Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
e500
Jou nal sec ion: O al Su ge y
Publica ion Types: Re iew
Repai o comple e bila e al cle lip wi h se e ely p o uding p emaxilla
pe o ming a p emaxilla y se back and ome ine os ec omy in one s age su ge y
Nabil Fakih-Gomez, Ma a Sanchez-Sanchez, Fe nando Iglesias-Ma in, Albe o Ga cia-Pe la-Ga cia,
Rodol o Belmon e-Ca o, Luis-Miguel Gonzalez-Pe ez
Depa men o O al and Maxillo acial Su ge y, Vi gen del Rocio Uni e si y Hospi al, Se ille, Spain
Co espondence:
Depa men o Maxillo acial Su ge y
Vi gen del Rocio Uni e si y Hospi al
Se ille, Spain
d nabil [email protected]
Recei ed: 25/12/2014
Accep ed: 26/02/2015
Abs ac
Backg ound: The au ho s p esen a echnique o selec ed cases o CBCL. The p ima y epai o he CBCL
wi h a se e ely p o uding p emaxilla in one s age su ge y is e y di icul , essen ially because a good muscula
apposi ion is di icul , o cing synch onously o do a p emaxilla y se back o acili a e subsequen bila e al
lip epai and, hus, achie ing sa is ac o y esul s. We achie e his by a educ i e os ec omy on he ome o-
p emaxilla y su u e.
Ma e ial and Me hods: 4 pa ien s wi h CBCL and se e ely p o uding p emaxilla unde wen p emaxilla y se back
by ome ine os ec omy a he same ime o lip epai in he pas 24 mon hs. The ex en o p emaxilla y se back
a ied be ween 9 and 16 mm. The equi ed amoun o bone was emo ed an e io o he ome o-p emaxilla y
su u e. The au ho s did an addi ional simul aneous gingi ope ios eoplas y in all pa ien s, achie ing an enough
s abili y o he p emaxilla in i s new posi ion, o be able o close he al eola gap bila e ally.
The au ho s ha e examined he posi ion o p emaxilla and den al a ch be ween 6 and 24 mon hs. We did no do he
p ima y nose co ec ion, because his inc eased he isk o impai men o he al eady comp omised ascula i y o
he phil um and p emaxilla.
Resul s: The ollow-up pe iod anged be ween 6 and 24 mon hs. None o he pa ien s had any majo complica ion.
Du ing ollow-up, he p emaxilla was minimally mobile. We achie ed a good lip epai in all cases: adequa e
muscle epai , symme y o he lip, p olabium and Cupid’s bow, as well as good sca s.
Cloncusions: To ou knowledge, he e a e ew epo s o one s age su ge y wi h ome ine os ec omy o epai
CBCL wi h se e ely p o uding p emaxilla. Doing his ome ine os ec omy, we don’ know how i will a ec he
subsequen g ow h o he p emaxila and es ic he na u al maxilla y g ow h. Applying his al e na i e ea men
o child en wi h CBCL and p o uded p emaxilla wi hou any p eope a i e o hopedic, we can success ully
Fakih-Gomez N, Sanchez-Sanchez M, Iglesias-Ma in F, Ga cia-Pe la-Ga -
cia A, Belmon e-Ca o R, Gonzalez-Pe ez LM. Repai o comple e bila e al
cle lip wi h se e ely p o uding p emaxilla pe o ming a p emaxilla y
se back and ome ine os ec omy in one s age su ge y. Med O al Pa ol
O al Ci Bucal. 2015 Jul 1;20 (4):e500-7.
h p://www.medicinao al.com/medo al ee01/ 20i4/medo al 20i4p500.pd
A icle Numbe : 20568 h p://www.medicinao al.com/
© Medicina O al S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: [email p o ec ed]
Indexed in:
Science Ci a ion Index Expanded
Jou nal Ci a ion Repo s
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emca e
Indice Médico Español
doi:10.4317/medo al.20568
h p://dx.doi.o g/doi:10.4317/medo al.20568
Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
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pe o m, in a single-s age su ge y, a good p ima y lip epai a ou cen e . Fu he con i ma ions o his su ge y wi h
ollow up and an h opome ic s udies o hese pa ien s du ing childhood and adolescence a e equi ed.
Key Wo ds: P o uding p emaxilla, bila e al cle lip, ome ine os ec omy, one s age su ge y, Milla d II echnique.
In oduc ion
P ominen p emaxilla is a cha ac e is ic o in an s wi h
comple e bila e al cle lip. I is ela ed o he a achmen
o p emaxilla o he ome and he nasal sep um ia he
sep o-p emaxilla y ligamen in he absence o la e al
s ains. The p o uding wis ed p emaxilla adds he
p oblems o su gical managemen o bila e al comple e
cle o lip pa ien s (CBCL). P emaxilla is un es ained
by ei he o he maxilla y al eoli and only a ached o
nasal sep um by sep omaxilla y ligamen . In no mal
child en, he ca ilaginous sep um mus slide o wa d in
ela ion o he p emaxilla y egion owing o he es ain
on he p emaxilla by he lip and la e al maxilla y
segmen s. In bila e al cle , he p emaxilla is ca ied
o wa d a he same a e as ha o he g owing sep um
o which i is i mly held. The p emaxilla has only one
es aining connec ion, he ome . This es ain is
ealized as a ension be ween hese bones bo ne by he
ome o-p emaxilla y su u e, hus c ea ing he condi ion
o bone o ma ion (1,2).
Va ious appliances o p emaxilla y se back such
as ex ao al head cap, elas ic s aps, apes, La ham
appliance and Bu s on pla e ha e been success ul a e
a ious su ge ies and long ime ea men (3-6). The
li e a u e has men ioned abou he lip adhesion as he
ea men o p o uding p emaxilla; i is no always
success ul o mold p emaxilla wi hou muscle epai .
In addi ion, i adds o one mo e su ge y and also adds
sca s o he lip making he nex epai mo e di icul .
The p oblems a e compounded in BCLP by p o uding
p emaxilla (7).
So condi ioned on amilia demand and lack o
p eope a i e o hopedic ea men o ce us o use one
s age su ge y o ea hem. This p ima y epai o
CBCL wi h a se e ely p o uding p emaxilla in one
s age su ge y is e y di icul , essen ially because a good
muscula apposi ion is di icul , o cing synch onously
o do a p emaxilla y se back o acili a e subsequen
bila e al lip epai .
While ollowing he p incipals desc ibed by Milla d in
1977 (8,9), we added he ome ine os ec omy echnique o
sui he local ci cums ances. So by his educ i e os ec omy
on he ome o-p emaxilla y, we can pe o m i in one
s age su ge y. A he same ime as p emaxilla y se back,
he blood supply o he p emaxilla is impai ed, wi h he
isk o p emaxilla y nec osis. The e a e ew epo s o one
s age su ge y wi h ome ine os ec omy o epai CBCL
wi h se e ely p o uding p emaxilla. (10-13). To ou
knowledge, his is he i s epo using bo h combina ions
ome os ec omy and Milla d II echnique.
Pa ien and Me hods
- Su gical Technique:
Unde gene al anes hesia, supine posi ion and minimal
ex ension o he pa ien ’s neck, he p ocedu e begins
wi h ome ine os ec omy. The equi ed o bone was
emo ed an e io o he ome o-p emaxilla y su u e.
We did addi ional simul aneous gingi ope ios eoplas y,
achie ing an enough s abili y o he p emaxilla in
i s new posi ion, o be able o close he al eola gap
bila e ally, ollowed by su u ing he o biculus muscle
hen using Milla d II echnique o epai he lip. We did
no do p ima y nose co ec ion, because his inc eased
he isk o impai he al eady comp omised ascula i y
o he phil um and p emaxilla. The ala ca ilages a e
eadjus ed h ough im incisions.
- Clinical Cases:
Be ween Decembe 2011 and Ap il 2013, 4 pa ien s wi h
comple e bila e al cle lip wi h p o uding p emaxila
unde wen p emaxilla y se back by ome ine os ec omy
a he same ime o lip epai . All pa ien s had pala ine
cle associa ed who hey unde wen a second ime
su ge y o epai he pala ine cle . Pa ien ages anged
be ween 7 mon hs and 4 yea s 5 mon hs wi h a mean age
o 19 mon hs. The e we e 2 males and 2 emales. None
o he child en had unde gone any p e ious o hodon ic
ea men .
- Case 1: A 4-yea -old male pa ien wi h no amily
his o y no isk ac o s, no associa ed anomalies
and synd ome, ha a e being ea ed se e al imes
p e iously in o he cen e s, e e ed o ou cen e o
esol e he pala e cle and he p ojec ed p e- ea ed
p emaxilla wi h he closu e o he cle lip. Only in his
pa ien we epai ed a he same ime he pala e cle wi h
he ome ine os ec omy ollowed by a new lip epai 4
mon hs la e . We unde wen p emaxilla y se back a he
ime o pala e epai because he had unde wen o he lip
su ge ies in o he clinics wi hou ea ing he p ojec ed
p emaxila (Fig. 1).
- Case 2: A male pa ien o 6 mon hs wi h no amily
his o y no isk ac o s, no associa ed anomalies and
synd ome (Fig. 2).
- Case 3: A emale pa ien o 9 mon hs wi h amilia
his o y (pa e nal uncle) wi h cle lip, wi h mo he
his o y o d ug in ake and no associa ed anomalies no
synd ome (Fig. 3).
Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
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- Case 4: A emale pa ien o 7 mon hs wi hou amily
his o y o isk ac o s and bila e al hypoacusis (Fig. 4).
The h ee o he cases unde wen he su gical echnique
desc ibed be o e. Case 2 had cle pala e epai 13
mon hs la e . The o he wo emaining cases a e
awai ing su gical in e en ion o pala e cle .
The ex en o p emaxilla y se back a ied be ween 9
and 16 mm. The equi ed amoun o bone was emo ed
an e io o he ome o-p emaxilla y su u e. Only in case
1, being olde , elas ic ac ion is pe o med o g adually
e ac he p emaxilla. To achie ing an enough s abili y
o he p emaxilla in i s new posi ion, and o be able o
close he al eola gap bila e ally, we did an addi ional
simul aneous gingi ope ios eoplas y.
Resul s
The ollow-up pe iod anged be ween 6 and 24 mon hs.
We examined he den al a ch and posi ion o he
p emaxilla clinically and documen ed pho og aphically
in all e isions. None o he pa ien s had any majo
complica ion, such as loss o he p emaxilla o any
ischemic episode o ascula comp omise o he
p emaxilla o skin dehiscence o he lip. Du ing ollow-
up, i was no ed ha he p emaxilla was minimally
Fig. 1. (case 1): A 4-yea -old male wi h CBCL wi h p o uding p emaxilla and pala e cle . (A) P eope a i e an e io and
la e al iew. (B) CT scan showing he ex eme p o usion o he p emaxilla wi h a e ical excess ; No ice he leng h o he
ome ine bone needed o be excised on CT scan. (C) Occlusal in a-o al iew, showing he un es ained an e io nasal sep al
and ome o-p emaxilla y su u e a e wedge os ec omy o he ome . (D) Pos ope a i e esul s on la e al iew (18 mon hs
pos ope a i ely).
AB
D
C
Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
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mobile in all pa ien s. The ex en o p emaxilla y se back
a ied be ween 9 and 16 mm. We achie ed a good lip
epai in all cases wi h adequa e muscle epai , wi h an
excellen symme y o he lip, p olabium and Cupid’s
bow as well as good sca s. No is ulas appea ances we e
documen ed. Re e ing o case 1, speech e alua ion
showed imp o emen wi h ega d o in elligibili y,
hype nasali y, and a icula ion e o . Howe e , as
expec ed, i was no no mal because o ob ious ac o s,
such as la e pala e epai and habi ual pa e ns. In he
o he cases, a e s ill young o eco d in elligibili y and
wo o hem is s ill awai ing pala e cle epai .
Discussion
I is bes o ini ia e ea men as ea ly as possible
because su gical sca s a e less isible ollowing su ge y
in in an s (14). In addi ion, he bone and ca ilage
issues a e so and moldable in in an s acila ing mo e
he su gical co ec ion, and no mal o al unc ion can be
es ablished once he lip s uc u es ha e been epai ed
ana omically. Psychological p oblems o he baby and
amily a e also minimized (15).
P o usion o he p emaxilla in CBCL can be seen as
ea ly as 10 weeks o ges a ion (1). Un es ained an e io
nasal sep al and ome o-p emaxilla y su u e g ow h,
combined wi h lack o bony and so issue con inui y,
and dis up ion o balance be ween he ci cumo al
muscula u e and he ongue a e hough o p oduce he
classic bila e al p emaxilla y de o mi y (16,17). This
p emaxilla y ela ionship may esul in signi ican
unc ional p oblems such as absence o p ope an e io
occlusion, la e al mobili y o he p emaxilla y segmen
and labial o pala al o onasal is ulae wi h consequen
p oblems in speech and o al hygiene. P ominence o
e ical o e de elopmen o he p emaxilla also may
esul in signi ican psychological ha m du ing a child’s
Fig. 2. (case 2): A 6 mon hs male wi h CBCL wi h p o uding p emaxilla and pala e cle . (A) P eope a i e an e io iew. (B) Oc-
clusal in a-o al iew, showing ome o-p emaxilla y su u e and he si e o he wedge os ec omy o he ome wi h a bone cu e .
(C) Occlusal in a-o al iew, showing he gap a e he wi hd awal o he wedge os eo omized ome . (D) Lip epai and immedia e
pos ope a i e esul s on an e io iew a e su u ing he o bicula is muscle and he gingi ope ios eoplas y.
AB
D
C
Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
e504
o ma i e yea s. Bila e al cle lip epai wi h p o uding
p emaxila emains one o he mos challenging p oblems
o su geons. To ou knowledge, he e a e ew epo s
o one s age su ge y wi h ome ine os ec omy o epai
CBCL wi h se e ely p o uding p emaxilla (10-13).
Co ec ion o he displaced p emaxilla by o hodon ic
ea men alone is impossible. On he o he hand,
su gical eposi ioning is echnically demanding and
may in e e e wi h he blood supply o he p emaxilla.
Two-s age p ocedu e was ad ised by some au ho s (18),
bu os eo omy o he p emaxilla, in combina ion wi h
he co ec ion o he lip cle , has been also epo edly
success ul in selec ed cases, especially en olde
pa ien s. This p ocedu e enables closu e o la ge is ulae
(inc easing he chances o success o lip econs uc ion
wi hou ension in he lip skin), acili a es o e je
and o e bi e co ec ion, and may ha e psychosocial
ad an ages o he child and his amily which demand
one ime su ge y and whe e we can no o e hem
nasoal eola moldings (NAM) o p e ious o hodon ic
ea men . Al hough ea ly esul s wi h p eope a i e
NAM ha e good esul , objec i e analysis o long- e m
ou come has no ye been epo ed (19,20).
Mul iple s udies compa ed un epai ed adul cle lip and
cle pala e maxilla y mo phology o ha in adul s wi h
epai ed cle s (21-26). The esul s a e well- documen ed:
adul s wi h un epai ed cle lips o pala es ha e maxillas
wi h a no mal o sligh ly p ogna hic cephalome ic
posi ion an e io -pos e io ly, and a no mal o widened
maxilla y ans e se wid h. Based on hese s udies, i is
e iden ha he acial cha ac e is ics o an un epai ed
adul cle lip and pala e pa ien a e unique: a no mal
Fig. 3. (case 3): A 9 mon hs emale wi h CBCL wi h p o uding p emaxilla and pala e cle . (A) P eope a i e an e io iew.
(B) Occlusal in a-o al iew, showing he wedged os eo omized ome . (C) Lip epai and immedia e pos ope a i e esul s on
an e io iew. (D) Pos ope a i e esul s on an e io iew (1 mon h pos ope a i ely).
AB
CD

Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
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o sligh ly p o usi e uppe jaw, p o uded maxilla y
an e io den i ion, and a no mal o sligh ly hypoplas ic
mandibula ela ionship. In addi ion, he cle lip and
cle pala e dimensions a e ha much g ea e , because
he cle g ows p opo iona ely wi h he su ounding
ana omy. Padwa e al. (27) sugges ed ha a p o usi e
p emaxilla could be su gically eposi ioned a e 6 o 8
yea s wi hou dele e ious e ec s on mid acial g ow h.
F eiho e e al. (28) also no ed ha by his age (8 o 13
yea s), he de elopmen o he maxilla is a ad anced
and he g ow h dis u bance a his age by p emaxilla y
se back has only a ela i ely es ic ed nega i e
in luence. Howe e , F iede and P uzansky (29) no ed
ha he majo i y o pa ien s wi h bila e al comple e cle
lip and pala e who ha e unde gone p emaxilla y se back
ha e conca e aces because o maxilla y e usion.
Al hough his is a eal side ec , i is essen ial o b ing
he p emaxilla y se back in alignmen wi h he la e al
segmen so ha subsequen al eola bone g a ing and
o hogna hic p ocedu es can be pe o med. Mid acial
g ow h is easily documen ed by la e al cephalome y
and by analysis o plas e den al cas s. Many den al
specialis s emphasize ha he deg ee o maxilla y
e usion is a e lec ion o he su gical p o ocol o he
ope a i e echnique. Some specialis s belie e ha
closu e o he seconda y pala e should be delayed un il
childhood, despi e s udies o show ha his s a egy can
esul in poo speech. I has been clea ly documen ed
ha adul s wi h un epai ed cle lip/pala e exhibi
no mal acial g ow h (30,31). Repai o bila e al cle
lip/pala e inhibi s maxilla y g ow h, ye he deba e
con inues whe he labial o pala al closu es, o bo h,
Fig. 4. (case 4): A 7 mon hs emale wi h CBCL wi h p o uding p emaxilla and pala e cle . (A) P eope a i e an e-
io iew. (B) Occlusal in a-o al iew, showing ome o-p emaxilla y su u e and he si e o he wedge os ec omy
o he ome . (C) Occlusal in a-o al iew, showing he wedged os eo omized ome . (D) Pos ope a i e esul s on
an e io iew (1 mon h pos ope a i ely).
AB
D
C
Med O al Pa ol O al Ci Bucal. 2015 Jul 1;20 (4):e500-7. Repai o comple e bila e al cle lip
e506
a e esponsible. Also Be kowi z e al. (32) has epo ed
ha ea ly p eope a i e o hopedics leading buccal bi e
o he p emaxilla wi h conca e acial p o iles wo sen
wi h ime.
Wi h limi ed in o ma ion in he li e a u e abou
ollow-up s udies o CBCL wi hou any p eope a i e
o hopedics, his s udy showed he ou come posi ion o
he p emaxilla and he lip epai esul s. In all ou ou
pa ien s, applying his al e na i e ea men o child en
wi h CBCL and p o uded p emaxilla wi hou any
p eope a i e o hopedic, we can success ully pe o m,
in a single-s age su ge y, a good p ima y lip epai a
ou cen e . Single-s age p ima y ope a ion is ela i ely
easie o pe o m, as he e a e no sca ed issues. The
ome ine os ec omy acili a e subsequen bila e al lip
epai and adequa e muscula epai , which is i al o
labial unc ion. Simul aneous gingi ope ios eoplas y on
bo h sides p o ides be e s abili y and alignmen o he
a ches in addi ion o he bila e al closu e o he al eola
gap. Using Millad II echnique achie es an excellen
symme y o he lip, p olabium and Cupid’s bow as
well as good sca s. No complica ions we e documen ed.
Doing his ome ine os ec omy, we don’ know how i
will a ec he subsequen g ow h o he p emaxila and
es ic he na u al maxilla y g ow h, bu as desc ibed
be o e, i is essen ial o b ing he p emaxilla y
se back in alignmen wi h he la e al segmen so ha
subsequen al eola bone g a ing and o hogna hic
p ocedu es i equi ed can be pe o med. In addi ion
many adolescen s wi h epai ed bila e al cle lip need
maxilla y ad ancemen o imp o e p ojec ion o he
nasal ip, o p o ude he uppe lip, and o a ain no mal
sagi al skele al ha mony. Howe e , we a e suppo e s o
pe o ming ea ly su ge y, assuming he sequels o be
co ec ed la e bu a o ing he be e de elopmen o
language and aes he ics du ing childhood (14,15,29).
Conclusions
Applying his al e na i e ea men o child en
wi h CBCL and p o uded p emaxilla wi hou any
p eope a i e o hopedic, we can success ully pe o m,
in a single-s age su ge y, a good p ima y lip epai a
ou cen e . Fu he con i ma ions o his su ge y wi h
ollow up and an h opome ic s udies o hese pa ien s
du ing childhood and adolescence a e equi ed.
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