The Protruding Premaxilla: Is Our Current Approach the Right Answer?

Area of Science:

• Craniofacial surgery
• Pediatric plastic surgery
• Orthodontics

Background:

• Standard surgical algorithms for bilateral cleft lip and palate (BCLP) involve posterior repositioning of the premaxilla.
• BCLP patients frequently develop maxillary hypoplasia, questioning the efficacy of current treatment strategies.
• The positional relationship of lateral segments to the premaxilla in BCLP requires evaluation for effective surgical planning.

Purpose of the Study:

• To assess the position of lateral segments in relation to the premaxilla in infants with BCLP.
• To determine if lateral segments are appropriately positioned to serve as a target for premaxillary movement.
• To inform surgical algorithms for BCLP by evaluating maxillary skeletal relationships.

Main Methods:

• Retrospective review of BCLP patients treated from 1997-2015 with skull radiographs or CT imaging at age 3 or younger.
• Inclusion of noncleft patients (<3 years old) with negative imaging as controls.
• Measurement of sella-nasion-A (SNA), sella-nasion-piriform (SNP), and sella-nasion-posterior nasal spine (SN-PNS) angles in both groups.

Main Results:

• Analysis included 7 BCLP patients and 13 controls.
• BCLP patients exhibited a significantly higher mean SNA angle (100.8 vs. 86.1, P=.002).
• BCLP patients showed significantly lower mean SNP (62.9 vs. 71.3, P=.02) and SN-PNS (23.2 vs. 33.8, P=.005) angles compared to controls.

Conclusions:

• The maxilla in BCLP patients demonstrates early deficiency and posterior positioning of lateral segments.
• Lateral segments are not ideally positioned to serve as a reference point for premaxillary repositioning in BCLP treatment.
• Findings necessitate a re-evaluation of current surgical approaches for managing the premaxilla in BCLP.