What to Do Or Not to Do

WHAT TO DO OR NOT TO DO

BOUT THE PROJECTING PREMAXILLA

HI SHAKESPEARES PRINCE OF DENMARK HAVING LOST HIS

AND DISCOVERED HEINOUS CRIED OUT IN FATHER SEEN GHOST CRIME ODE WITH WHAT MIGHT WELL BECOME PLASTIC SURGEONS TO

PROJECTING PREMAXILLA

THE TIME IS OUT OF JOINT CURSED SPITE

THAT CVER WAS BORN TO SET IT RIGHT

NAY COME LETS GO TOGETHER

NO APOLOGIES ARE OFFERED FOR THE SIZE OF THIS CHAPTER WITHOUT

DOUBT THE OMINOUS SHADOW CAST BY THE PROJECTING PREMAXILLA OVER

ITS FLANKING MAXILLARY SEGMENTS AND THE OBLITERATION OF THIS SHADOW BY THE ULTIMATE ALIGNMENT OF THE TRIPLET IS THE NUMBER

ONE PROBLEM IN CLEFT LIP AND PALATE SURGERY TODAY REVIEW OF THE

LITERATURE REVEALS WHAT APPEARS TO HAVE BEEN AND STILL IS FRANTIC EFFORT TO EQUALIZE GIANT AND TWO DWARFS OF THE SAME AGE WITH

NYTHING AVAILABLEMALLET RUBBER BANDS CHISEL SAW SCA

PLATES MECHANICAL SQUEEZERS MUSCLES GROWTH AND TIME YET IT IS

ESSENTIAL TO KNOWWHAT HAS BEEN TRIED IN ORDER TO KNOWNOT ONLY

WHAT TO DO AND NOT TO DO BUT WHAT IS LEFT STILL TO BE TRIED

IN BILATERAL CLEFTS THE POSITION OF THE PREMAXILLA IS THE KEYSTONE

TO THE RECONSTRUCTION IF IT RESTS WITHIN THE MAXILLARY ARCH CLOSURE OF THE LIP CLEFTS OFFERS NO GREAT PROBLEM THIS IS THE USUAL SITUA

TION IN INCOMPLETE BILATERAL CLEFTS IN COMPLETE BILATERAL CLEFTS

HOWEVER THE PREMAXILLA INVARIABLY EXTENDS IN FRONT OF THE

PREMAXILLARY ELEMENTS AND THE PROJECTION CAN VARY FROM INSIG NIFICANT ALMOST TO INSURMOUNTABLE PROTRUSION OFTEN ASSOCIATED

WITH DEVIATION THIS PROJECTION HAS BEEN TREATED IN NUMEROUS

WAYS OVER THE CENTURIES

PRIMARY EXCISION

PIERRE FRANCO PIONEER IN CLEFT LIP SURGERY WAS THE FIRST TO

DESCRIBE DISCARD BY PRIMARY EXCISION OF THE PROJECTING PREMAXILLA

BILATERAL CLEFTS IN HE ALSO ADVOCATED SURGICAL FREEING OF THE LIP

ELEMENTS OFF THE MAXILLA TO AID IN THE CLOSURE IN 1556 HE WROTE

THERE IS ANOTHER OF CLEFT TYPE LIP WHICH IS COMMONLY CALLED HARES TOOTH

BECAUSE THERE ARE TEETH WHICH PROTRUDE FROM THE MOUTH IN FRONT OF THE

MAXILLA SOMETIMES ONLY ONE MORE OFTEN TWO AND SOMETIMES THEY ARE

ALSO ACCOMPANIED ON BOTH SIDES BY CLEFTS OF THE MAXILLA AS FOR THE METHOD

OF TREATMENT WHEN THESE TEETH OR MANDIBLES ARE SO LARGE THAT THEY

PIERRE FRANCO CANNOT BE COVERED THERE IS NO DANGER IN CUTTING OFF THE EXCESS WITH CUTTING

FORCEPS OR WITH SMALL SAW LEAVING THE FLESH OVER THEM PROLABIUM IF THERE

IS OLLGH FOR IT WILL BE POSSIBLE TO SEW THE MARGINS TO IT THE PROLABIUM

ON EACH SIDE AND IF THE DISTANCE BETWEEN THE MARGINS WAS SO GREAT THAT THEY

COULD NOT BE JOINED IT WOULD BE NECESSARY TO USE INCISIONS WITHIN THE MOUTH

TO UNDERMINE LIP ELEMENTS FROM THEIR ATTACHMENTS TO THE MAXILLA

IN 1661 HENDRIK VAN ROONHUZZE OF AMSTERDAM ADVISED

CUTTING AWAY WITH PINCERS THE PROJECTING PREMAXILLA IN HARE

MOUTH SO AS TO PERMIT SUTURING OF THE BILATERAL CLEFT LIP

DE IA OF PARIS GEORGES FAYE IN 1733 REMOVED THE PROJECTING

PREMAXILLA WITH SCISSORS WHICH HAD

LONG BLADES AND WERE MADE LIKE WATCHMAKERS CHISEL

DUPUYTREN

IF GUILLAUME OF II DUPUYTREN PARIS KNOWN BY SOME AS THE NAPOLEON

OF ALSO IN SURGERY WAS PIONEER PLASTIC SURGERY HE WAS 130 YEARS

AHEAD OF WITH NITRATE OF SILVER IN MOYER BURNS 20 YEARS AHEAD OF

LANGER WITH LINES OF SKIN TENSION 10 YEARS AHEAD OF CURLING WITH

IS ULCER AND AHEAD OF ALMOST GASTROINTESTINAL EVERYONE ON THE

CONTRACTURE OF THE PALMAR APONEUROSIS HE ALSO ENJOYED SELF

AGGRANDIZEMENT ALLOWING HIS NAME TO BE ATTACHED TO POWDER TO REDUCE AND ITCH AN OINTMENT AGAINST BALDNESS AND EVEN MAN GUZILAUME DUPUYTREN AGING TO GET KING LOUIS XVIII TO MAKE HIM BARON IN 1816

YET EVEN HIS JEALOUS ENEMIES HAD TO ADMIT HE WAS HARD WORKER

AS GOLDWYN NOTED MONSIEUR LE BARON WOULD BE SEEN STILL

42 IT THE WARDS AT NINE IN THE EVENING SLOPPILY MAKING ROUNDS ON OLD FROCK AND SOCKS OVER THE OF HIS ATTIRED IN AN GREEN TOPS OF STUDENTS AND VISITORS FROM ALL BOOTS FOLLOWED BY AN ENTOURAGE

OF THE WORLD PARTS LESS HIS CONTRIBUTIONS IN BILATERAL CLEFT LIP SURGERY WERE RE THE WITH THE MARKABLE FOR HE SHOWED SAME IMPATIENCE PROJECTING

THAT HE DID WITH TROUBLESOME PATIENT ACCORDING TO PREMAXILLA MASON WARREN DUPUYTREN5 AMERICAN STUDENT JONATHAN

HE MAKES OF HIS IF HIS ORDERS ARE NOT IMMEDIATELY OBEYED NOTHING STRIKING THEM FAVORITE OF HIS IS TO MAKE PATIENTS AND ABUSING HARSHLY PRACTICE AND HIM DOWN ON HIS HANDLE OF MANS NOSE SEIZING HIM BY IT PULLING

HALF IN HALF IN UNTIL HE IS ALLOWED TO KNEES WHERE HE REMAINS SORROW ANGER

HIS RISE AND DESCRIBE

BARON WAS NOT LIKE MANY SURGICAL PIONEER DUPUYTREN ONLY

BAFFLED BUT FRUSTRATED BY THE PROBLEM OF THE PROJECTING PRE

RISEN SUCH THAT MAXILLA BY 1829 HIS EXASPERATION HAD TO AN EXTENT HE TOOK HOLD OF THIS MALPOSITIONED KNOB AND TWISTED IT OFF THE COLUMELLA HE DID UTILIZING THE PROLABIUM TO CONSTRUCT

ACKNOWLEDGE LATER

MALGAIGNE THINKS THAT THIS IS LIABLE TO OBJECTIONS THE MOST SERIOUS THE OF THREE OR EVEN THE FOUR ACCORDING TO HIM IS THE REMOVAL OF GERM TWO

INCISORS

SIMS

MARION SIMS OF NEW YORK DESERVEDLY BETTER KNOWN FOR HIS REMOVED ON VESICOVAGINAL FISTULA THAN ON PREMAXILLA

THIS STRUCTURE IN MOST HORRIBLE CASE OF HARELIP PRESERVING THE

PROLABIUM THIRTYSEVEN DAYS AFTER PREMAXILLARY EXCISION HE AND TRIMMED THE CLEFT EDGES AND THE PROLABIUM WITH SCISSORS

APPROXIMATED THE WOUND EDGES WITH SINGLE THROUGHAND

THROUGH NEEDLE AND WITH SEVERAL INTERRUPTED SUTURES WHICH WERE

LATER REINFORCED BY TYPE OF TAPE SUPPORT

ROSE

IN WILLIAM ROSE OF KINGS COLLEGE HOSPITAL LONDON WROTE 1891

TO OF THE INCISIVE BONE SO MY OWN MIND THE DISADVANTAGES OF THE RETENTION

CLEARLY OUTWEIGH THE PRIMAFACIE ADVANTAGES THAT IN MY PRACTICE HAVE

43 FOLLOWED THE USUAL COURSE ADOPTED BY THE MAJORITY OF BRITISH SURGEONS IN THE BONE REMOVING AT THE EARLIEST OPPORTUNITY BY THIS REMOVAL THE OPERATION OF THE CAN BE MORE LIP SUCCESSFULLY ACCOMPLISHED AND AS REGARDS THE PROFILE

EFFECT THE LATER INTRODUCTION OF DENTAL PLATE WITH ARTIFICIAL INCISORS WILL

GREATLY IMPROVE THE APPEARANCE AND ENABLE THE PATIENT TO BITE IN SATISFAC

TORY MANNER FAR MORE SO IN FACT THAN WITH THE MOBILE OS INCISIVUM

OBJECTION TO REMOVAL

YET AS EARLY AS THE LATTER PART OF THE EIGHTEENTH CENTURY CHORIN SHOWED REMARKABLE INSIGHT BY OBJECTING TO THE PRIMARY EXCISION OF THE PREMAXI OBVIOUSLY BY OBSERVATION HE RECOGNIZED THAT

THE ULTIMATE RESULT WAS TIGHT LIP DISH FACE OF THE MIDDLE THIRD OF

THE FACE AND RELATIVE MANDIBULAR PROGNATHISM HE WROTE

IT WILL LEAVE CONSIDERABLE SPACE BETWEEN THE MAXILLARY BONES IT WILL DEPRIVE LI THE OF LIP ITS POINT OF SUPPORT AT THE PLACE WHERE IT IS DIVIDED AND IF THE

REUNION TAKES IN OF THE OF AA PLACE SPIRE DISADVANTAGES SUCH AN ARRANGEMENT THE ACTION OF THE MUSCLES WILL SOON LESSEN THE SPACE BETWEEN THE MAXILLARY

BONESARRDTH UPPER JAW WILL BECOME CONTRACTED ENOUGH TO FALL WITHIN THE

UNDER ONE CIRCUMSTANCE WHICH AT THE SAME TIME THAT IT RENDERS MASTICA

NON VERY DIFFICULT WILL OCCASION FRESH DEFORMITY

WHAT SIMS AND OTHERS DID FRANCO DUPUYTREN ON PURPOSE AND OUT OF DESPERATION SOME SURGEONS DO INADVERTENTLY THE RESULTS

ARE STILL LOSS OF THE PREMAXILLA AND CENTRAL DEFORMITY OF THE FACE

POSTERIOR TRACTION BY VARIOUS TYPES OF EXTRAORAL APPARATUS

II FOLLOWING DISSATISFACTION WITH PRIMARY EXCISION INGENIOUS

METHODS OF EXTERNAL COMPRESSION WERE DEVISED IT SEEMS TO HAVE BEEN TUGOFWAR BETWEEN THE GERMANS AND THE FRENCH AS TO 11 WHO COULD TUG THE HARDEST ON THE PREMAXI IN 1686 GERMAN JOHAN PHILIP HOFMAN PRESENTED HEADCAP

WITH CHEEK EXTENSIONS ARMED WITH CORSET HOOKS AT THE SIDES OF THE LACED LIP WHEN WITH TENSION THIS APPARATUS COULD SERVE BOTH TO II PRESS ON THE PREMAXILLA AND TO RELIEVE THE TENSION OF THE BILATERAL

CLEFT CLOSURE

BY 1768 LOUIS FRENCH SURGEON BLAMED THE CLEFTS ON LACK OF

MUSCLE RETRACTION RATHER THAN LOSS OF TISSUE AND ADVOCATED

44 WITH THE AID OF BONNET CHAUSSIER ANOTHER UNITING BANDAGE IN 1776 DESIGNED CHEEK COMPRESSION BANDAGE FRENCH SURGEOFL OBTAIN NUMBET OF CURES DESPITE THE FOR CLEFT LIP TO GREATER OF THE LITTLE CONTINUOUS MOVEMENTS PATIENTS

DESAULT

DEVISED RATHER ELABORATE CLOTH 1790 DESAULT COMPRESSION THE FOR BANDAGE WHICH HE APPLIED AGAINST PROJECTING PREMAXILLA TO EXERT BACKWARD THIS IS II DAYS PREOPERATIVELY STEADY PRESSURE DESAULTS ON BILATERAL CLEFT DESCRIPTION OF BANDAGE FIVEYEAROLD

HIS CHORIN LIP BY JUNIOR SURGEON

LEVEL WITH THE AND THE IN ORDER TO BRING THE PROTUBERANCE TO LIP TO DEPRESS

OF THE WHO AS THE PROJECTING PORTION MAXILLARY BONES DESAULT PRINCIPAL H6TEL UNDERTOOK THE TREATMENT OF THE HAD SURGEON OF THE DIEU PARIS CASE FIXED RECOURSE TO LINEN BANDAGE WHICH PASSED OVER THE UPPER LIP AND WAS AT

THE EFFECTS OF THIS IN THE BACK PART OF THE NECK GOOD BANDAGE COMPRESSING

THAT ITS USE WAS CONTINUED UNTIL THE THE PARTS IN QUESTION WERE SO OBVIOUS

OPERATION WAS PERFORMED

MALGAIGNE AND HULLIHEN

MALGAIGNE USED SIMILAR TYPE OF CLOTH COMPRESSION BANDAGE

IN ABOUT 1844 SIMON HULLIHEN AMERICAN DENTIST OF WHEEL

ING WEST VIRGINIA WAS ANOTHER TO USE EXTERNAL RETRACTION IN

BILATERAL CLEFTS ALSO IN 1844 AS NOTED BY ROBERT GOLDWYN IN

PLASTIC AND RECONSTRUCTIVE SURGERY SEPTEMBER 1973 HULLIHEN URGED

PREPARATORY TREATMENT IN ALL CASES ESPECIALLY WHEN THE LIP

DEFORMITY WAS ACCOMPANICD BY CLCFT OF THC ALVEOLAR AND PALA

TINE ARCHES HIS INITIAL TREATMENT LIKE THAT OF THIERSCH WAS AN

ADHESIVE STRAP FROM ONE CHEEK TO THE OTHER BUT HE ADVOCATED

CINCHING IT CONSTANTLY

THE STRAP SHOULD BE KEPT PERFECTLY TENSE IT IS THEREFORE NECESSARY TO TIGHTEN

IT EVERY DAY OR TWO WHICH MAY BE DONE BY CUTTING SMALL PORTION OUR OF

THE NARROW PART AND THEN SEWING IT TOGETHER WITHOUT DISTURBING ITS

ADHESION TO EITHER CHEEK THE TIME GENERALLY REQUIRED TO CLOSE CLEFT OF THE ALVEOLAR THE ARCH DEPENDS MORE UPON THE AGE OF THE INFANT THAN UPON

SIZE OF THE CLEFT IT GENERALLY REQUIRES FROM FOUR TO SIX WEEKS TO CLOSE THE CLEFT

IN INFANTS THE CLEFT OF THE UNDER FIVE MONTHS OLD AS SOON AS EDGES

ALVEOLAR ARCH ARE BROUGHT TOGETHER SO AS TO TOUCH EACH OTHER IN THE SLIGHTEST

MANNER THE OPERATION FOR THE CURE OF THE HARELIP MAY BE PROPERLY PERFORMED

45 THE GERMANS AND OTHERS

THEN THE GERMANS BEGAN TO TUG AGAIN IN 1868 VON BARDELEBEN USED WITH COMPRESSION BANDAGE BONNET AS SHOWN IN 1875 II KARL THIERSCH OF LEIPZIG BETTER KNOWN FOR HIS THIN SPLITSKIN USED RUBBER BANDS GRAFTS STUCK TO THE CHEEKS WITH AN ADHESIVE

THIS COURSE OF EVENTS NOT REVEALS ONLY THE PARTICIPATION OF FAMOUS IN GENERAL SURGEONS THE TREATMENT OF CLEFTS IN THE NINETEENTH

CENTURY BUT POINTS OUT THE VALUE OF THEIR SOUND LOGIC TURNED TOWARD CLEFT CORRECTION IN THE EARLY DAYS BY 1892 VON ESMARCH AND KOWALZIG WERE EMPLOYING AN ELASTIC BAND ATTACHED TO HEADCAP WHICH IS BEGINNING TO GET QUITE MODERN

THE AMERICANS THE JOINED RANKS AGAIN AND IN 1907 ORAL SURGEON BROWN USED ADHESIVE TAPE PRESSURE ACROSS THE NEEDLESS PREMAXILLA TO SAY THE SKIN DID NOT TAKE THIS TOO WELL BY 1922 WAS USING THE ELASTIC BAND AND ADVOCATED IT STILL IN 1964 KARL THIERSCH HANS THE DERICHSWEILER AT 34TH CONGRESS OF THE EUROPEAN ORTHODONTIC IN SOCIETY COPENHAGEN CLAIMED THAT THE BILATERAL

CLEFT COULD BE FUSED PREMAXILLA WITH THE PREVOMERINE SEGMENT EXTRAORAL BY TRACTION ALONE THIS ASSERTION STIMULATED MERTON GRISWOLD AND WILLIS OF SAGE NEW JERSEY IN 1966 TO DEVELOP AN ULTRAMODERN BONNET OF STOUT MUSLIN ON WHICH LIP TRACTION BAND MADE OF WOMANS PLAYTEX GIRDLE WAS HOOKED TO EXERT OUNCES OF TENSION IN BABIES AND UP TO 14 OUNCES IN OLDER CHILDREN THE WAS APPARATUS APPLIED FOR SIX WEEKS TO THREC MONTHS DEPEND ING ON THE EFFECT TO OFFSET THE MAXILLARY COLLAPSE BEHIND THE PRE MAXILLA HELD THE THEY PREMAXILLA IN ALIGNMENT WHILE TRACTION DEVICES ATTACHED THE TO TEETH WERE EXPANDING THE ARCH WITH VARIATIONS THIS GENERAL IS APPROACH PROBABLY THE MOST POPULAR PREOPERATIVE TREATMENT IN USE TODAY

CONTROLLED FIXED EXTERNAL TRACTION

IN 1968 THE DUKE MEDICAL UNIVERSITY CENTER TEAM OF GEORGIADE MLADICK AND THORNE SUGGESTED PASSING TWO KIRSCHNER WIRES

46 THE ONE THE AND HORIZONTALLY THROUGH CHEEKS THROUGH PREMAXILLA MAXILLA THE ENDS OF THE OTHER THROUGH THE POSTERIOR THE WIRES AND RUBBER BANDS WERE BENT INTO HOOKS WERE APPLIED TO ACHIEVE

CONTROLLED POSTERIOR TRACTION SUBSEQUENT EXPERIENCE REVEALED THAT

WIRES TENDED TO CUT THROUGH THE SOFT BONE OF THE PREMAXILLA NICHOLAS THEN IN 1970 GEORGIADE PART GREEK PART AUSTRIAN

ARMED WITH DENTAL AND MEDICAL DEGREES CUNNING AND AS CAPABLE DEVISED IN CASBAH AS ON COLLEGE CAMPUS DACRON HALTER FOR

HIS CONTROLLABLE TRACTION WATCHED HIM PLACE ONE ON PROJECTING

PREMAXILLA AT DUKE IN 1971

FIVE DAYS BEFORE CLOSURE OF THE BILATERAL CLEFT LIP UNDER LOCAL

ANESTHESIA GEORGIADE PASSED ONE 0054 KIRSCHNER WIRE THROUGH

THE CHEEK JUST DISTAL TO THE MAXILLA NEAR ITS JUNCTION WITH THE

PTERYGOID PLATE OF THE SPHENOID BONE AND DISTAL TO THE TOOTH BUD NICHOLAS GEORGIACK

FOLLICLES THE WIRE WAS THRUST ACROSS THE CLEFT AND THROUGH THE

OPPOSITE SIDE OF THE MAXILLA UNTIL PALPABLE UNDER THE CHEEK SKIN

LATER IMPROVEMENT IN HIS DESIGN WAS THE FASHIONING OF

PREMAXILLARY HALTER FROM HALFINCH STRIP CUT FROM DACRON ARTERIAL

MATERIAL THIS DACRON STRIP WAS SPLIT INTO LOPSIDED WITH ONE

PRONG EXTENSION SEVERAL TIMES THE LENGTH OF THE OTHER THE LONGER EXTENSION UNDER WAS PASSED THE PROLABIUM TO HUG THE PREMAXILLA

WHILE THE WIDER SHORTER EXTENSION WAS BROUGHT AROUND IN FRONT OF THE PREMAXILLA AND FASTENED BY SUTURES TO THE OTHER END COMING FROM UNDER THE PROLABIUM THUS THE HALTER WAS COMPLETE ITS TWO BANDS THE ENCOMPASSING HEAD AND NOSE OF THE PREMAXILLA AND THE ENDS LEAVING TWO AS RESTRAINING REINS THROUGH WHICH STANDARD RUBBER BANDS THREADED WERE THE RUBBER BANDS WERE THEN LOOPED

AROUND TRANSVERSE KIRSCHNER GEORGIADES POSTERIOR WIRE EXERTING THE TENSION REQUIRED TO CAUSE RETROPOSITIONING OF THE PREMAXILLA

47 FIVE LATER THE CLEFTS OF DAYS THE LIP WERE CLOSED AND THE INTRAORAL TRACTION WAS MAINTAINED ANOTHER WEEKS TWO FOLLOWING THE LIP SURGERY THIS INTERFERED WITH CONTRAPTION SURGERY AND WAS NOT CONTROLLABLE COMPLETELY SO BETTER TRACTION DEVICE WAS SOUGHT

THE VALUE OF COMBINED DENTAL AND SURGICAL EFFORT IN THE

TREATMENT OF CLEFTS IS NOT NEW TO NICHOLAS GEORGIADE WHONEARLY 30 YEARS AGO HAVING COMPLETED DENTAL SCHOOL AND ORAL SURGERY TRAINING AT KINGS COUNTY STARTED MEDICAL SCHOOL AT DUKE UNI

VERSIRY THE SUMMER AND DURING HOLIDAYS HE JOINED THE TEAM OF DUNNING AND IN NEW YORK MCCAFFREY CITY HENRY DUNNING 11 MD WAS CHARTER MEMBER DDS OF THE BOARD OF PLASTIC SURGERY AND MCCAFFREY DDS WAS AN EXALLAMERICAN FOOTBALL PLAYER FROM FORDHAM GEORGIADE WHOFITTED INTO THIS TEAM WELL AS HE WAS MEDICAL STUDENT AND HAD PLAYED LITTLE FOOTBALL AT FORDHAM FOUND HIMSELF INVOLVED IN THE SURGICAL TREATMENT OF TWO TO THREE AND CLEFTS LIP PALATE DAY

DUKECAROLINA GAME

SO IMPORTANT ARE THE AND PREMAXILLARY OTHER CLEFT PROBLEMS THAT ARCHANTAGONISTS HAVE BURIED GRIDIRON RIVALRIES AND JOINED ORAL AND

PLASTIC FORCES AGAINST COMMON THE ENEMY PROJECTING PREMAXILLA GEORGIADE OF DUKE AND LATHAM OF CAROLINA HAVE DEVELOPED WHAT REFER THEY TO AS THE MARK III COAXIAL ARCH ALIGNMENT APPLIANCE WITH TWO CONCENTRIC KNOBS PROTRUDING FROM THE MOUTH ONE FOR ARCH EXPANSION AND THE OTHER FOR PREMAXILLARY RETRACTION THE

EXPANSION IS OF COMPONENT COMPOSED PROSTHESIS FITTED ON EACH

MAXILLARY ELEMENT AND IN PINNED POSITION WITH CROSS WIRE ATTACHED TO GEARBOX SO THAT TURN OF THE THUMBSCREWS SPREADS JF THE SEGMENTS OF THE ARCH MAXILLARY APART THE RETRACTION COMPO NENT IS SADDLE ATTACHMENT STRADDLING THE ANTERIOR VOMER AND

FIXED WITH PIN THE AREA THROUGH POSTERIOR TO THE DENTITION OF THE MARK ILL PREMAXILLA THIS ATTACHMENT IS OPERATED THROUGH HOLLOW TUBE BY SCREW DEVICE PASSING POSTERIOR TO GEARBOX JACKSCREW ON THE CENTER OF THE CROSS WIRE OF THE PROSTHESIS ONE MILLIMETER OF

POSTERIOR MOVEMENT OF THE PREMAXILLA IS ACHIEVED BY EVERY TURN OF THIS SECOND AND THUMBSCREW TURN IN THE MORNING AND

48 THERE ARE TWO TO DAY THEORETICALLY ACTUALLY EVENING GAINS MM CUMULATIVE EFFECT EVIDENCE OF CHANGE BUT THE THREE DAYS WITH NO SHOW MEASURABLE REDUCTION IN THE FIVE BEGINS TO BY FOUR TO DAYS THE AND THE MAXILLAE IN ADDITION DISTANCE BETWEEN PREMAXILLA THAN OR ANTEFLEXING SEEMS TO TELE THE VOMER RATHER DEVIATING WITH ACTUAL IN THIS THE SUTURE LINE BULGING SCOPE AT PREVOMERINE THE 10 THE IS CLOSE ENOUGH INTO AREA IN TO DAYS PREMAXILLA FOR TO REMOVE THE PROSTHESIS AND AC MAXILLARY ARCH GEORGIADE FOR USING ALVEOLAR EDGE MUCOPERIOSTEUM COMPLISH GINGIVOPLASTY LABIALBUCCAL FOR HIS ORAL HIS NASAL LAYER AND MUCOPERIOSTEUM HIS BILATERAL CLOSURE AT THE SAME TIME HE ACCOMPLISHES STRAIGHT

CLOSURE DESCRIBED IN CHAPTER LINE LIP II OF INFANT WITH HIS IN 1974 GEORGIADE SENT ME PHOTOS AN

IN ACTION THE WITHIN PERIOD APPARATUS SHOWING RETROPOSITIONING OF NINE DAYS HE WROTE

HOW HANDLE THE LAM NOT SURE WE HAVE ALL THE ANSWERS YET AS TO TO PREMAXILLA

REVIEW 25 OF IN WITH BUT CERTAINLY WHEN MY PAST YEARS EXPERIENCE DEALING STANDARD THESE INFANTS WHO RECEIVED THE BEST TREATMENT ACCORDING TO OUR

AND WHO ARE NOW ADULTS WITH COLLAPSED MAXILLAE AND FLAT UPPER LIPS CANNOT

HAVE LEARNED BELIEVE THIS HELP HUT HOPE THAT WE SOMETHING CERTAINLY DIRECTION RATHER SIMPLE APPLIANCE MUST BE STEP IN THE RIGHT TO PREVENT

THOSE HORRIBLE MAXILLARY DEFORMITIES CERTAINLY THIS METHOD OF EXPAND THE HAVE ING THE MAXILLARY SEGMENTS IS LOT BETTER THAN WHAT ORTHODONTISTS

TRIED TO FORCE US TO USE WITH ORAL APPLIANCES THAT HAD TO BE TURNED IN

MCNEIL IS SCREAMING UNHAPPY INFANT THE USE OF THE CUMBERSOME TECHNIQUE

NOT EVEN IN THE SAME BALL PARK AS THIS SIMPLE APPARATUS

LATHAM WROTE ME ON JUNE 15 1973

DR GEORGIADE AND ARE SATISFIED WITH THE CABLESCREW PREMAXILLARY RETRACTORS

AND BILATERAL CLEFT INFANT THE GEAR CONTROLLED EXPANSION APPLIANCE AS USED IN AAZ AT DUKE UNIVERSITY MEDICAL CENTER LAST WEEK DR GEORGIADE MANAGED TO DO

THE VERTICAL GINGIVOPERIOSREOPLASRY AS WELL AS THE LIP ALTHOUGH RELATIONSHIPS

WILL HAVE TO BE WERE POOR THE ANTERIOR ENDS OF THE MAXILLARY SEGMENTS

CONTROLLED IN THE VERTICAL PLANE AS WELL AS IN THE HORIZONTALIE THE USUAL

EXPANSIONCOLLAPSE PROBLEM HOPE THAT IT WILL SOON BE ACCEPTED THAT AN

EFFORT SHOULD BE MADE TO CLOSE THE ALVEOLOGINGIVAL CLEFT AT THE SAME TIME AS

LIP CLOSURE

49 BY LATE OCTOBER 1973 LATHAM REPORTED

WE HAVE NOW USED THIS APPLIANCE THREE TIMES WITH CONSIDERABLE SUCCESS IN

MADE TO DOWNWARD ALL THREE TO MY GREAT SATISFACTION AN ATTEMPT WAS PUT

TRACTION ON THE MAXILLARY SEGMENTS THIS WORKED WELL ON THE FIRST AND NOT SO

WELL ON THE OTHER TWOBUT IM DEALING WITH SOME OF THE DIFFICULTIES AND

IM SURE THIS IS GOING TO BE BIG PART OF THE TREATMENT

LATHAMS REASONING

UNDER TENSION AND AS THE BRAIN GROWS THE CRANIAL VAULT SUTURES ARE PUT SUTURAL SURFACES OSTEOGENESIS OCCURS AS REQUIRED YOU HAVE TWO SEPARATING

AND NEW GROWTH OCCURRING TO KEEP THE BONE EDGES THE SAME DISTANCE

TOWARD IN IN APARTSAY 02 MM IN MY WORK PHD LIVERPOOL 1966

FOUND THAT IN THE RAPIDLY GROWING FACIAL SKELETON OF THE FETUS OSTEOGENESIS

WAS NOR FEATURE OF THE SUTURES AROUND THE MAXILLA IT WAS OBVIOUS THAT AT

THAT TIME SKULL GROWTH WAS MOST RAPID THEN CAME TO WHAT REGARD AS MY

MOST IMPORTANT OBSERVATION THE BONES WERE SLIDING PAST ONE ANOTHER AT THE

SUTURES THEY WERE ALIGNED IN THE DIRECTION OF BONE MOVEMENT AND BONE

FORMATION WAS NOT NECESSARY FOR THIS MOVEMENT THE FACTOR THAT WOULD

CONTROL SUCH SLIDING WOULD HE THE ADJUSTMENT OF THE COLLAGEN FIBRES HOLDING OF THE BONES TOGETHER AT THE JOINT IT SEEMS THAT SUCH ADJUSTMENT THE

COLLAGEN FIBRES INTERLACING ACROSS THE SUTURE COULD ALLOW MUCH MORE RAPID

MOVEMENT OF THE HONES THAN IF SUCH MOVEMENT WERE DEPENDENT UPON THE

RATE OF BONE DEPOSITION AT SEPARATING SUTURE THINK OF THE CONTINUOUSLY OF ERUPTING INCISOR TOOTH OF THE RODENT THE TOOTH IS MOVING OR SLIDING OUT

THE SOCKET ALL THE TIME WHILE COLLAGEN PERIDONTAL LIGAMENT ADJUSTS IN THE

II INTERMEDIATE PLEXUS WHERE THE FIBRES FROM THE BONE AND TOOTH DIVIDE INTO WITH FINE INRERMESHING NETWORK PUT THE PALMS OF YOUR HANDS TOGETHER

ELBOWS OUTWARD NOWSLIDE ONE HAND OVER THE OTHER WITH ELBOWS MOVING

OUR THE HANDS MAY MOVE IN OPPOSITE DIRECTIONS FOR GREAT DISTANCE HEFORE

CONTACT AT THE INRERPALMAR SURFACE IS LOST NOWTO MAINTAIN THAT CONTACT THE OF HONE GROWTH NEEDS ONLY OCCUR AT THE FINGER TIPS SUCH IS ECONOMY

FORMATION IN THE RAPIDLY GROWING SKULL

HERE IS CORONAL SECTION OF THE ZYGOMATICMAXILLARY SUTURE

INFANT OFFERED LATHAM TO DEMON III FROM THREEWEEKPOSTNATAL BY OF THE STRATE THE FIVE LAYERS WHICH HE SAYS ARE INDICATIVE SUTURE

ADJUSTMENT MECHANISM HE NOTED

THE SUTURE UNITING THE TWO BONES SHOWS FIVE TISSUE LAYERS THE PERIOSREAL WITH OSTEOGENIC AND FIBROUS CAPSULAR LAYERS OF EACH HONE RESPECTIVELY

50 ZYGOMATIC BONE

THE FIBERS OF THE LAYERS ARE MIDDLE LOOSE VASCULAR LAYER COLLAGEN CAPSULAR AND THIS FACILITATES THE MOVE ORIENTED MAINLY PARALLEL TO THE BONE MARGINS THE OTHER SINCE OCCUR MAINLY IN MENT OF ONE BONE IN RELATION TO ADJUSTMENTS WHERE OF THE MIDDLE ZONE AND AT THE PERIPHERY OF THE SUTURE UNITING LAYERS FROM ONE BONE TO THE OTHER FIBERS PASS DIRECTLY TERRITORY

LATHAM ADDS

BETWEEN TWO BONE SURFACES THIS MEANS THAT SLIDING IS NORMAL MECHANISM THE SUTURE AS AND THIS IS WHAT IS BEING REQUIRED OF VOMEROPREMAXILLARY SO HAVE TO THIS RETRACTION FORCE IS PLACED ON THE PREMAXILLAE WE EXPLOIT DIDNT LIKE MECHANISM WORK WITHIN ITS LIMITATIONS AND THATS MAINLY WHY THE MECHANISM ALLOWS US TO DO THIS JOB DR GEORGIADES RUBBER BANDS SCREW

WOULD THE AS FAR AS IT IN SERIES OF STEPS AT EACH STEP WE PUSH COLLAGEN

WOULD ADJUST AND STRETCH WITHIN THE BOUNDS OF NORMAL PHYSIOLOGY LAM KEEN THE MAYBE YOU WILL BEGIN TO SEE WHY TO PUT MAXILLARY SEGMENTS CONFIDENT THAT WILL EXACTLY WHERE WE WANT THEM BECAUSE IM THEY MOVE

WHEN GIVEN SOME REASON TO MOVE

LATHAM AND WORKMANIN THE 1974 SYMPOSIUM ON MANAGEMENT FURTHER OF CLEFT LIP AND PALATE AND ASSOCIATED DEFORMITIES JUSTIFIED THE THE MARK III POSITIONING OF PREMAXILLA BY RAPID COMPRESSION

COLUMELLA COVERED AND OBSCURCD THE ALVEOLAR OF THE CARRILAGES ARE BY PROCESS

OF THE MEDIAL CRURA IS THE PREMAXILLARY SEGMENT THE POSITION PROBABLY THE MEDIAL CORRECT AND SHOULD BE PRESERVED THE CLOSE RELATIONSHIP BETWEEN

CRURA AND THE BONY ALVEOLAR PROCESS IS ONE OF GRADUAL ACQUIRED APPROXIMA BE TION THEY ARE NOR FIRMLY UNITED ONE TO THE OTHER AND MAY READILY MOVED TO SEPARATED BY POSTERIOR TRACTION THE PREMAXILLARY SEGMENT MAY BE

HT 51 MORE NORMAL POSIRION AR RHE SAME RIME UNCOVERING RHE COLUMELLA

CARRILAGES IR IS RO BE HOPED THAR THIS RARIONALE WILL REND ROWARD RHE MANIFESTATION OF NORMAL AND RELATIONSHIPS APPEARANCES IN RHE LIP AND

COLUMELLAR REGION WITH LATER GROWTH

IN FINALLY JULY 1975 GEORGIADE AND LATHAM AGAIN PROMOTED

THEIR PINNED COAXIAL SCREW APPLIANCE

BECAUSE THE PROTRUDED PREMAXILLARY SEGMENT MAY BE RETRACTED RAPIDLY IN

TO 10 DAYS AND THIS BE SCHEDULED AT THE TIME MAY SAME AS LIP SURGERY

ORTHOPEDIC OF THIS FORMIDABLE MALFORMATION IS MANAGEMENT NOW PRACTICAL

AND AVAILABLE TO ALL SUCH THEREFORE INFANTS AS ROUTINE PROCEDURE 41

SIMPLE EARLY CLOSURE OF LIP CLEFTS TO SERVE AS MOLDING ACTION

THE RECONSTITUTION OF THE NORMAL RESTRAINING MUSCLE BAND

SATISFACTION IN GIVES GOOD PERCENTAGE OF CASES IN FACT WHEN THE

PREMAXILLA IN ADDITION TO THE PROJECTION IS ROTATED TO ONE SIDE THE CLOSURE CAN BE STAGED TO ADVANTAGE BY CLOSING THE LIP CLEFT ACROSS THE WIDEST ONE CAN THE GAP PULL PREMAXILLA INTO STRAIGHT

POSITION IN PREPARATION FOR LIP CLOSURE ON THE SECOND SIDE DEHAAN

ADMITTED IN STARKS 1968 THAT CLEFT PALATE SURGEONS DISAGREE ON WHETHER THE SHOULD PREMAXILLA BE RECESSED PRIMARILY BUT CON CLUDED

HAVE NOR FOUND THE PROMINENT PREMAXILLA SERIOUS PROBLEM ONCE THE

IS CLOSED IT LIP USUALLY EXERTS SUFFICIENT PRESSURE FOR THE DESIRED RERRODISPLACE MENT WE FEEL THAT OPERATIVE RECESSION OF THE PREMAXILLA MAY WELL INTERFERE WITH GROWTH OF THE CENTRAL THIRD OF THE FACE

BAUER TRUSLER AND TONDRA IN INDIANA IN 1959 AND GLOVER AND

NEWCOMBIN OHIO IN ALL 1961 AS RESULT OF LONGTERM REVIEWS DECIDED SETBACK OF THE AGAINST SURGICAL PREMAXILLA AS THEIR BEST RESULTS WERE WITH SIMPLE SOFT TISSUE CLOSURE

AS AS THERE EARLY 1954 APPEARED AN INTERESTING REPORT SLAUGH TER OF AND LOYOLA UNIVERSITY THE UNIVERSITY OF WISCONSIN AND OF THE OF PRUZANSKY UNIVERSITY ILLINOIS COLLEGE OF DENTISTRY

REALIZED THE IMPORTANCE OF MUSCLE CLOSURE ACROSS THE CLEFT

52 IS THE SIMULTANEOUS REESTABLISHMENT OF THE ACCOMPANYING THE CLEFT LIP REPAIR OTIS MUSCLETHAT OF FUNCTION OF THE ORBICULARIS SPHINCTERLIKE PRIME OF THE ACCESSORY MUSCLES OF THE ACTION PLUS THE ACCOMPANYING CHANGES THE FORCE FOR IMMEDIATE VICINITY THIS IS PRIME MOTIVATING RESPONSIBLE SKELETON OF THE MIDDLE ONETHIRD OF THE FAVORABLE RECONFIGURATION OF THE BONY

FACE

MAIN THEME WAS THAT THE SLAUGHTER AND PRUZANSKYS SURGERY HAVE ADVERSE EFFECT THE FUTURE SHOULD NOT BE ALLOWED TO AN ON

GRBWTH PATTERNS THEY ACKNOWLEDGED

SINCE THE COSMETIC RESULTS IMMEDIATELY FOLLOWING REPAIR OF THE BILATERAL LIP

IT IS THAT SERIAL DEFR MAY BE LESS THAN DESIRED SIGNIFICANT TO NOTE STUDIES HAVE

INDICATED THAT THE DIFFERENTIAL PROCESSES OF FACIAL GROWTH TEND TO MINIMIZE

THE DEFORMITY AND PROVIDE MORE DESIRED END RESULT IN SOME CHILDREN SUCH

SPONTANEOUS CORRECTION OF THE PREMAXILLARY PROTRUSION MAY OCCUR RATHER EARLY

AND IN OTHERS AT LATER AGE OF COURSE THERE ARE RARE EXCEPTIONS IN WHICH

THERE IS NO SUCH IMPROVEMENT IN FACIAL PROFILE IN SUCH INSTANCES SECTION OF

PORTION OF THE NASAL SEPTUM MAY BE REQUIRED BUT ONLY AS LAST RESORT

AND BASED ON DOCUMENRED SERIAL OBSERVATION CEPHALOMERRIC ROENRGENO

GRAPH OVER PERIOD OF AT LEAST FIVE TO SIX YEARS

IN 1972 FROM THE CENTER FOR CRANIOFACIAL ANOMALIES AT THE UNIVERSITY OF ILLINOIS MEDICAL CENTER HANS FRIEDE DDS AND SAMUEL PRUZANSKY DDS SUMMED IT UP WITH CEPHALORNETRIC AND RADIOGRAPHS DENTAL MODELS IN LONGITUDINAL STUDY OF 54

COMPLETE BILATERAL CLEFT LIP AND PALATE CASES THEIR CONCLUSIONS WERE

THE COMMON DENOMINATOR THAT CHARACTERIZES THIS CLEFT IS

THE MARKED OF PROTRUSION THE PREMAXILLA RESULTING FROM AN

OVERGROWTH AT THE PREMAXILLARYVOMERINE JUNCTION

CONSIDERABLE INGROUP VARIATION EXISTED IN THE EXTENT TO WHICH THE PREMAXILLA PROTRUDED AHEAD OF THE PALATAL SHELVES THE OF DEGREE PREMAXILLARY PROTRUSION FIRST OBSERVED IN THE

UNOPERATED INFANT IS USEFUL PROGNOSTIC INDICATOR OF LATER CHANGES

IN HIS PROFILE

IN CASES CLOSURE OF OPERATED BY THE LIP WITHOUT PREMAXILLARY SETBACK THE FACIAL PROFILE APPROXIMATED THE AVERAGES FOR THE NONCLEFT POPULATION BY THE TIME THE CHILDREN REACHED EARLY ADOLESCENCE

53 THE AND DIRECTION AMOUNT OF MANDIBULAR GROWTH IS

SIGNIFICANT FACTOR IN THE ULTIMATE IMPROVEMENT OF THE FACIAL

PROFILE

TWELVE AFTER YEARS THEIR SWITCH FROM SURGICAL SETBACK BAUER TRUSLER AND TONDRA REPORTED CANDIDLY IN 1971

OF THE SURGICAL RERROPOSIRIONING PREMAXILLA IN OUR HANDS HAS CONSISTENTLY

RESULTED IN SEVERE GROWTH DISTURBANCE OF THE MIDDLE THIRD OF THE FACE SINCE

EXCELLENT RESULTS WITH SURGICAL RERROPOSIRIONING OF THE PREMAXILLA IN SELECTED CASES HAVE BEEN REPORTED BY CRONIN AND MONROE IT MAY BE ASSUMED THAT OUR

WAS IN ERROR IF THE IS IN TECHNIQUE LIP REPAIRED TWO STAGES IT IS OUR BELIEF THAT

SURGICAL RERROPOSIRION IS THE MOTOR FORCE OF THE UNNECESSARY REPAIRED LIP WILL THE EVENTUALLY BRING PREMAXILLA INTO PROPER RELATIONSHIP WITH THE MANDIBLE RECENT ARTICLES ON THIS SUBJECT BY BERKELEY GLOVER AND SKOOG HAVE BEEN IN AGREEMENT WITH THIS APPROACH

IT IS THAT THE INDIANA INTERESTING GROUP CLOSED THE FIRST SIDE AT

TWO WEEKS OF AGE AND THE SECOND SIDE TWO MONTHS LATER

SKOOG OF SWEDEN IN THE SAME 1971 ROME SUMMARIZED

SURGICAL CORRECTION OF BILATERAL CLEFTS IS ACCOMPLISHED BY OPERATING UPON ONE SIDE AT THE RIME FIRST OPERATION BEING DONE AT THE AGE OF MONTHS IN DEFORMITIES ASYMMETRICAL THE MOST SEVERE CLEFT IS REPAIRED FIRST THREE MONTHS LATER THE OTHER SIDE IS OPERATED UPON

PREMAXILLA SECONDARILY

PROFESSOR KILNER OF OXFORD CLOSED THE LIP OF HIS BILATERAL CLEFTS IN

TWOSTAGES TRUSTING THE PULL OF THE UNITED MUSCLE TO REDUCE THE

OF THE PROMINENCE PREMAXILLA ACTUALLY THIS MUSCLE PULL WAS

FOR THE IN OF THE RESPONSIBLE SWINGING MAXILLARY PROCESSES WHICH

TRAPPED THE PREMAXILLA IN FRONT OF THE ALVEOLAR ARCH AND NECESSI

TATED ITS REMOVAL IN ABOUT 90 OF CASES DID PERCENT HE NOR APPROVE OF OF WEDGE OSTEOTOMY THE SEPTUM EXPLAINING THAT IT WAS TOMMY KILNER THE OF DANGEROUS TO GROWTH THE PREMAXILLA WHICH HE PREFERRED TO

MAINTAIN AS RACK FACIAL LIP DURING DEVELOPMENT AT THE AGE OF FIVE TO SEVEN YEARS HOWEVER IF IT WAS WOBBLY AND USELESS HE REMOVED IT AND SUBSTITUTED DENTURE

54 PARTIAL PREMAXILLARY EXCISION

WAS SUGGESTED BY GILLIES WHOWAS FAMILIAR IN 1957 COMPROMISE WHICH OFTEN FAILS TO GAIN UNION AND BECOMES WITH THE PREMAXILLA WITH ABNORMAL TEETH DESERVING DISCARD HC POSED WOBBLY PROW QIIII THAT THE POSSIBILITY

MEMBRANE BE BACK FROM THE AND THE THE ANTERIOR MUCOUS PEELED PREMAXILLA TOOTHBUDS BE THIS LEAVES ANTERIOR BONE AND RONGEURED AWAY POSTERIOR

OF BONE SANDWICHED BETWEEN TWO LAYERS OF MUCOSA IF THIS BONE STRIP IS STRIP INTO THE THE OF WHICH NOW MOVED BACK AND INTRODUCED SNUGLY CLEFT EDGES

THERE IS THE BETTER CHANCE OF UNION HAVE BEEN FRESHENED TO BONE BONY ACROSS

OF THE FULL ARCH THE GAP AND PRESERVATION

IN 1968 IN THE BRITISH JOURNAL OF PLASTIC SURGERY JOHN POTTER

MORE RADICAL OF THE EXPAINEVD HIS CHANGE TO HANDLING PREMAXILLA SOMEWHAT LIKE THAT OF GILLIES IN 1959 HE HAD BEEN FACED WITH IN THE TWINS EACH HAVING BILATERAL CLEFTS OF THE LIP AND PALATE GIRL

HE HAD USED THE STANDARD CLOSURE OVER THE PROJECTING PREMAXILLA THE THE WHO HAD RETAINING THE PROLABIUM IN LIP BOY TWIN

THE IN THE FIRST FCW WEEKS OF DEVELOPED TUMOR OF PREMAXILLA LIFE 1959 UNDERWENT EXCISION OF THE TUMOR PATHOLOGICAL REPORT BY

PROFESSOR QILLIS IS OF INTEREST

THIS OF THE OF THE IS TYPICAL SPECIMEN PIGMENTED EPULIS INFANCY UPPER

OF INTEREST INCISOR REGION IS ITS COMMONEST SITE BUT YOUR SPECIMEN IS SPECIAL

OF ITS IN THAT IT CAME FROM THIS SITE IN CASE OF CLEFT PALATE IN SPIRE EXTENT CURED AND INFILTRATION IT IS ESSENTIALLY BENIGN LESION WHICH IS READILY BY

LOCAL EXCISION AND WHICH HAS NOR METASTASIZED IN ANY OF THE REPORTED CASES

OF THE SUBSEQUENT SURGERY INVOLVED TWOSTAGE UNION LIP TO

RESULT OF THIS FORCED REDUCTION OF THE ANTERIOR PROLABIUM THE 1973

PREMAXILLA IMPRESSED POTTER WITH ITS BETTER NASAL TIP COLUMELLA

AND LIP IN FACT THE TWINS MOTHER REMARKED THAT SHE WISHED THE HAD HAD INSTEAD OF AFTER THREE GIRL THIS TYPE OF REPAIR THE BOY

YEARS OBSERVATION POTTER DECIDED

IT WASWORTH BETTER NASAL MAKING FURTHER EFFORTS IN AN ATTEMPT TO OBTAIN TIP AT THE ORIGINAL REPAIR

IN FACT 14 YEARS LATER HE WAS STILL PLEASED WITH THE NASAL TIP

IN 1968 HE THIRD PRESENTED REPORT ON THE TWINS AND CASE

55 WHICH WAS HANDLED IN MANNER GREATLY INFLUENCED BY HIS EXPERI

ENCE WITH THE TWINS HE STARTED OUT

THE IS THAT BEFORE THE THERE EXISTS FLATTENED NASAL PROBLEM REPAIR TIP WITH SHORT COLUMELLA AND WIDE NOSTRILS BECAUSE THE PREMAXILLA BULGES INTO THE NOSTRILS

HE THEN THAT WHAT THE THIS EXPLAINED NO MATTER SURGERY CONDITION

LEADS TO OBSTRUCTION OF THE AIRWAY AND CHRONIC CATARRH HIS

SURGERY INVOLVED ELEVATING THE PREMAXILLARY MUCOSA AND HE CONTINUED

THE ANTERIOR OF THE PLATE PREMAXILLA WAS EXPOSED AND REMOVED IN THE UPPER TWOTHIRDS THE TOOTH SACS WERE REMOVED THE CENTRAL SEPTUM WAS LEVELED

BACK IN ORDER TO GET IT INTO WHAT WAS THOUGHT TO HE ITS NORMAL RELATIONSHIP WITH THE NASAL SPINE THE SOFT TISSUES WERE ALLOWED TO SETTLE FOR EIGHT

WEEKS AND THEN THE FLOOR OF THE NOSE AND THE LIP WERE REPAIRED IN ONE THE STAGE PROCEDURE GAVE GOOD NASAL RIP GOOD AIRWAY AND NO

CBRONIC NASAL DISCHARGE THE LIP IS GOOD BUT MAY NEED AN ABBE FLAP

POTTER MENTIONED LOSS OF THE INCISOR AND UPPER TEETH THREE YEARS LATER THE PROFILE WAS ALREADY SHOWING DEFINITE RETROPOSITION OF THE DID PREMAXILLARY AREA HE USE SMALL ABBE FLAP EVENTUALLY IN 1974 POTTER WROTE

HAVE NEW CASE TO BEGIN AND HOPE TO SAVE THE TEETH

SECONDARY RENDITION OF THIS RATHER RADICAL APPROACH WAS

PRESENTED IN 1973 AT DUKE UNIVERSITY BY FRANK MASTERS OF KANSAS AND CITY PUBLISHED WITH APFELBERG IN 1974 WHEN THE

PREMAXILLA IS OTHERWISE USELESS BECAUSE OF MALPOSITION MUCO

PERIOSTEAL FLAPS OF THE PREMAXILLA AND MAXILLAE ARE OPENED ON EACH

SIDE OF THE CLEFTS AND SUTURED TOGETHER TO FORM ONE LONG TROUGH INTO WHICH BONE FROM THE PREMAXILLA IS PACKED AS CANCELLOUS

JIIIIJIIII

56 LI CLOSED TO FORM REDUCED ALVEOLAR RIDGE THEN THE FLAPS ARE CHIPS CAN BE FITTED WHICH DENTAL PLATE ON NA

PROSTHODONTIC ASSISTANCE

FOLLOWED ARCH OF LIP CLOSURE BY MAXILLARY WAS THE EXPERIENCE WORK OF KERR MCNEIL WHO THAT LED TO THE 1954 INFLUENCE THE DIREC DELICATE BUT CONTINUOUS FORCES TO THESE FORCES THE GROWING BONE BURSTON SOON JOINED THEY

IDEAL OSED AS AN APPROACH KERR MCNEZI

STIMULATION OF THE MAXILLAE TECHNIQUES OF EARLY BY

UNTIL ARE IN WITH THE PROTRUDING HA PROSTHESIS THEY ALIGNMENT AND THUS ALLEVIATE THE NECESSITY TO SECTION THE VOMER

BURSTON HAS IN HIS FHE ELABORATE SETUP THAT ANATOMY DEPARTMENT WORLD TRANNNL CANNOT BE DUPLICATED MANY PLACES IN THE

IN SCREW HAGERTY AND MYLIN IMPROVISED PINNING PLATE OF BE MAINTAINED WITH I4 IF FITTED IN THE EARLY DAYS LIFE CAN THE RELATIVE EASE AND CAN HAVE GREAT INFLUENCE IN POSITIONING

MAXILLARY ELEMENTS THE JUTTING PREMAXILLA STILL POSES PROBLEM

SPRING PLATE AND RUBBER BAND

IN 1967 WILLIAM MANCHESTER OF MIDDLEMORE HOSPITAL IN

AUCKLAND NEW ZEALAND IN HIS TYPICAL DIRECT MANNER CROWNED

THE BILATERAL CLEFT THE MOST DIFFICULT MODERN SURGICAL PROBLEM NOT

AND BLAMED THE EXCLUDING CARDIAC SURGERY PREMAXILLARY PROTRU

SIQN ON LACK OF MUSCLE RESTRAINT AND ABNORMAL TONGUE PRESSURE ORTHODONTIST TO COMBAT THIS DEFORMITY HE ENLISTED THE SERVICES OF DIVIDED PEAT WHO DEVELOPED AN UPPER DENTAL PLATE IN TWO

HALVES JOINED BY SPRING THE PLATE HAS TWO SEGMENTS WHICH

UNDER ITS OVERLAP EACH OTHER SO THAT WHEN THE APPARATUS SPREADS

OWN SLIGHT SPRING TENSION THERE IS STILL AN EFFECTIVE ROOF TO THE

MOUTH THIS PLATE IS USED IN CONJUNCTION WITH RUBBER BAND

TRACTION AND PREVENTS THE TONGUE FROM COUNTERACTION AFTER FIVE MONTHS IN CASE WITH PROTRUDING PREMAXILLA THE ALVEOLAR ARCH FORMS CONTINUOUS HORSESHOE AND THE PREMAXILLA IS ACTING AS STABLE KEYSTONE BETWEEN THE MAXILLARY SEGMENTS

57 LIP ADHESION

IN FRANTIC ATTEMPT TO OBTAIN SOME KIND OF CLOSURE OVER THE

PROJECTING PREMAXILLA IN BILATERAL CLEFTS SIMON IN 1864 CUT TWO

LATERAL CHEEK FLAPS TRANSPUSCD AND SUTURCD THEM TO THE SIDES OF THE PROLABIUM IN WHAT WAS PROBABLY ONE OF THE FIRST ADHESION

PROCEDURES EVER DONE ONCE THE PULL OF THE FLAPS HAD PARTIALLY

REPOSITIONED THE PREMAXILLA SIMON PROCEEDED WITH HIS SECOND

STAGE DEFINITIVE LIP CLOSURE

THE NEXT EXAMPLES OF ADHESIONS WERE MORE SOPHISTICATED IN

1955 OF USED OF ADHESION II JOHANSON G6TEBORG TYPE TO CREATE

TISSUE FOR THE INSERTION OF BONE BRIDGE GRAFTS BY 1958 WAS USING

EARLY LATERAL VERMILION ATTACHED TO THE INFERIOR PROLABIUM FOR

BLOOD THAT BUT IN THE SUPPLY TO COMPONENT PROCESS OF COURSE SOME PREMAXILLARY MOLDING OCCURRED BY 1961 JOHANSON HAD BECOME OF BONE SUSPICIOUS PRIMARY GRAFTING BUT INTRIGUED BY THE

BENEFICIAL EFFECT OF THE ADHESION IN EARLY 1963 ENCOURAGEDBY THE

EFFECT OF THE EARLY ADHESION IN BILATERAL CLEFTS USED HIGH MUCOSAL ADHESION IN SEVERE CLEFT SPECIFICALLY AS STALLING TACTIC AND DEVICE MOLDING MY REPORT WAS PUBLISHED WITH OTHER REFINEMENTS IN 1964

IN 1965 RANDALL ADVOCATED MODIFICATION OF THIS ADHESION

LI WITH SACRIFICE OF SKIN MORE LIP EXPENDABLE ONLY IN HIS TYPE OF CLEFT

LIP CLOSURE TAKAHASHI OF TOKYO IN 1970 DIAGRAMED BOTH THE MILLARD AND THE RANDALL ADHESIONS AND PUBLISHED SOME INTER

BILATERAL CASES IN WHICH HE HAD USED ESTING LIP ADHESION PROCE DURES IN TWO STAGES PRIOR TO FORKED FLAP COLUMELLA LENGTHENING

II IN 1971 HAMILTON GRAHAM AND RANDALL REPORTED THE LIP

ADHESION IN 14 COMPLETE BILATERAL CLEFTS AND ON THE COMPLETE

CLEFT SIDE IN FOUR WITH CASES THE INCOMPLETE CLEFT ON THE OPPOSITE SIDE IN THE COMPLETE CLEFTS ONE SIDE WAS JOINED AT TIME AND AT THE OF AVERAGE 35 MONTHS OF AGE THE OPPOSITE SIDE BEING JOINED ABOUT 12 MONTHS LATER THE ADHESIONS WEREMAINTAINED FOR APPROXI SIX AND MATELY MONTHS THEN DEFINITIVE LIP CLOSURE WAS PERFORMED

FEW EXTRACTS FROM RANDALL AND GRAHAM SUMMARIZE THEIR USE

OF THE ADHESION PROCEDURE

BROADBASED RECTANGULAR FLAPS WERE CONSTRUCTED FROM TISSUE THAT IS ORDI

NARILY DISCARDED EXTRAORAL TRACTION ON PROTRUDING PREMAXILLAE HAS NOR

58 HAS SELDOM TO REPOSITION PROTRUDING PREMAXILLA BEEN NECESSARY OSTEOTOMY HAS BEEN RARE AND MINI LATERAL SOFT TISSUE UNDERMINING BEEN NEEDED ANY THE ADHESION OPERATION HAS BEEN CARRIED OUR ON MAI FOR TWO YEARS LIP CLEFTS AT THE CHILDRENS HOSPITAL OF UNILATERAL AND BILATERAL COMPLETE WHEN CONSIDERABLE SEPARATION OF THE LIP MARGINS IS PHILADELPHIA WHENASSOCIATED WITH BONY DISTORTION THE OPERATION PRESENT PARTICULARLY

SEEMS TO HAVE MERIT

RANDALL EARLY COLUMELLA LENGTH FINALLY IN 1973 INCORPORATED FORKED ONE SIDE OF AN ADHESION WITH PRIMARY FLAP DURING AND THREE MONTHS LATER CREATED AN AT THREE MONTHS

ON THE OTHER SIDE OF THE LIP

ADVOCATED THE 20 LYARIETY OF DHESIONS HAVE BEEN OVER PAST YEARS CLOSURE IN 962 CELESNIK OF LJUBLJANA PROPOSED SIMPLE HIGH UP

HE NASAL FLOOR ON EACH SIDE AS FIRST STAGE THIS APPROACH WAS PRE IN COPENHAGEN IN 1973 BY HIS PREVIOUS STUDENT PERKO OF ZURICH AFTER ORTHODONTIST MARGARET HOTZ CREATES

MAKES CELESNIK NASAL FLOOR ADHESION LG NMENR OF PARTS PERKO

AT SIX MONTHS AND ONE MONTH LATER CARRIES OUT BILATERAL VEAU OR OF MANCHESTER DEFINITIVE LIP CLOSURE HERE IS ONE THEIR CASES

FOLLOWED THROUGH AN IMPRESSIVE ORTHODONTIC AND ADHESION STAGED LAADA LATER IN THE 1975 SCANDINAVIAN ALIGNMENT PUBLISHED 0714I NIAL AND RECONSTRUCTIVE UJ RI SURGERY

POSRORRHODONTIA POSRADHESION UJR

LOWEST

SINCE 1967 HOLLMANN OF AUSTRIA IN DESIRE TO AVOID THE

CHANCES OF MAXILLARY GROWTH RETARDATION BY MUCOPERIOSREAL DIS

SECTION HAS BEEN CARRYING OUT ONESTAGE INFERIOR LIP ADHESION

ALMOST IDENTICAL TO THE ONE USED FOR SEVERAL CASES BEGINNING IN

1958 HOLLMANN ATTACHES MUCOSAL FLAPS FROM THE CLEFT EDGES OF

THE LATERAL LIP ELEMENTS TO THE INFERIOR PROLABIUM VERMILION HIS

VARIATION IS TUCKING OF THE TIPS OF THE LATERAL FLAPS UNDER THE

CENTRAL PROLABIUM RATHER THAN OVERLAPPING IT HE POSTPONES HIS

UNTIL OF DEFINITIVE LIP CLOSURE TWO YEARS AGE

SINCE EARLIEST HAVE BEEN PERSONALLY MY CASES NOT PARTICULARLY

INTERESTED IN USING THE ADHESION PROCEDURE FOR TRACTION IN BILATERAL

CLEFTS USUALLY THERE IS NOT THE PROBLEM OF ASYMMETRYIN WHICH

FIND AN ADHESION MOST BENEFICIALLY EQUALIZING THE DEFINITIVE LIP THE HAS SURGERY IS RELATIVELY EASY AS SOON AS RUBBER BAND TRACTION

ADJUSTED THE PREMAXILLA PREFER TO SKIP THE ADHESION AND CLOSE

BOTH CLEFTS IN ONE OPERATION IN THOSE RARE CASES IN WHICH THE

RUBBER BAND IS INEFFECTUAL WOULD FAVOR BILATERAL MUCOSAL FLAP

ADHESION TO SURGICAL SETBACK

TWOSTAGE ADHESION WITHOUT UNDERMINING

IN 1966 WALKER COLLITO MANCUSIUNGARO AND MEIJER OF EAST

ORANGE NEW JERSEY ADVOCATED THE ULTRACONSERVATIVE COMBINA

TION OF ELASTIC EXTRAORAL TRACTION FOLLOWED BY LIP CLOSURE WITHOUT

UNDERMINING

IN BAND SUBSTITUTES FOR AND EFFECT THE ELASTIC AN INTACT LIP CREATES THE

FORCES OF NORMAL ORBICULARIS MUSCLE ABSENCE ANTAGONISTIC ORIS IN THE OF LIP

SURGERY AND INTRAORAL APPLIANCES ELASTIC TRACTION DECREASES THE SEVERITY OF THE

AND DEFECTS THE FOUNDATION IS ESTABLISHED FOR LIP PALATE THUS BONY LIP

CLOSURE WITH MINIMAL OR NO UNDERMINING OF THE SOFT TISSUE

THEY FEEL THAT UNDERMINING THE LIP ELEMENTS FROM THEIR ATTACH

MENTS TO THE MAXILLA CHANGES THE MUSCLE ENVIRONMENT AND THAT

THE IS DELETERIOUS THE OF SCARRING PRODUCED TO GROWTH YOUNGBONE

FAR GREATER NUMBER OF SURGEONS SEEM TO BE CONCERNED FOR THE

FREEING OF THE ABNORMAL ATTACHMENTS OF THE MUSCLES SO THAT THE

TENSION OF LIP CLOSURE WILL BE REDUCED

IN 1971 DUTCHMAN ROBBY MEIJER OF THE PEER GROUP AND

DENTIST MICHAEL COLLITO OF EAST ORANGE NEWJERSEY REPORTED ON

ROBBY MEIJER 60 WITH OF THE USE OF THE CW TECHNIQUE FIVEYEAR FOLLOWUP TREATED CASES THE PRELIMI OF 20 UNSELECTED CONSECUTIVELY FROM TWO DAYS TO OVER FIVE AND ADHESION WAS CARRIED OUT NARY LIP OF WHILE THE DEF LIP CLOSURE WAS ONE HALF MONTHS AGE MONTHS AND ONE AND ONEHALF BETWEEN AGES TWO YEARS BUT THE ALVEOLAR AVERAGED 102 MM FOLLOWING 42 ORIGINAL GAP WITH CONTACT OCCURRED IN IDHESION ALVEOLAR PROCESS APPROXIMATION 35 SHOWED OF THE CASES THE RE1114111111 PIIC AP WITHOUT CONTACT IN NO INSTANCE WAS THERE OVERLAP OF THESE RESULTS WITH THOSE THE SEGMENTS COMPARISON

IS OF INTEREST THE LATTER FOUND UB1ISLED IN 1964 BY PRUZANSKY FAVORABLE WITHOUT CONTACT 24 ERCENT ACHIEVING APPROXIMATION OF THE OR COL 395 PERCENT SHOWING OVERLAPPING SEGMENTS COLLITO 1APSE AS NOTED BY MEIJER AND

CONTINUED HOWEVER IS THAT IN OUR GROUP ALL CASES OF SPECIAL SIGNIFICANCE

INTO FAVORABLE ARCH FORM WHILE 60 PERCENT OF THE PRUZANSKY

MICHAEL COLLITO HAD HERE IS CASE SENT BY MEIJER IN 1974 WHICH PRELIMINARY

AND THE LEFT CLOSURE ON THE RIGHT 31965 ON 62365 11565 AND THE DEFINITIVE LIP CLOSURE WAS DONE ON THE RIGHT ON

LEFT 122165 THE SOFT ALATE WAS CLOSED 6166

ONGINAL AFTER PRELIMINARY SURGERY AFTER DEFINITIVE SURGERY 1965 1I 62967 SHORTENING THE PTOVOMERLNE STALK

COMPRESSION FRACTURE

IN 1833 GENSOUL IN PARIS IS REPORTED TO HAVE SEIZED THE PROJECTING WITH PREMAXILLA STRONG FORCEPS AND FORCED IT BACK WITH SUFFICIENT

61 STRENGTH TO FRACTURE THE VOMER

IN 1844 PANCOAST OF PHILADELPHIA ILLUSTRATED HIS METHOD OF SKETCH FOL POSITIONING THE PREMAXILLA HE EXPLAINED HIS IN THE

LOWING MANNER

FLATBLADED OF THIS REPRESENTS THE FORCING BACKWARDS WITH PAIR OF FORCEPS

THE PROMINENT PORTION OF THE JAW IN WHICH THE TWO INCISOR TEETH ARE LODGED

THIS ATTEMPT TO BRING THE TEETH DOWN TO THEIR PROPER LEVEL IS COMMONLY WITH FRACTURE OF THE ATTENDED SLIGHT BONE

FACED IN 1961 CYRIL INNIS OFF IN NORTH BORNEO AND WITH

TWO PROJECTING PREMAXILLAE IN NINEYEAROLD CHINESE CHILDREN THE THEN REVIVED THE IDEA OF COMPRESSION FRACTURE OF VOMER HE

WEDGED THE MOBILE UNIT BACK BETWEEN THE LATERAL ALVEOLAR SEG

MENTS AND CLOSED THE LIP ON BOTH SIDES USING NO FURTHER FIXATION HE CONCLUDED

THIS METHOD HAS FEEL THE ADVANTAGE OF SIMPLICITY AGREED THERE IS

MINIMAL DISTURBANCE WITH GROWTH CENTRES OF THE PREMAXILLA THE

DISADVANTAGE PROBABLY LIES IN THAT BY THIS METHOD OBSTRUCTION OF THE NASAL

AIRWAY MIGHT RESULT AND IT IS DIFFICULT TO CORRECT EXCESSIVE DOWNWARD DIS

IFI PLACEMENT IN RELATION TO THE REST OF THE ALVEOLAR ARCH OF THE PREMAXILLA

ACCORDING TO FOMON ABOUT 1873 DRACHTER WAS NICKING THE

NECK OF THE PREMAXILLA FORCING THE BONE INTO CONTACT WITH THE AT THE ALVEOLUS AND REPAIRING THE CORRESPONDING SIDE OF THE LIP SECOND THE THE SIDE THIS STAGE HE REPEATED PROCESS ON OPPOSITE

MANEUVER NOT ONLY TILTED THE FRAGMENT BACKWARD CAUSING THE IJ TEETH TO ERUPT LINGUALLY BUT DISPLACED THE SEPTUM BACKWARD

FLATTENING THE ALAE AND RETRACTING THE COLUMELLA

FULLTHICKNESS RESECTION OF VOMER

IN 1842 BLANDIN RETROPOSED THE PROTRUDING PREMAXILLA BY RESECT

62 OF BONE AND IN RATHER TRIANGULAR PIECE VOMER MUCOSA SETBACK UNSOPHISTICATED

SECTION OF VOMER

ADOLF VON BARDELEBEN OF GERMANY WAS THE FIRST TO SECTION THE 1O ADOLF VON BARDELEBEN SUBPERIOSTEALLY IN THROUGH CM INCISION ALONG

THE FREE BORDER OF THE VOMER BEHIND THE PREMAXILLA THE MUCO

WAS ELEVATED ON BOTH SIDES SO THAT SCISSOR SECTION OF

ALLOWED THE SECTIONED THE SEPTUM AS HIGH UP AS POSSIBLE SEPTAL

ENDS TO GLIDE PAST EACH OTHER WITHOUT BUCKLING AS THE PREMAXILLA

REPOSITIONED THERE HAVE BEEN MANY MODIFICATIONS OF THIS

DESIGN BUT VON BARDELEBENS APPROACH REMAINS THE BASIS OF THE

OPERATIONS IN USE TODAY

ANOTHER BACKWARD OVERLAP

JOHN BINNIE OF KANSAS CITY MISSOURI IN HIS 1916 EDITION THE

SEVENTH OF OPERATIVE SURGERY NOTED

SOME ADVISE THAT THE BONE BE SURGEONS MISPLACED INRERMAXILLARY ENTIRELY REMOVED UNDOUBTEDLY IT IS WISE TO RETAIN THE BONE AND REPLACE IT IN ITS

PROPER POSITION SOMETIMES INSTEAD OF EXCISING WEDGE FROM THE

SEPTUM IT IS SUFFICIENT TO MAKE VERTICAL CUT THROUGH IT AND SLIDE THAT

PORTION OF THE ANTERIOR TO THE CUT BACK THE SEPTUM ALONGSIDE POSTERIOR JOHN BENNEE PORTION

BINNIE USED DRAWING FROM VON ESMARCH AND KOWAIZIG TO

DEMONSTRATE THIS METHOD OF OVERLAPPING THE SEPTUM

PICHIER

IN 1918 PICHLER OF AUSTRIA DISSECTED THE MUCOPERIOSTEUM FROM THE DIVIDED VOMER THE DENUDED VOMER CM BEHIND THE PRE MAXILLA AND DURING THE PREMAXILLARY SETBACK SLID THE SEPTAL FRAGMENTS SIDE BY SIDE INSTEAD OF CLOSING THE MUCOPERIOSTEUM OVER THE SECTIONED AND OVERLAPPING SEPTUM PICHLER INGENIOUSLY

63 TURNED THESE FLAPS LATERALLY AND TUCKED THEM UNDER THE PALATAL

MUCOPERIOSTEUM WHICH HE HAD ELEVATED FROM THE HARD PALATE

FEDERSPIEL

MATTHEW FEDERSPIEL PROFESSOR OF ORAL SURGERY AND ORTHO

DONTICS AT MARQUETTE UNIVERSITY IN MILWAUKEE IN 1927 DESCRIBED FRESHENED THE OF VARIATION OF PREMAXILLARY SETBACK HE EDGES

THE ALVEOLAR CLEFT THEN THROUGH LONGITUDINAL INCISION IN THE

MUCOPERIOSTEUM OVER THE VOMER ACHIEVED AN OBLIQUE SECTIONING

OF THE VOMER SO THAT WITH SLIDE BACK THERE WAS OVERLAPPING BUT

REDUCTION IN PREMAXILLARY PROTRUSION

VAUGHAN

VAUGHAN DESCRIBED SIMILAR METHOD OF PREMAXILLARY POSITIONING

IN 1946 THROUGH SUBMUCOSAL DISSECTION BEGINNING 15 CM

POSTERIOR TO THE PREMAXILLA AN OBLIQUE SECTION OF THE VOMER WAS

ACHIEVED WITH CHISEL THIS CUT WAS EXTENDED UPWARD INTO THE BLOOD CARTILAGINOUS SEPTUM IN AN AREA WHERE THE PREMAXILLARY

SUPPLY WAS IN NO DANGER THE PREMAXILLA WAS THEN SLID POSTERIORLY

AND OVERLAPPED WITHOUT ROTATION ON ITS TRANSVERSE AXIS AND WITH

NASAL THE FIXED OUT BLOCKING THE PASSAGES VOMER OVERLAP WAS WITH SILVER SUTURE AND THE MUCOSA CLOSED

SCHULTZ

IN 1946 LOUIS SCHULTZ OF CHICAGO SET BACK THE PREMAXILLA AND

MENTIONED THE NUMEROUS PROBLEMS FACED SUCH AS TIME INVOLVED

LIP SCARRING FROM TENSION LACK OF BONY UNION FISTULAE AND POOR

BITE IF SETBACK WAS NOT DONE

ALL THESE UNDESIRABLE FACTORS ARE AVOIDED IF THE INTERMAXILLARY BONE IS

BROUGHT TO ITS NORMAL POSITION WHEN THE CHILD IS ABOUT ONE MONTH OLD

HE SUGGESTED TWO WAYS TO MOBILIZE THE PREMAXILLA ONE BY

RESECTION OF THE VOMER AND THE OTHER BY DIAGONAL SECTIONING AND

64 OF VOMER OVER THE OTHER IN MANNER DE SLIDING ONE SEGMENT AND TWO MONTHS SCRIBED ORIGINALLY BY FEDERSPIEL BY VAUGHAN ONLY

BEFORE HIS OWN PRESENTATION

THE VOMER SUBPERIOSTEA RESECTION OF

THE IN 1868 GUERIN RETRODOSED PREMAXILLA UY SUBPERIOSTEAL RESEC BONE THE OF TION OF TRIANGLE OF VOMER COMBINING PRINCIPLES

BLANDIN AND VON BARDELEBEN

IN 1911 REICH SUPPLEMENTED THE VERTICAL WEDGE RESECTION OF

THE VOMER WITH HORIZONTAL SEPTAL CARTILAGE DIVISION TO

REDUCE THE PREMAXILLARY PROMINENCE BUT AT THE SAME TIME PREVENT

RAL AND NA SAL AND AVOID WHAT HE REFERRED TO AS SEP TIP COLLAPSE BLUNT AND BULL DOG NOSE THIS GENERAL APPROACH IS SIMILAR TO WHAT CRONIN ADVOCATED LATER

VEAU

IN 1922 VEAU DESCRIBED RESECTION OF THE NECK OF THE PREMAXILLA AS OF WOULD PRELUDE TO DISPLACEMENT THE BONE AS ONE CLOSE

DRAWER TO PROMOTE UNION AT THE ALVEOLUS THE BONE ENDS WERE

FRESHENED AND SUTURES WERE USED FOR STABILIZATION

YET IN 1938 VEAU REVIEWED 208 CASES OF BILATERAL CLEFTS WHICH

HE HAD TREATED SURGICALLY IN DIFFERENT WAYS AND DECIDED AGAINST

OPERATION ON THE PREMAXILLARY PROMINENCE

VEAUS FINAL FEELINGS ARE EXPRESSED MORE POIGNANTLY IN FRENCH GUESS

LE MAIHEUR DE CETTE EST NOUS NE TITER UN CHIRURGIE QUE POUVONS ENSEIGNE 41 MENT DE NORRE OPERATION QUE PLUSIERS ANNS APR 1AVOIR PRATIQU6E

ST LOUIS SOUNDNESS

MOST SURGEONS TODAY STILL AGREE WITH THE WISE WORDS OF BROWN MCDOWELL AND BYARS OF 1947

65 THAT IT IS TOO FAT BRIEFLY THE PROBLEM OF THE PREMAXILLA IS NEATLY ALWAYS BE FORWARD IN THE NEWBORN BABY BUT ONLY WITH CONSIDERABLE EFFORT CAN IT IN THE ADULT KEPT FROM BEING RETRUDED TOO FAR BACKWARD

THEY SET FORTH SOUND PLAN

IF THE BE CLOSED AS RULE THE PREMAXILLA IS NOT DISTURBED OR SET BACK LIP CAN

TILTED ROTATED OR WITH IT IN ITS ORIGINAL POSITION UNLESS IT IS BADLY OR OF THE CLOSED BEND THE IT IS SO FAR FORWARD THAT THE ELASTIC PRESSURE LIP MIGHT

BOTH NASAL IF THE IS TO HE SET SEPTUM AND OCCLUDE ONE OR AIRWAYS PREMAXILLA TO ALLOW SUCCESSFUL BACK IT IS SET BACK THE LEAST POSSIBLE AMOUNT NECESSARY THE THE BOTTOM OF CLOSURE OF THE LIP THIS IS DONE BY SPLITTING MUCOSA OVER

THE VOMER AND RESECTING BLOCK OF THE VOMER JUST BACK OF THE PREMAXILLA WITH THE AND THE PREMAXILLA IS SET BACK UNTIL IT IS IN CONTACT VOMER AGAIN BETTER IMMOBILIZED BY WIRE SUTURE THROUGHBOTH FRAGMENTS OR BY NAILING THE CENTER OF THE STRAIGHT KEITH NEEDLE DIRECTLY BACKWARD THROUGH

AND IS OB VOMER BONY UNION BETWEEN THE PREMAXILLA VOMER RARELY

TAMED BUT THE FIBROUS UNION HELPS GOOD DEAL IN KEEPING IT CENTERED

REVIEWED THE CASES OVER TWENTY YEARS LATER MCDOWELL HAVING

STATED THAT THE SITUATION WITH THE CONTIN THOSE YEARS PREMAXILLA RECALLED THEIR ADVICE TO SET BACK THE UED AS PREDICTED HE PRE MAKE IMMEDIATE MAXILLA SURGICALLY THE MINIMUM AMOUNT TO

II SUCCESSFUL CLOSURE OF THE LIP POSSIBLE AND CONCLUDED

FEARS THAT THIS WOULD BE FOLLOWED VARIOUS VARIOUS SURGEONS EXPRESSED BY OCCURRED WHEN THE WORK WAS TYPES OF DISASTER BUT THESE HAVE NOT CAREFULLY

EXECUTED

HUFFMAN

IN 1949 HUFFMAN AND LIERLE AT THE STATE UNIVERSITY OF IOWA RESECTION OF REPOSITIONED PROJECTING PREMAXILLAE BY QUADRILATERAL AT THE ATTACHED THE ELEVATED II VOMER SAME OPERATION THEY ALREADY

INCISED IN IF VOMERINE FLAPS TO THE MEDIAL PALATAL FLAPS FIRSTSTAGE IJ WHICH LEAVES THE SEC PALATE CLOSURE FEAT NOT ALWAYS POSSIBLE TIONED VOMER IN THE OPEN

66 NOT

CRONIN RESECTION FOLLOWED THOMAS OF QUADRILATERAL OTHER FORMS OF MEDICINE HOUSTO UNIVERSITY COLLEGE CRONIN OF BAYLOR FOR BETTER WAY WAS PROMOTER AND ALWAYS SEARCHING THOUGHTFUL OF FIVE CRONIN REPORTED THAT OUT RESECTION IN 1957 OF THE VOMER OF VOMER IN ONE THE WEDGE RESECRIONS CASES OF TRIANGULAR IN ANOTHER THERE WAS LOOSE AND DISPLACED POSTERIORLY AND AND TWO SHOWED SURGICAL DISPLACEMENT TDOTH REMOVAL LED CRONIN TO HIS RECTANGULAR THOMAS CRONIN OVABILITY THESE FINDINGS SLIGHT REICHS SIMILAR IN TO OF THE PRINCIPLE PUSHBACK PREMAXILLA THE METHOD AS FOLLOWS LIE DESCRIBED ABOUT FREE BORDER OF THE VOMER MADE OVER THE INFERIOR CM INCISIOFL IS SIDE OF IS ELEVATED FROM EACH THE THE MUCOSA DN POSTERIOR TO PREMAXILLA LESS IS MEASURED AND 34 MM THE AMOUNT OF PROTRUSION SHARP IS REMOVED AS RECTANGLE USING THIS AMOUNT OF VOMER THAN KNIFE CUT SURFACES WITH RIGHT ANGLE PALATE OSREOROME TO GET CLEAN TOWARD THE BRIDGE OF THE NOSE IN THE CARTILAGE HORIZONTAL CUT IS MADE SEPTAL OF THE TEETH BE SLID STRAIGHT BACK WITHOUT TILTING SO THE PREMAXILLA CAN AND 035 KIRSCHNER WIRE IS DRILLED LIFTED WITH HOOK THE PROLABIUM IS UP SURFACE TLICZ TWO AND VOMER OUT THROUGH THE CUR THROUGH THE PREMAXILLA THE THE WIRE IS DRIVEN INTO LINED CAREFULLY AND VOMERIAN FRAGMENTS ARE UP OF VOMER IS CUT INTO WITH MALLET THE RESECTED PIECE POSTERIOR PORTION SIX TO INSURE BONY UNION IA AROUND THE HELP A2FKA SMALL CHIPS AND PACKED JUNCTION THE SOLID AND THE IS REPAIRED OVER LATER THE WIRE IS REMOVED LIP TO EIGHT WEEKS

PRERNAXILLA

ANATOMICAL CRONIN CALLED ATTENTION TO TWO IMPORTANT A4AJF IN 1964 THAT HAD BEEN NOTED TO PREMAXILLAE ASPECTS PERTINENT PROJECTING VOMERINE OF THE LIES IN THE BY SCOTT THE LOWER EDGE SEPTUM OF FROM THE BONE BY MASS FATTY GROOVE WHERE IT IS SEPARATED OF THE VOMER THERE IS FIBROUS TISSUE ON THE INFERIOR MARGIN THIS IS THE TO THE PREMAXILLA BULGE ABOUT 10 TO 15 CM POSTERIOR AND THE BONE AND SITE OF SUTURE BETWEEN THE VOMER PREVOMERINE OCCURS WHERE FORWARD OF THE PREMAXILLA JZ IS DOUBTLESS GROWTH SHOULD AVOID DAMAGE CRONIN POINTS OUT THAT SURGICAL PROCEDURES SEPTAL ONLY TO THIS SUTURE BUT TO THE ALLIMPORTANT GROWING

FOR MARKED THAT CARTILAGE HE ADVISED THE SETBACK ONLY PROTRUSION OF THE HE ALSO NOTED THAT SERIOUSLY COMPROMISES REPAIR LIP AND KERNAHAN OF LIVERPOOL IN MODIFICATION SUGGESTED BY BURSTON DISTURBANCE IN TA BE LESS TO CAUSE 1961 MIGHT POSSIBLY LIKELY ANY OF THE GROWTH SEPTAL CARTILAGE INSTEAD OF MAKING THE CRONIN HORIZONTAL INCISION IN THE ADVOCATED CARTILAGE THEY FREEING THE SEPTUM FROM THE IN THE GROOVE PREVOMERINE BONE WITH SEPTAL ELEVATOR AND THE SLIDING PREMAXILLA BACKWARD AFTER MAKING AN OBLIQUE CUT THE THROUGH PREVOMERINE BONE THE PREMAXILLA IS THEN SKEWERED ONTO THE VOMER WITH KIRSCHNER WIRE IN KAHN 1960 AND WINSTEN FROM NEW YORK MOUNT SINAI

HOSPITAL ADVOCATED THE CRONIN OF TYPE PREMAXILLARY RETROPOSI TIONING STATING

IF PROPERLY NO RETARDATION OF THE PERFORMED GROWTH NOSE NOR INSTABILITY OF THE CENTRAL SECTION OF THE LIP WILL OCCUR WE SET BACK ABOUT 50 OF THE CASES

YET CITED THEY ONLY THREEYEAR FOLLOWUP OF THE CASES IN FOR AND 1971 CLEFT LIP PALATE RAY BRAUER GAVE THE LATEST TEXAN REFLECTIONS FOR THE CRONIN SURGICAL SETBACK

CRONIN AND BRAUER HAVE RELIED ON THIS PROCEDURE IN THE PAST AND THOUGH SOME OF RETRUSION HAS DEGREE APPEARED IN THESE PATIENTS IT HAS BEEN NO MORE THAN THAT SEEN IN PATIENTS IN WHOMNO OPERATIVE SETBACK WAS DONE IN THOSE

PATIENTS IN WHOM RETRUSION AND HAVE COLLAPSE APPEARED RESPONSE TO ORTHO

DONNA HAS BEEN EXCELLENT THE IS MUCOSA CAREFULLY ELEVATED OFF THE

SEPTUM AND OF BONE IS REMOVED RECTANGULAR SEGMENT USUALLY MM

LESS THAN WOULD BE FOR REQUIRED COMPLETE SETBACK RIGHTANGLE KNIFE IS USED TO MAKE HORIZONTAL CUR THROUGH THE SEPTAL CARTILAGE FROM THE SIDE OF THE RESECTION TOWARD THE TIP OF THE NOSE TO ALLOW THE PREMAXILLA TO MOVE

BACK IT IS STRAIGHT THEN FIXED BY LONGITUDINALLY PLACED 0035 INCH KIRSCH NER WIRE

A4ON ROE

IN 1965 CLARENCE MONROE PUBLISHED REPORT ON RECESSION OF THE

PREMAXILLA IN BILATERAL CLEFT LIP AND PALATE HE HAS REMAINED STAUNCH BUT CONSERVATIVE DEFENDER OF THIS ACTION EVER SINCE AND AT

MANY HAS BEEN CALLED TO THE MEETING ROSTRUM TO JUSTIFY OR HIS STAND EXPLAIN HE HAS SINCE BEEN JOINED AT CHICAGOS CHIL II DRENS MEMORIAL HOSPITAL BY SUAVE ORTHODONTIST SHELDON ROSEN

STEIN AND IN THE OF SPRING 1973 AT THE FOUNDATION SYMPOSIUM AT DUKE UNIVERSITY THEY PRESENTED THEIR COMBINED APPROACH ROSEN STEIN ADVOCATED SOMETHING EARLY TO IMPROVE THE LATE RE SULTS AND EXPRESSED CONVICTION THAT ARCH CLARENCE MONROE PROSTHESIS MOLDING

68 OF THE UNTIL PALATE WITH MAINTENANCE PROSTHESIS AND BONE GRAFTING THCCLUSION AND ARCH FORM TO 18 MONTHS PRODUCE CLOSURE AT 15 HIS BELIEF THAT WHEN NECES MONROE REPEATED THAN BEFORE IBETT RECESSION IS NOT WEEKS TO THREE MONTHS PRIMARY THREE EPIPHYSEAL LINE SAI THE RESECTION HE PROPOSED RECTANGULAR IF DONE CORRECTLY SUTURE COMBINED WITH TO THE ENLARGEMENT EPTUM POSTERIOR TO ALLOW IN THE SEPTAL CARTILAGE PREMAXILLARY HDT4ZQNTAL INCISION KIRSCHNER WIRE THE SETBACK SHOULD AND FIXATION WITH MENTIONED CASE OF 18 MM AND AS AN EXAMPLE HE

II RECESSION OF 13 OR MM SHORT RECEIVED MM RUSIOFL WHICH KIRSCHNER WIRE ARCH MONROEREPORTED IN HIS INSET INTO THE MAXILLARY MANNER THAT 15 OUT OF 19 CASES OF EARLY UKT UNPRETENTIOUS BUT ADMITTED THAT IN SETBACK SHOWED GOOD OCCLUSION

WITH RESULTS HE RARELY DOES ONE OF THIS 75 PERCENT GOOD

HE HAS SET BACK ONLY THREE PREMAXILLAE DAY SINCE 1964 15 IN RETARDED PATIENT MM PROJECTION MENTALLY AND CLEFT CLOSURE FAILED TO WHICH USE OF PROSTHESIS ONE WITH SO MUCH SO MM SETBACK WAS EXECUTED

THAT RECESSION WAS FOR LIP CLOSURE PROTRUSION REQUIRED RECESSION OF THE MONROE WHO AS EARLY AS 1959 PROPOSED THE OCTOBER 1974 CLINIC SUMMARIZED PREMAXILLA IN FOLLOWUP

EVIDENCE THAT OUR PROCEDURE APPRE EVEN THOUGH WE DO NOT HAVE OPERATIVE IN THESE CHILDREN WE ARE NO LONGER DOING CIABLY ALTERS THE GROWTH PATTERN OUR ORTHODONTISTS HAVE BEEN ABLE TO GUIDE THE OPERATION IN THE NEWBORN BETTER WITH IN THE MOUTH THAN WE THE POSITION OF THE PREMAXILLA PROSTHESIS THE MUSCULAR WILL ERE ABLE TO DO IT BY SURGICAL MEANS AFTER CLOSURE LIP AND THE IN THE CLEFT WILL USUALLY USUALLY RESTRAIN THE PREMAXILLA PROSTHESIS BACK MAINRAIN THE WIDTH OF THE MAXILLARY ARCH UNTIL THE PREMAXILLA COMES THE TIME OF INTO IT IF THE PREMAXILLA DOES NOT COME BACK PROPERLY BY PALATE DOES THEN RECESS THE REPAIR ONE TO TWO YEARS AND IT OCCASIONALLY NOTWE

PREMAXILLA BEFORE REPAIRING THE PALATE

CALIFOR JOHN WILDE OF VALLEY CHILDRENS HOSPITAL FRESNO

NIA IN 1960 EXPRESSED PREFERENCE FOR REMOVING QUADRILATERAL

SECTION OF VOMER BUT ADVOCATED FIXATION OF THE PREMAXILLA USING

NOTED THAT BILATERAL TRANSPALATAL CROSSNEEDLES HE

RIIFI THE VOMER AND TO THE LATERAL HE POSITION OF THE REMAXILIA IN RELATIONSHIP TO THE OF NEEDLES PALATAL PROCESSES IS READILY MAINTAINED USE TWO PREVENTS 49

69 ROTARY DISPLACEMENT AND DOES NOT THE PERMIT PREMAXILLA TO SLIP THE ONLY DISADVANTAGE IS THE OF POSSIBILITY DAMAGE TO TOOTH BUDS IN THE PREMAXILLA

PREVOMERINE BONE EXCISION

MORE ANTERIOR QUADRILATERAL RESECTION WAS USED IN LONDON SIR DENIS BROWNE PEDIATRIC SURGEON WAS ORTHOPEDIC IN HIS THINK NG HIS REASONS AND FOR DESIGN SETTING BACK THE PREMAXILLA ARE NTERESTING AS HE WROTE IN 1949

FOR SOME WHEN MYSTERIOUS REASON THERE IS CLEFT OF THE GUM NEW BONE BEGINS TO FORM IN FRONT OF THE BETWEEN VOMER IT AND THE PREMAXILLA SO RAWING THE LATTER FORWARDTHE VOMER ITSELF DOES NOT GROW AND THE DIVISION BETWEEN IT AND WHAT MAY BE CALLED THE PREVOMERINE BONE IS MARKED BY SIR DENIS BROWNE CARTILAGEFILLED SUTURE LINE

HE FELT THAT IF THE PREMAXILLA WERE NOT MOVED INTO NORMAL AND POSITION FIXED FIRMLY THERE WOULD BE GREAT DIFFICULTY CLOSING THE LIP OVER IT VERY UGLY PROFILE LIKE THAT OF AN ANIMAL SNOUT

WOULD OCCUR AND IT WOULD BE EXTREMELY HARD LATER TO FIT DENTURE OVER WOBBLY HE REFUSED GUM TO ACCEPT THE CLAIM OF OTHERS THAT CLOSURE OF THE MUSCLE IN FRONT WOULD POSITION THE PREMAXILLA HE ADMITTED

THE REPLACING PREMAXILLA HAS GOT BAD NAME BECAUSE OF THE ERRONEOUS WAY IN WHICH IT HAS BEEN CARRIED OUR FOR INSTANCE IF WEDGE IS TAKEN FROM THE AS THE VOMER USUALLY ADVISED FOUNDATIONS OF THE NOSE ARE RUINED AND IT GOES FLAT ON THE FACE

II LIII TO GET GOOD RESULT HE EXPLAINED

CUT THE SOFT TISSUES OF THE FROM THE LIP AWAY YREMAXLUIA RIGHT BACK TO NASAL SEPTUM

MAKE LONGITUDINAL CUR OVER THE PREVOMERINE BONE AND REMOVE IT SUBMUCOUSLY WITH NARROW THIS BITING FORCEPS SHOULD ALLOW THE PREMAXILLA TO BE FORCED STRAIGHT BACKWARDS INTO THE NORMAL LINE OF THE GUMS IT IS PREFERABLE TO LEAVE IT LITRLE TOO FAR FORWARD RATHER THAN TO FORCE IT TOO FAR BACK

WITH AN AWL STITCH OF CARRY VERY STRONG SUTURE THROUGH THE ALVEOLAR ON EITHER RIDGE SIDE OF THE THIS GAP BRING THROUGH THE HOLES IN THE SPIKED BAR FORCE THIS BAR INTO THE NARROW UPPER PART OF THE RAW SURFACE OF THE AND PREMAXILLA TIE IT SO THAT THIS IS FIXED IN FIRMLY POSITION CUT THE MUCOSA OFF THE AND LATERAL POSTERIOR SIDES OF THE PREMAXILLA THIS IS TO GIVE RAW SURFACE TO RECEIVE MUCOPERIOSTEAL FLAPS CUR FROM THE

70 THESE ARE SUTURED WITH LINEN OF THE HARD PALATE FLAPS ANTERIOR ENDS IN FOR FORTNIGHT LEAVE THE PLATE POSITIOFL

OF THE METHOD HE ADMITTED WAS POSSIBLE ONE DISADVANTAGE TOOTH BY THE SUTURES THROUGH THE ALVEOLAR DAMAGE TO THE GERMS

RIDGE ARTICULATE DAVID MATTHEWS ALSO OF THE THE DYNAMIC AND SICK CHILDREN LONDON AND IN POSITION TO MAKE AN HOSPITAL FOR STATED IN 1952 UNEMOTIONAL EVALUATION OF BROWNES APPROACH

NUMHER OF CHILDREN WHO HAVE DENIS BROWNE NOW HAS VERY LARGE GROWN UP DISTORTIONS AND THE EXCELLENCE OF HIS RESULTS WITHOUT ANY SECONDARY APPEARING

IS AND HAS CONVINCED ME THAT PREMAXILLARY REPOSIRION SATISFACTORY PROCEDURE

THE MORE SEVERE CASES OF IS INDICATED IN PROTRUSION DAVID MATTHEWS

USED MATTHEWS SETBACK WAS SIMILAR TO BROWNES EXCEPT THAT HE

BAR AND CARRIED OUT THE NASAL BAYONETSHAPED PIN RATHER THAN THE OF VEAU ON ONE SIDE AT THE SAME FLOOR AND ANTERIOR PALATE CLOSURE CLOSED HIS TIME THREE WEEKS LATER THE OPPOSITE SIDE WAS SIMILARLY

1973 COMMENTS ARE OF INTEREST

ABOUT DENIS BROWNES OF THE IN ANSWER TO YOUR QUESTION PUSHBACK

HAVE OF HIS CASES AND OF PREMAXILLA IN BILATERAL CLEFTS SEEN GOOD MANY THE MINE AND THERE IS NO DOUBT AT ALL THAT IF THE SWELLING ON SEPTUM DESCRIBED THE CENTIMETER BEHIND THE PREMAXILLA WHICH DENIS BROWNE AS RETARDATION OF SUBSE PREVOMERINE SUTURE LINE IS ENCROACHED UPON THERE IS HAVE SEEN THIS QUENT DEVELOPMENT OF THE PREMAXILLA NOT HOWEVER HAPPEN THE IF THIS PREVOMERINE SUTURE LINE IS UNDAMAGED IF ONE RESTRICTS OPERATION

IN FRONT OF THE TO THE VERY SEVERE CASES OF PROTRUSION SEPTAL RESECTION

PREVOMERINE SUTURE DOES BRING THE PREMAXILLA BACK FAR ENOUGH TO PRODUCE INVARIABLE GOOD ARCH ALIGNMENT WITH THE LATERAL SEGMENTS IT IS THEREFORE MY

AND THE LATERAL RULE TO PUT PRIMARY RIB GRAFT BETWEEN THE PREMAXILLA BACK WITH SEGMENT ON BOTH SIDES IN THE CASE IN WHICH SET THE PREMAXILLA THE THE STABILIZATION OF THE PREMAXILLA OBTAINED IN THIS WAY NOT ONLY DOES

IS PREMAXILLA SEEM TO GROW SATISFACTORILY BUT THE DOGMOUTH DEFORMITY

AVOIDED AND THE ARCH REMAINS REASONABLY GOOD ON OCCASION AS YOU KNOW

THE TOOTH BUDS MIGRARE ALONG THE LINE OF THE BONE GRAFT

PREVOMERINE BONE GRAFT

IN 1960 IN MUNICH OBERNIEDERMAYR ADVOCATED SURGICAL RETRO KIRSCHNER WIRE POSITIONING OF THE PREMAXILLA STABILIZATION WITH

TRANSFIXATION AND THE USE OF THE RESECTED PREVOMERINE BONE FOR

GRAFTING ALTHOUGH THIS WAS AN ECONOMICAL MANEUVER EVIDENTLY IT

71 WAS IN VAIN AS MOST OF THIS BONE WAS REPUTED TO BE LOST FROM INFECTION

THEN IN 1962 GERHARD PFEIFER OF HAMBURG WHILE WORKING UNDER PROFESSOR SCHUCHARDT DEVELOPED METHOD OF TRIPLE

OSTEOSYNTHESIS FOR EXCEPTIONAL CASES OF BILATERAL CLEFT WITH EXTREME OF PROTRUSION THE PREMAXILLA MUCOSA WAS TURNED TO FORM BED

FOR THE TRANSPLANTS CYLINDRICAL PIECE OF PREVOMERINE BONE WAS

TAKEN SPLIT INTO TWO PIECES AND INSERTED INTO BOTH ALVEOLAR CLEFTS

FIX GERHARD PFEZFTR TO THE OF THE ALIGNMENT RETROPOSED MOBILE PREMAXILLA

PFEIFER CLAIMED STABLE UNION WITH YET SYMMETRY TO GCT ENOUGH BONE FOR EFFECTIVE GRAFTING THERE MIGHT BE OVERCORRECTION OF THE PREMAXILLA INCLUDING THE SEPROVOMERINE SUTURE IN THE

BONE GRAFT CERTAINLY INCREASES THE CHANCES OF RETARDATION OF CENTRAL

FACIAL GROWTH WHEN ENOUGH PREVOMERINE BONE HOWEVER IS

AVAILABLE TO SUPPLY SUFFICIENT GRAFT AND STILL UNDERCORRECT THE

THIS PREMAXILLARY PROJECTION OPERATION HAS SOME APPEAL

ABSENCE OF CLEFT PALATE MAKES DIFFERENCE

THERE IS PROJECTING PREMAXILLA THAT OFFERS AN UNUSUAL PROBLEM

AS NOTED ANTIA OF IN THE BRITISH BY BOMBAY JOURNAL OF PLASTIC SURGERY IN 1966

CLEFTS OF THE LIP ASSOCIATED WITH CLEFT ALVEOLUS BUT NOT OF THE HARD OR SOFT

PALATE REPRESENT COMMON TYPE OF CLEFT IN INDIA THE PREMAXILLA IN THIS CASE FROM MAY VARY SMALL GROSSLY INADEQUATE ELEMENT TO AN EXCESSIVELY LARGE

BONY PROMINENCE THE GENERAL DEVELOPMENT OF THE ALVEOLAR ARCH IS NOT

AFFECTED BY PARING OF THE EXCESSIVE PREMAXILLARY ELEMENT DUE TO THE NORMAL FUSION OF THE HARD PALATE BEHIND THE INCISIVE FORAMEN IT IS RECOMMENDED

THAT BONY EXCISION OF REDUNDANT PREMAXILLA BE UNDERTAKEN

WITH THE RECOMMENDATION AGREE AS DID EXACTLY THIS EXCISION

72 AND TOOTH 1958 AND ALVEOLAR ALIGNMENT DEVELOP IN NOVEMBER AS SHOWN IN CHAPTER 18 MENT ARE EXCELLENT TODAY

NOT TO TO PUSH OR PUSH OF FRANTIC CONSERVATIVE AND INGENIOUS METHODS DESPITE THE MANY IT IS STILL WELL OUT IN FRONT AS DEALING WITH PROJECTING PREMAXILLA AND DIFFICULT IN LIP AND PALATE THE MOST CONTROVERSIAL PROBLEM WORK

II SETBACK EARLY AND LATE DISAPPROVAL OF

IN 1916 BINNIE NOTED

OF ALL THESE TO THE INTER LANE THOROUGHLY DISAPPROVES ATTEMPTS REPLACE

MAXILLARY BONE

LANES TREATMENT OF THIS COMMENT IS INTERESTING AS SIR ARBUTHNOT AND LEAVING CLEFT PALATE BY TURNING LARGE MUCOPERIOSTEAL FLAPS CONSERVATIVE OTHERWISE HUGE RAW AREAS WAS BY NO MEANS WITH BILATERAL CLEFT THE AFTER 15 YEARS EXPERIENCE LIPS USING METHODS OF VAUGHAN AND BROWN FOR PREMAXILLARY SETBACK BAUER

TRUSLER AND TONDRA DECIDED

THE BECAUSE OF THERE SHOULD BE NO SURGICAL RERROPOSITIONING OF PREMAXILLA OF THE FACE INTERFERENCE WITH GROWTH AND DEVELOPMENT

IN HIS HARELIPS LEMESURIER USED HIS ORTHOPEDIC LOGIC 1962

AND THEIR TREATMENT

THE THE IS TOO TO ALLOW EXCEPT IN THE FEW CASES WHERE PREMAXILLA PROMINENT BETTER LEAVE THE INTACT IF CLEFTS TO BE CLOSED OVER IT IT IS MUCH TO SEPTUM ANY TO ALLOW RESECTION HAS TO BE DONE IT SHOULD BE ONLY OF THE AMOUNT NECESSARY

BE CLOSED THE CLEFTS OF THE LIP TO

THE VARIOUS METHODS FOR SECTIONING AND REPOSITIONING VOMER HAVE LED TO AN IN GEORGIADES EXPERIENCE AT DUKE UNIVERSITY AND EVENTUAL UNSTABLE PREMAXILLARY SEGMENT IN SOME PATIENTS

WITH RESULTANT OF TILTING OF THE PREMAXILLA LINGUALLY MALPOSITION

THE PERMANENT INCISOR TECTH IN OTHERS

HAS ALSO BEEN CONSIDERATION DECREASED GROWTH OF THE PREMAXILLARY SEGMENT OF THE FOLLOWING WEDGE RESECTION OF PORTION VOMER

FARA AND HRIVNAKOVA NOTED IN 1965 IN ACTA CHIRURGIAE

PLASTICAE

73 TOTAL OF 506 HAVE BEEN TREATED PATIENTS FOR BILATERAL TOTAL CLEFT AT THE

OF PRAGUE UNIVERSITY DEPARTMENT PLASTIC SURGERY IN 31 OUT OF 317 CASES WITH MARKED OF THE PROTRUSION PREMAXILLA SURGICAL RERROPOSIRION WAS UN

DERTAKEN MOSTLY AS SECONDARY OPERATION IN MOST PATIENTS THIS LED TO TO THE OF THE DAMAGE GROWTH PREMAXILLA EITHER ALONE OR TOGETHER WITH DEVELOPMENTAL RETARDATION OF THE ENTIRE MAXILLAE MARKED SIGNS OF ATROPHY OFTEN AFTER THE DEVELOP MANY YEARS OPERATION IN SOME CASES UP TO 1113 WE MUST THEREFORE OF THE REGARD SURGICAL RERROPOSIRION PREMAXILLA AS RISKY PROCEDURE WHICH AS FAR SHOULD AS POSSIBLE BE MADE UNNECESSARY BY CONSERV ARIVE TREATMENT WE CONSIDER OF OSREOROMY THE VOMER AS PRIMARY OPERATION IN INFANTS HE HARMFUL TO WITHOUT EXCEPTION

THEY MENTIONED THEIR INTEREST IN KARFIKS SUGGESTION OF STUDY

OF THE BLOOD OF THE CENTRAL SUPPLY SEGMENT OF THE MAXILLA TO CONSIDER RESTRICTION IN DEVELOPMENT OF PROTRUSION OF THE PRE MAXILLA BY

PALLIATIVE ON THE ARTERIAL OPERATIONS NETWORK WITH SLIGHT DISTURBANCE OF THE

GROWTH ZONE IN ITS NECK

BILL HOLDSWORTH OF ST THOMAS HOSPITAL LONDON AND QUEEN

MARYS HOSPITAL IN HIS 1970 EDITION OF ROCLIAMPRON CLEFT LZ

AND PALATE SET TWO LINES AND FOR DIVISION OR RESECTION OF THE

IN THE REDUCTION OF THE SEPTUM SURGICAL PROMINENT PREMAXILLA HE THEN SUMMARIZED RATHER WELL

WHO HAVE HAD AMONG PATIENTS THE OPERATION SURGICAL SETBACK OF THE

IN LIFE PREMAXILLA EARLY FLAT FACES ABOUND AND ITS PROTAGONISTS ARE DIMIN

ISHING BAND MATTHEWS USES IT FOR ONLY EXTREME PROTRUSION BARSKY REPORTED

ITS USE IN SOME 50 AND IN PERCENT MOST HANDS IT IS RESERVED FOR GROSS AND NEGLECTED CASES WHEN CHILD WITH DOUBLE CLEFT AND PROMINENT PREMAXILLA IS NOT SEEN UNTIL LATE CLOSURE OF THE SOFT TISSUES EVEN IF POSSIBLE BE INSUFFICIENT MAY TO BRING THE PREMAXILLA INTO LINE AND THERE MAY BE NO

ALTERNATIVE TO SURGICAL REPOSITION

EXPERIMENTS IN THE HARE

CLINICAL CONCERN ABOUT THE MIDDLETHIRD GROWTH OF THE FACE IS

FORTIFIED BY EXPERIMENTAL EVIDENCE

BERNARD SARNAT OF CEDARSSINAI MEDICAL CENTER LOS ANGE STUDIED LES GROWTH OF THE RABBIT SNOUT WITH SELMAN FOL

LOWING EXTIRPATION OF THE FRONTONASAL SUTURE IN 1957 AND WITH

WEXLER AFTER DISLOCATION OF THE NASAL SEPTAL CARTILAGE IN 1965 AND AFTER RESECTION OF THE SEPTAL CARTILAGE IN 1966 THEY

BERNARDSANAT AFTER RESECTION ARREST OF THE UPPER FACE IN RABBITS REPORTED GROWTH AT FOUR TO FIVE MONTHS OF AGE AND THE OF THE SEPTOVOMETINE REGION THEIR NASAL ALONE AT 21 TO 48 DAYS OF AGE CARTILAGINOUS SEPTUM FROM 18 TO 131 DAYS AFTER CARTILAGINOUS NASAL SEPTUM 1967 REPORT DECELERATION OF GROWTH OF RESECTION REVEALED SIGNIFICANT EARLY FACE LEADS BONES THIS GROWTH ARREST OF THE UPPER TO ADJACENT WITH MALOCCLUSION OF THE MCI RELATIVE MANDIBULAR PROGNATHISM BECOME MORE PRONOUNCED IN THE POSTOPER SORS THE DEFORMITIES

ATIVE SURVIVAL PERIOD SUMMARIZED AT THE ROME CONGRESS IN 1967 SARNAT

THAT THE FRONRONASAL SUTURE WAS SITE OF ACTIVE ALTHOUGH IT WAS FOUND OF THE OF IT DID NOT AFFECT GROWTH SNOUT GROWTH EXTIRPATION GROSSLY AFFECT DISLOCATION OF THE CARTILAGINOUS NASAL SEPTUM LIKEWISE DID NOT GROSSLY OF NASAL OF THE SNOUT IN CONTRAST HOWEVER RESECTION CARTILAGINOUS IC GROWTH SEVERE AND STRIKING GROWTH ARREST OF THE SNOUT SEPTUM PRODUCED FRONRONASAL SUTURE IS FROM THESE EXPERIMENTS IT IS CONCLUDED THAT THE OF WHEREAS THE NASAL SECONDARY OR ACCOMMODATING SITE GROWTH CARTILAGINOUS

SITE OF THIS CONCLUSION HAS IMPLICA SEPTUM IS PRIMARY GROWTH IMPORTANT RELATION THE BASIC OF THE TIONS AND APPLICATIONS IN NOT ONLY TO PROBLEM OF OF THE NOSE AND GROWTH OF BONES BUT ALSO TO THE CLINICAL PROBLEMS SURGERY

PALATE

INHIBITION OF GROWTH BY STAPLING

FOR CRANIOFACIAL THE DAPPER JOHN CURTIN FROM THE CENTER

NOTED AT THE ANOMALICS UNIVERSITY OF ILLINOIS WITH PRUZANSKY

MELBOURNE CONGRESS IN 1971

STUDIES THAN 50 WITH COMPLETE LONGITUDINAL GROWTH ON MORE PATIENTS AND HAVE INDICATED THAT OF THE BILATERAL CLEFT LIP PALATE OVERGROWTH PRE

CHARACTERISTIC OF THE MAXILLARYVOMERINE SUTURE CONTRIBUTES TO THE DEFORMITY MIDFACE

JOHN CURTIN OF STA BORROWING FROM THE ORTHOPEDIC SURGEONS TECHNIQUE

RETARD OF BONES PLING ACROSS THE EPIPHYSEAL PLATE TO GROWTH LONG OF ACROSS THE THEY DEVISED AN INSTRUMENT AND METHOD STAPLING

PREMAXILLARYVOMERINE SUTURE MUCOSAL FLAP DESIGNED TO WRAP DISTAL AROUND THE WAS BASED LATERALLY ON ONE SIDE WITH ITS KA STAPLING THE END ON THE OTHER SIDE IT WAS ELEVATED WITHOUT DISTURBING TEL 44A TOTAL OF 506 PATIENTS HAVE BEEN TREATED FOR BILATERAL TOTAL CLEFT AT THE

PRAGUE UNIVERSITY DEPARTMENT OF PLASTIC SURGERY IN 31 OUR OF 317 CASES WITH MARKED PROTRUSION OF THE PREMAXILLA SURGICAL RERROPOSIRION WAS UN

DERTAKEN MOSTLY AS SECONDARY OPERATION IN MOST PATIENTS THIS LED TO THE DAMAGE TO GROWTH OF THE PREMAXILLA EITHER ALONE OR TOGETHER WITH RETARDATION OF THE ENTIRE DEVELOPMENTAL MAXILLAE MARKED SIGNS OF ATROPHY

OFTEN AFTER THE IN DEVELOP MANY YEARS OPERATION SOME CASES UP TO 1113 WE

MUST THEREFORE REGARD SURGICAL RETROPOSITION OF THE PREMAXILLA AS RISKY WHICH PROCEDURE SHOULD AS FAR AS POSSIBLE BE MADE UNNECESSARY BY CONSERV

ARIVE TREATMENT WE CONSIDER OSREOTOMYOF THE VOMER AS PRIMARY OPERATION

IN INFANTS TO BE HARMFUL WITHOUT EXCEPTION

MENTIONED THEIR THEY INTEREST IN KARFIKS SUGGESTION OF STUDY OF THE BLOOD SUPPLY OF THE CENTRAL SEGMENT OF THE MAXILLA TO

CONSIDER RESTRICTION IN DEVELOPMENT OF PROTRUSION OF THE PRE MAXILLA BY

ON THE ARTERIAL NETWORK WITH PALLIATIVE OPERATIONS SLIGHT DISTURBANCE OF THE

GROWTH ZONE IN ITS NECK

BILL HOLDSWORTH OF ST THOMAS HOSPITAL LONDON AND QUEEN

IN MARYS HOSPITAL ROEHAMPTON HIS 1970 EDITION OF CLEFT LZJ

AND PALATE SET TWO LINES AND FOR DIVISION OR RESECTION OF THE

IN THE SEPTUM SURGICAL REDUCTION OF THE PROMINENT PREMAXILLA HE THEN SUMMARIZED RATHER WELL

AMONG PATIENTS WHO HAVE HAD THE OPERATION SURGICAL SETBACK OF THE

IN LIFE FLAT PREMAXILLA EARLY FACES ABOUND AND ITS PROTAGONISTS ARE DIMIN BAND MATTHEWS ISHING USES IT ONLY FOR EXTREME PROTRUSION BARSKY REPORTED

ITS USE IN SOME 50 PERCENT AND IN MOST HANDS IT IS RESERVED FOR GROSS AND

NEGLECTED CASES WHEN CHILD WITH DOUBLE CLEFT AND PROMINENT

IS UNTIL PREMAXILLA NOT SEEN LATE CLOSURE OF THE SOFT TISSUES EVEN IF POSSIBLE

BE INSUFFICIENT MAY TO BRING THE PREMAXILLA INTO LINE AND THERE MAY BE NO

ALTERNATIVE TO SURGICAL REPOSITION

EXPERIMENTS IN THE HARE

CLINICAL CONCERN ABOUT THE MIDDLETHIRD GROWTH OF THE FACE IS

FORTIFIED BY EXPERIMENTAL EVIDENCE

BERNARD SARNAT OF CEDARSSINAI MEDICAL CENTER LOS ANGE LES STUDIED GROWTH OF THE RABBIT SNOUT WITH SELMAN FOL

LOWING EXTIRPATION OF THE FRONRONASAL SUTURE IN 1957 AND WITH

WEXIER AFTER DISLOCATION OF THE NASAL SEPTAL CARTILAGE IN

1965 AND AFTER RESECTION OF THE SEPTAL CARTILAGE IN 1966 THEY

BERNARD SARNAT FACE IN RABBITS AFTER RESECTION ARREST OF THE UPPER REPORTED GROWTH AT FOUR TO FIVE MONTHS OF AND THE OF THE SEPROVOMETINE REGION AGE

NASAL ALONE AT 21 TO 48 DAYS OF AGE THEIR CARTILAGINOUS SEPTUM FROM 18 TO 131 DAYS AFTER CARTILAGINOUS NASAL SEPTUM 1967 REPORT DECELERATION OF GROWTH OF RESECTION REVEALED SIGNIFICANT EARLY BONES THIS GROWTH ARREST OF THE UPPER FACE LEADS TO ADJACENT WITH MALOCCLUSION OF THE MCI RELATIVE MANDIBULAR PROGNATHISM BECOME MORE IN THE SORS THE DEFORMITIES PRONOUNCED POSTOPER

ATIVE SURVIVAL PERIOD

AT THE ROME CONGRESS IN 1967 SARNAT SUMMARIZED

FOUND THAT THE FTONTONASAL SUTURE WAS SITE OF ACTIVE ALTHOUGH IT WAS

OF IT DID NOT AFFECT OF THE SNOUT GROWTH EXTIRPATION GROSSLY GROWTH DISLOCATION OF THE CARTILAGINOUS NASAL SEPTUM LIKEWISE DID NOT AFFECT GROSSLY

IN HOWEVER RESECTION OF NASAL GROWTH OF THE SNOUT CONTRAST CARTILAGINOUS SEVERE AND ARREST OF THE SNOUT SEPTUM PRODUCED STRIKING GROWTH

IS FROM THESE EXPERIMENTS IT IS CONCLUDED THAT THE FRONTONASAL SUTURE OF WHEREAS THE NASAL SECONDARY OR ACCOMMODATING SITE GROWTH CARTILAGINOUS

SITE OF THIS CONCLUSION HAS SEPTUM IS PRIMARY GROWTH IMPORTANT IMPLICA THE TIONS AND APPLICATIONS IN RELATION NOT ONLY TO THE BASIC PROBLEM OF

THE CLINICAL OF OF THE NOSE AND GROWTHOF BONES BUT ALSO TO PROBLEMS SURGERY

PALATE

INHIBITION OF GROWTH BY STAPLING

FOR CRANIOFACIAL THE DAPPER JOHN CURTIN FROM THE CENTER

ANOMALIES UNIVERSITY OF ILLINOIS WITH PRUZANSKY NOTED AT THE

MELBOURNE CONGRESS IN 1971

LONGITUDINAL GROWTH STUDIES ON MORE THAN 50 PATIENTS WITH COMPLETE OF THE BILATERAL CLEFT LIP AND PALATE HAVE INDICATED THAT OVERGROWTH PRE

MAXILLARYVOMERINE SUTURE CONTRIBUTES TO THE CHARACTERISTIC DEFORMITY OF THE MIDFACE

JOHN CURTIN OF BORROWING FROM THE ORTHOPEDIC SURGEONS TECHNIQUE STA OF PLING ACROSS THE EPIPHYSEAL PLATE TO RETARD GROWTH LONG BONES

THEY DEVISED AN INSTRUMENT AND METHOD OF STAPLING ACROSS THE

PREMAXILLARYVOMERINE SUTURE MUCOSAL FLAP DESIGNED TO WRAP

AROUND THE STAPLING WAS BASED LATERALLY ON ONE SIDE WITH ITS DISTAL

END ON THE OTHER SIDE IT WAS ELEVATED WITHOUT DISTURBING THE THESE

PERIOSTEUM THE STAPLES WERE SEATED ACROSS THE SUTURE AND FLAP WAS THE REPLACED THEIR ANIMAL EXPERIMENTS AND WERE THE NUMBER OF INCONCLUSIVE INFANTS WAS TOO FEW OFTEN FURTHERMORE THE ACTED AS THE STAPLE FOREIGN BODY THAT IT IS AND TENDED REJECTED TO BE NEVERTHELESS THEY PROPOSE STAPLING AS POSTULATING POSSIBILITY TEMPTING ADVANTAGES

STAPLING INHIBITS GROWTH AT THE THE PREMAXILLA1 SUTURE SEVERITY OF THE REDUCING DEFORMITY IT IS REVERSIBLE CAN BE TECHNIQUE REMOVED THE STAPLE WITHOUT INJURY TO BONE OR PERIOSREUM CONTINUE GROWTH FOLLOWING REMOVAL OF MAY THE STAPLE

WHEN FIRST HEARD OF THIS STAPLING PLAN WAS MUST ADMIT HOPEFUL AND DISAPPOINTMENT THAT THE RESULTS SO FAR SIVE ARE INCONCLU WROTE CURTIN IN JUNE 1973 ASKING FOR THE LATEST ON HIS STAPLING IN BILATERAL CLEFTS AND HE SCRIBBLED ON THE BOTTOM OF LETTER MY

NOTHING NEWSTILL IN RESEARCH FORM AWAITING MATURATION RESULTS BY TO SUBSTANTIATE PRUZANSKY DOCUMENTATION

TH PRINCIPLE SEEMS TO OFFER AN APPEALING SOLUTION TO PROBLEM BUT DIFFICULT AS ONE THINKS ABOUT IT THERE BESIDES THE EMERGES MAJOR FLAW FOREIGN BODY REJECTION PHENOMENON SHOULD IDEALLY ITS BE INTRAUTERINE USE BY THE TIME OF BIRTH WITH THE ALREADY PROJECTION DEVELOPED IT IS TOO LATE TO DO MUCH MORE THAN BE DONE WITH WHAT CAN ELASTIC TRACTION OR MUSCLE CLOSURE

PERSONAL STRUGGLE WITJJ THE PREMAXILLA

MY PERSONAL EXPERIENCE WITH THE PROJECTING VARIED TO PREMAXILLA HAS BEEN SAY THE LEAST AT BOSTON CHILDRENS FLIOSPITAL IN THE MID OBSERVED MACCOLLUM MERELY TWEAK THE PREMAXILLA FORCEPS WITH PRIOR TO THE JOINING LIP ACROSS IT WHILE STILL IN THE IN NAVY NASHVILLE IN FORTUNE 1946 HAD THE TO SCRUB ON TWO GOOD MAJOR SURGICAL WILLIAM PROCEDURES DAY WITH CORE LARGE GENERAL SURGEON WITH HUGE PRACTICE MORNING BEFORE THE EVERY USN RECRUITING OFFICE REQUIRED SER VICES WE DID HYSTERECTO MY GASTRECTOMJ CHOLECYSTECTO

76 AND EVEN AN OCCASIONAL BILATERAL THYROIDECTOMIES CLEFT LIP WITH WAS PROTRUDING PREMAXILLA IMPRESSED WITH HIS SPEED AND SKILL HIS LIMITED AND CONSIDERING PLASTIC SURGICAL TRAINING AMAZED THAT HE COULD THESE LITTLE CREATURES CLEFTS CLOSED GET STILL VIVID IN MY HOWEVER IS THE ROUND INTESTINAL MEMORY LARGE NEEDLE CARRYING CNROMLC SUTURE TAKEN CATGUT WHICH HAVING BITE THROUGH ONE MAXILLA AND THE PASSED THROUGH PREMAXILLA EXITED WITH DEJECTED TOOTH BUD ITS IMPALED ON POINT LIKE MARTINI ONION ON TOOTH PICK

THEN DURING 19481949 ON SATURDAYS VISITED KILNER AT ALT ON ENGLAND HERE OBSERVED BILATERAL LIP CLEFTS CLOSED IN TWO

STAGES WITHOUT PREMAXILLARY SETBACK AND NUMBER OF WOBBLY PREMAXILLAE EXCISED AND REPLACED WITH DENTURE AT AGE FIVE TO SEVEN YEARS ON TUESDAYS DURING THIS SAME VISITED PERIOD THE HOSPITAL FOR SICK CHILDREN AT GREAT ORMONDSTREET LONDON IT WAS ONLY AFTER SEVERAL RATHER TRYING IN EXPERIENCES HEAVY FOG THAT FINALLY LOCATED THE HOSPITAL HIDDEN JUST OFF RUSSELL SQUARE ON THE EIGHTH FLOOR DENIS BROWNE RENOWNED PEDIATRIC SURGEON WAS SCRUBBING FOR BILATERAL CLEFT LIP HE WAS SO MUCH TALLER THAN ANYONE ELSE IN THE ROOM THAT AT FIRST HE BE THOUGHT MUST STANDING ON STOOL HIS WAS HEADLIGHT ATTACHED TO BATTERY FROM SWINGING HIS HIP SO THAT HE NEED BE NOT PLUGGED TO THE WALL HE NIBBLED AWAY THE BONY OVERGROWTH BETWEEN THE AND THE SEPTUM PROTRUDING PREMAXILLA AFTER AND FRESHENING THE SET EDGES THE PREMAXILLA BACK IN THE ALVEOLAR ARCH AND FIXED IT WITH AN ANTERIOR TOOTHED METAL BAR BETWEEN CASES CORNERED HIM ASK TO HOW HE DARED TAKE THIS APPROACH WHEN CONSIDERED MANY THE DEFORMITY IN THE UNDERDE

VELOPMENT OF THE MAXILLA RATHER THAN THE OVERDEVELOPMENT OF THE PREMAXILLA HE POINTED OUT THAT IN HIS OPINION THE VOMER WAS OF NORMAL DIMENSIONS BUT BETWEEN IT AND THE PREMAXILLA NEW BONE HAD FORMED DRIVING THE LATTER FORWARD BY REMOVING THIS BONE HE WAS ABLE TO REPLACE THE PREMAXILLA AND OBTAIN UNION BILATERALLY IN 70 PERCENT OF CASESON ONE SIDE IN 100 PERCENTWHICH HE CLAIMED PREVENTED SHRIVELING OF THE PREMAXILLA THEN DURING MY TRAINING TIME IN ST LOUIS HAD CHANCE TO WATCH BARRETT II BROWN PUSH BACK JUTTING PREMAXILLA AND PIN IT

77 WITH KEITH NEEDLE THE SIMPLICITY OF THIS MANEUVER WAS IM PRESSIVE WHEN GOT TO KOREA MY FIRST CLEFT CASE WAS BILATERAL CLEFT IN WHICH THE ORAL HAD SURGEON ALREADY LOST THE PREMAXILLA

DURING MY EARLY YEARS IN PRACTICE IN MIAMI TRIED THE BROWN AND DID PUSHBACK ONE GILLIES PARTIAL EXCISION WITH LESS THAN SUCCESS THEN USED PARTIAL THE CRONIN APPROACH OR THE BURSTON KERNAHAN MODIFICATION EITHER OF WHICH FAVOR TODAY IF THE PROJECTION IS TREMENDOUS IN 1960 MY ATTITUDE TOWARD THE

PREMAXILLA WAS EXPRESSED

THERE IS WHAT JUSTIFIED CONTROVERSY AS TO TO DO WITH THIS JUTTING PREMAXILLA FOR THE PRESENT COMPROMISE IS PREFERABLE IF THE PREMAXILLA IS WELL IN THE THEN ARCH BY TURNING MUCOSAL FLAPS FIBROUS UNION CAN BE ACHIEVED IF THE

PREMAXILLA IS FAR OUR ON THE END OF THE JUTTING NOSE THEN SEPTAL RESECTION

WHICH IS TO AFFECT DESIGNED GROWTH AS LITTLE AS POSSIBLE AND STILL LET THE

BACK IN PREMAXILLA UNDERCORRECTED POSITION SEEMS WARRANTEDBETWEEN THESE EXTREMES ARE PREMAXILLAE PROTRUDING VARYING DISTANCES AND MANY CAN BE MANEUVERED SUCCESSFULLY BY LIP MOULDING AND ORTHODONTICS

AT THIS UNIT POINT OUR WAS HONORED BY VISIT FROM BURSTON AND OUR PROSTHODONTIST GEORGE BALBER ATTEMPTED TO FOLLOW HIS DIRECTIONS AND PRODUCE WEDGE PLATES TO POUND THE MAXILLARY ELEMENTS FORWARD BUT WITHOUT THE PROPER FACILITIES HE WAS UNABLE

TO BURSTONS RESULTS DUPLICATE THEN AFTER VISIT BY HAGERTY AND MYLIN BALBER TO CONSTRUCT AND BEGAN PIN SCREW PLATES WHICH IN CERTAIN WHEN INSERTED CASES SOON ENOUGH SEEM TO WORKWELL THE DEATH OF BALBER UNTIMELY CAUSED THIS APPROACH TO BE DIS JI CONTINUED

AND FOR MEANWHILE SOME TIME HAD JOINED FORCES WITH SAMUEL BERKOWITZ PRUZANSKYTRAINED ORTHODONTIST HE LULLED ME INTO SEMICOMA TOWARD THE PREMAXILLA BY PROMISING THAT IF CLOSED THE OVER THE HE COULD LIP PREMAXILLA SPREAD THE MAXILLARY

ELEMENTS LATER FOR ITS RECEPTION AND BONE GRAFT FIXATION THE OF THE VOMER AND THE BUCKLING ANTEFLEXION OF THE PREMAXILLA DID NOT SEEM TO CAUSE HIM AN GREAT CONCERN OCCASIONAL SEVERELY

PROJECTING PREMAXILLA HAS NOT GONE BACK AND HERE BERKOWITZ HAS BEEN QUITE AMENABLE TO SETBACK AT ABOUT FIVE OF YEARS AGE

78 EXAMPLE AN OUTSTANDING

BUT WITHOUT THE WITH PROTRUDING PREMAXILLA BILATERAL CLEFT OF LIP TREATED IN INFANCY IN ALABAMA WITH APPROXI THE PALATE WAS CLEFT OF ELEMENTS TO THE PROLABIUM AS WE MARION OF THE LATERAL LIP INDICATED THIS VOMER RESECTION WAS MENTIONED EARLIER IN CHAPTER INTO NORMAL THE THE PREMAXIA11 POSITION EARLY HERE TO PLACE WITH THIS WAS FIRST SEEN AT YEARS FRIGHTENING PROJECTION PATIENT

YEARS

AND THE MUCOPERIOSTEUM OF THE VOMER STALK WAS INCISED BLOCK OF BONE COULD BE RESECTED DISSECTED SO THAT QUADRILATERAL

FROM THE VOMER THEN MUCOPERIOSTEUM WAS TURNED FROM BOTH OF MAXILLA LATERAL EDGES OF THE PREMAXILLA AND EACH CLEFT EDGE THE

79 THAT THESE SO FLAPS COULD BE SUTURED AFTER THE PREMAXILLA HAD BEEN

SET BACK BONE CHIPS FROM THE VOMERWERE USED TO FILL THE ALVEOLAR

GAPS BETWEEN THE MUCOPERIOSTEAL FLAPS AND KIRSCHNER WIRE WAS FROM RUN HIGH UP IN THE MIDLINE OF THE PREMAXILLA BACK TO FIX IT

TO THE VOMER

PATIENT NOW NEEDS FORKED FLAP MEDIAL ADVANCEMENT OF THE ALAR

BASES AND LIP REVISION

YET TO CONDEMN CHILDREN SUFFER WITH TO PROJECTING PROBOSCIS

LOOKING NOT UNLIKE DOGS MOUTH OR WOLFS SNOUT DURING THEIR CRUEL EARLY YEARS SEEMS DETERMINED TO BYPASS THIS PHASE WE

FINALLY CHANGED OUR GENERAL APPROACH TO BILATERAL CLEFTS IN FAVOR OF

IMMEDIATE ELASTIC TRACTION TO THE BABYS HEADCAP THIS HAS BEEN DRAMATIC IN SOME CASES AND OF MODERATE VALUE IN OTHERS BUT

IN ALL SO FAR WHEN AFTER ADEQUATE SEEN SOON BIRTH TO ALLOW PRIMARY WITHOUT THE OF PI LIP SURGERY NECESSITY SURGICAL SETBACK WHEN THE EXTREME OF THE PROTRUSION PREMAXILLA PERSISTS AND

MUSCLETOMUSCLE IS FORCED APPROXIMATION OVER THIS PROJECTION IT CAN BE BUT ACCOMPLISHED THE ULTIMATE ATTENUATION OF THE PRO LABIUM AND OF THE STRETCHING SCARS ARE DISCOURAGING IT MIGHT BE BETTER IN SUCH SEVERE CASES TO BYPASS THIS NONPROFIT PROCESS WITH BILATERAL MUCOSAL ADHESION MAINTAINED UNTIL BETTER PREMAXILLARY

ALIGNMENT FACILITATES LIP CLOSURE

III