral finding of an obviously anteriorly-inserted levator palatine muscle, good response to biofeedback speech therapy and a closing ratio better than 0.6-0.7 were considered to be the best candidates for a Furlow palatoplasty. Patients who did not fulfill the criteria will be chosen for pharyngeal flap plus a Furlow palatoplasty

The result during the past 15 years showed a Furlow palatoplasty can satisfactorily correct VPI in carefully selected patients and thus avoid the serious complications of pharyngeal flap surgery. 
 

INFLUENCE ON FACIAL GROWTH OF THE PATIENTS WITH CLEFT PALATE TREATED BY FURLOW PALATOPLASTY
BYUNG CHAE CHO, M.D
The purpose of this study was to investigate the facial growth in patients with incomplete cleft or submucous palate who underwent Furlow palatoplasty.
Twenty-three patients with incomplete cleft palate and thirty-six patients with submucous cleft palate underwent Furlow palatoplasty from 1993 through 1999. The mean follow-up period was 7 years 3 months. Thirty-six of 59 patients were followed up. Midfacial growth was measured using lateral cephalogram in 28 patients (8 incomplete and 20 submucous), whose age was older than 8 years of age. The parameters obtained in the lateral cephalogram were compared with a healthy population in Korea.

All of eight patients with incomplete clefts were within the clinically normal range for ANS-PNS ,SNB and ANB parameters. Seven patients (87.5%) were within and one patient (12.5%) was below the clinically normal ranges for SNA and Ba-ANS parameters. 13 (65%) of 20 patients with submucous cleft palate were within the clinically normal range for their age group for the ANS-PNS parameter. six (30%) were above the normal range, and one  patient (5%) was below the normal range. For the SNA parameter, 60% of patients were within, 25% were above and 15% were below the clinically normal range. For the SNB parameter, 60% of patients were within, 20% were above and 20% were below the clinically normal range. For the ANB parameter, 75% of patients were within and 25% were above the clinically normal range. For the Ba-ANS parameter, 75% of patients were within, 15% were above and 10% were below the clinically normal range.
Our results suggest that Furlow palatoplasty is a useful procedure for the initial treatment of the incomplete or submucous cleft palate. It appears to have a less harmful effect on facial growth, perhaps due to reduced surgical intervention on to the hard palate and alveolar process.

ALVEOLAR CLEFT MANAGEMENT
Kang Young Choi
Hee Moon Kyung
Byung Chae Cho
Reasons for closing alveolar clefts are to provide stability of the maxillary arch, to close oronasal fistulas and anterior palatal clefts, to provide better periodontal support for teeth bordering the cleft, and to provide esthetic support of paranasal-alar base area. The proper time for bone grafting is between the ages of 9 and 11 years when the canine root is one-fourth to one-half formed. The rationale was that no adverse effect on midfacial growth at this age and that grafting at this time has led to satisfactory canine migration and eruption through the bone graft.
53 alveolar bone grafting had been performed from 1995 to 2006. The parameters acquired radiologically(periapical, occlusal, orthopantomograms) at the time of surgery and flow-up examination(mean : 35months, range: 6 months to 10years) were
1)bone resorption in relation to interdental height of alveolar process,
2)alveolar crest height around adjacent teeth
3)amount of notching of bone graft and 4)bone bridging. The influence of adequate orthodontic treatment to the fate of grafted bone was evaluated.

The flaps of attached gingiva are used to provide periodontal support for the erupting canines or lateral incisors and to provide a greater width of attached gingival at the mesiobuccal surface of the erupting canine.  A marginal gingival incision is used along adjacent teeth, edges of the cleft, midway between the palate and the nasal floor. Superiorly based flaps are developed for nasal lining, and inferiorly based flaps are reflected caudally for closure of the palate. The dissection extends posteriorly well beyond the extent of the palatal cleft. The nasal lining and palatal lining are closed. The cancellous iliac bone or corticocancellous mandibular bone is packed into the entire extent of the cleft. Bone is also used to constitute a piriform rim and is packed into the alveolar defects as inferiorly as possible. The flap is transferred over the bone graft to provide anterior alveolar closure without tension.

The bony resorption was grade I in 44%, grade II in 18%, grade III in 26%, and grade IV in 12% of cases. Thus overall remaining grafted bone was 73.5%. Average alveolar crestal bony height was 77.5% and amount of bone notching was 42%.  Bone bridging was observed radiologically at the all cases.     

Considering bone resorption, about 30% overcorrection is recommended. Alveolar crest bony height remained more than central height of grafted bone, so physiological tooth support is important for maintenance of bone graft. Adequate orthodontic gap closure provides more favorable result than do gap opening in regard to resorption (p<0.05).

ORTHOGNATHIC SURGERY IN CLEFT PATIENTS
PHILIP KT CHEN
It is not uncommon for the cleft patients to develop the following problems after the soft tissue repair as lip and palate: (1) maxillary retrusion, (2) inappropriate facial proportion, (3) wide alveolar gap(s), (4) difficult post-alveolar oronasal fistula(e), (5)collapsed segment with dental crowding.

These problems can be well corrected by a well-designed orthognathic surgery after skeletal maturity. The treatment starts with presurgical evaluation by physical examination, cephalometric and panoramic X-rays and dental casts. The dental crowding or dental compensation should be corrected by pre-surgical orthodontics which takes 3-6 months. The surgical planning is made by orthodontist with cephalometric tracing, paper surgery and model surgery.

The surgery should correct the skeletal problem as good as possible which usually involves both maxilla and mandible. The bony movement can be 3 dimensional thus 2 surgical stents are better for its accuracy. The bony fixation is achieved by miniplates and screws without intermaxillary fixation in our present practice.
Post-surgical orthodontics is essential for maintaining the bony position and establishing dental occlusion.
Complications include bleeding, infection, plate exposure, nerve injury (inferior alveolar nerve, infraorbital nerve or facial nerve). Major complications are rare however; we have experienced optic nerve injury and post-surgical AV fistula.

CLEFT TREATMENT PROTOCOL IN KOREA
BYUNG CHAE CHO, M.D
The current author surveyed cleft treatment protocol for 15 surgeons in Korean Society of Plastic and Reconstructive Surgeon. Survey items were operative age, technique in incomplete cleft lip and isolate cleft palate, type of preoperative orthopedics in complete cleft lip and palate, correction time of cleft lip nasal deformity and alveolar cleft.
In incomplete cleft lip only, operative age ranged 10 weeks to 6 months (most common in 3 months), and most common used operative technique was modified Millard method. In isolate cleft palate, operative age ranged 8 months to 24 months (most common in 12 months), Furlow-Z plasty or push-back procedure or two-flap palatoplasty was used or combined. In unilateral complete cleft lip and palate, eleven of fifteen surgeons used preoperative orthopedics. Preoperative orthopedics was started between within 1 week and 2 months. Types of preoperative orthopedics were active appliance or combined with lip adhesion, passive appliance combined with lip adhesion, and nasoalveolar molding with skin tape. The definitive cheiloplasty was done between 3 months and 7 months. In bilateral complete cleft lip and palate, all surgeons used preoperative orthopedics, and used one-stage lip repair. The used operative techniques were Millard method in 6 surgeons, modified Mullikin method in 4 surgeons, modified Noordhoff method in 3 surgeons, and Veau III operation in 2 surgeons. The operative age was between 10 weeks and 6 months.
The correction time of cleftlip nasal deformity was at primary cheiloplasty in 3 surgeons, primary cheiloplasty and age 4 to 6 in 2 surgeons, age 4 to 6 in 9 surgeons, age 4 to 6 and age 9-16 in 2 surgeons. The alveolar bone graft was done at age 9 to 11 (mixed dentition period) in all surgeons.


MUITIDISCIPLINARY CLEFT MANAGEMENT IN TAIWAN
PHILIP KT CHEN
Surgery:
3M                               Lip repair
9M-12M                      Palate repair
4-5Y                            VPI management & lip/nose revision
9-11Y                          Alveolar bone grafting
16-18Y                        Orthognathic surgery
>18Y                           Final lip/nose revision
Dental:
First visit                     Nasoalveolar molding         
1Y after                       Regular checkup QY
8.5Y                            Pre-ABG orthodontics
12Y                             Definitive orthodontics or maxillary protraction
16-18Y                        Surgical orthodontics
ENT:
6M                               First checkup
9M-1Y                         Middle ear ventilation tubes
1-6Y                            Regular checkup Q6M; ventilation tubes PRN
12Y