Stoke Mandeville Abstracts

ABSTRACTS : GENERAL SESSION 1

16.45 VELOPHARYNGEAL INSUFFICIENCY FOLLOWING VERY EARLY PALATAL REPAIR M Copeland, S N Desai Stoke Mandeville Hospital
A review of a ten year period (1976-1986) revealed that of the 235 consecutive cleft lip and palate patients who had palate repair at 4 months at this Unit, a total of 24 (10%) were identified as having velopharyngeal insufficiency. The surgical treatment was a Hynes pharyngoplasty in all cases.
Tonsillectomy preceded the Hynes procedure in 9 cases. Outcomes, based on a speech assessment prior to surgery and at least 8 months after pharyngoplasty, show that postoperatively, 19 (8%) patients achieved acceptable speech. The amount of change and the difference in outcomes between the group who had tonsillectomy prior to pharyngoplasty and the group who had pharyngoplasty only is also discussed.

17.15 ASSESSMENT OF VELOPHARYNGEAL CLOSURE BY MEANS OF NASAL-ORAL AIRFLOW RATIOMETRY H R Mirlohi, S W Kelly University of Kent, Canterbury
Approaches to the screening of velopharyngeal closure are divided into two major streams of: a) Direct measurement of velopharyngeal port (e.g., Lateral Video Fluoroscopy and Nasoendoscopy and b) Measurement of consequence of the closure. Aerodynamic studies are amongst the most widely utilised techniques of the latter type. Nasal air flow measurement, as an aerodynamic study tool, is employed to detect the excessive nasal emission which occurs as a result of inadequate velopharyngeal closure. The strong dependence of nasal airflow on the subject's respiration has been realised for some time now. This has given rise to the need for a new method to be devised. This paper describes a new technique, where by application of the Nasal and Oral airflow to the function (Nasal-Oral)/(Nasal+Oral), a signal is obtained whose characteristic is inherently independent of the respiratory pattern and amplitude. A dedicated electronic hardware unit together with a comprehensive software package has been designed and developed to implement the desired algorithm.

17.00 PALATE RE-REPAIR - CLINICAL ASSESSMENT AND COMPUTER ANALYSIS OF PALATAL MOVEMENT B C Sommerlad*, M Henley*, K Harland*, M Birch** C Humphreys**,
J Boorman*** * St Andrew's Hospital Billericay, ** The Royal London Hospital, ***Queen Victoria Hospital East Grinstead
Palatal re-repair with muscle retropositioning may be an alternative to pharyngoplasty and provides some insight into palatal muscular function. Almost 150 re-repairs have been performed by a single surgeon, the last 33 cases having been studied pre- and post-operatively by a combination of speech assessment, resonometry, nasendoscopy and lateral videofluoroscopy.
Palatal movement has been quantified by computer analysis of the rate of closure and extensibility of the velum, giving an objective view of change in palatal function and demonstrating significant improvement in nasal escape and resonance as well as in the degree and rate of palatal closure. To date, only one of the 33 has gone on to a subsequent pharyngoplasty. Predictive factors include the degree of closure of the velum and its relative movement with different sounds. Operative factors correlating with surgical results include the bulk of musculature assessed at operation and the use of the operating microscope.
We believe that these results indicate a need for radical muscle correction in the primary cleft repair. Palate re-repair should be considered as the first line operation for velopharyngeal incompetence.

17.30 LATERAL VIDEOFLUOROSCOPY - A MODIFICATION TO AID IN VELOPHARYNGEAL ASSESSMENT AND MEASUREMENT B C Sommerlad, N Rowland, K Harland St Andrew's Hospital Billericay
By the use of a child's toy (a 3D View-master), the value of lateral videofluoroscopy in the assessment of velopharyngeal function has been greatly increased. The advantages include:
1. Increasing the enjoyment and decreasing the fear for children.
2. Providing prompts to encourage younger and less co-operative children to talk.
3. Reducing unwanted head movement.
4. Standardising head position in relation to rotation.
5. Protecting eyes from irradiation.
6. Enabling a microphone to be placed unobtrusively at a fixed distance close to the mouth.
7. Enabling accurate measurements to be taken by standardising the distance of the velum from both tube and spot film device and by using an object of known diameter, set in the plane of the velum, as a standard.

17.45 HOW BAD WAS THAT CLEFT TO START WITH?
J G Boorman Queen Victoria Hospital East Grinstead

Two techniques are described as aids to better recording of the extent of a deft prior to surgery and to make long term studies and comparison of results easier.
1. Taking a soft tissue impression, using Silastic foam whilst the baby is undergoing cleft repair which can be cast in plaster to provide a permanent record. This is quick and safe provided certain steps are followed.
2. A cleft severity scoring system which describes the salient points of the cleft in the form of a 3 digit code which is easy to computerise. One digit represents the primary palate and lip for each side and one the secondary palate.

18.00 AN IN-DEPTH ASSESSMENT OF 10 CONSECUTIVELY TREATED CASES OF UNILATERAL CLEFT LIP AND PALATE FOLLOWING NEONATAL PRIMARY REPAIR F B Christie*,
D Stirrups**, A Downing*** *Stoke Mandeville Hospital,
**Dundee University, ***Glasgow Dental Hospital
Introduction - This paper reports on the cephalometric analysis and clinical findings of cases now aged approximately 16 years having had neonatal primary repair.
Method - 10 consecutive cases have been analysed using the anatomical landmarks used by Ross (CPJ 1987) in order that a comparison could be made with the similar samples from Ross' study. The cases are also compared to a control group of non-cleft but British caucasian children. The numbers and types of surgical procedures are discussed also the timing and methods of orthodontic treatment.
Results - The analysis shows that growth and development of the facial complex is disturbed and there is a retardation of the middle third with altered posture of the mandible when compared to the control non-cleft group.
Conclusions - Growth and development in the neonatal group is average when compared with other cleft palate groups.

18.15 ANTERIOR CRANIAL FOSSA TUMOURS W Jaffe, P Richards, N Waterhouse Charing Cross Hospital London
Between 1990 and 1992 we have treated 19 patients with anterior cranial fossa tumours. These patients cover a wide spectrum of pathology and mode of presentation.
The surgical treatment of these patients is discussed with particular relevance to the use of galeal, pericranial and temporalis flaps; access osteotomies and cranial facial bone grafting techniques.
The result of surgery of these patients will be discussed both in terms of functional and aesthetic outcome and survival.

ABSTRACTS : GENERAL SESSION 2

09.00 THE ROLE OF TENSOR PALATI IN PALATE FUNCTION M Henley, B C Sommerlad, N Moleman St Andrew's Hospital Billericay
Dissection of the cleft musculature, using the operating microscope, in 50 palate repairs and re-repairs, suggested that adequate retropositioning of the levator palati muscle requires dissection also of the tensor palati.
To determine the normal anatomy of the tensor palati, ten cadaver dissections of en bloc palate specimens have also been performed under the operating microscope. These show considerable variability but the common factor was some attachment of the tensor tendon to the hamulus, with limited mobility and therefore little effect on the palatal aponeurosis.
Dissection of the tensor tendon and palatal aponeurosis medial to the hamulus would appear, therefore, not to be likely to compromise the probable major role of the tensor palati - its role in eustachian tube function.

O9.15 EAR RECONSTRUCTION O T Gault Mount Vernon Hospital Northwood
The results of ear reconstruction have improved greatly in recent years. Even in difficult circumstances, due to previous surgery, a satisfactory ear can be produced using carved autogenous vestal cartilage. This technique is applicable both for microtia and post traumatic cases. Many patients wishing autogenous ear reconstruction are not offered this technique as the results have in the past been deemed unsatisfactory. This review presents the results of 40 cases where a carved costal cartilage framework has been inserted for ear reconstruction.

09.30 THE SURGICAL CORRECTION OF HYPERTELORISM (Video) W Jaffe, P Richards, N Waterhouse Charing Cross Hospital London
Moderate to severe degrees of hypertelorism arc best treated by a transcranial technique. This video charts the management and surgery of an 8 year old who has moderate hypertelorism with an intraorbital wall distance of 35 mm. With the aid of operative footage and computer graphics the crucial steps in the surgery are described.
Finally, the patient is shown postoperatively having a short interview with her mother allowing further insight into the problems and anxieties faced by families involved with this condition.

09.45 IS THERE AN INDICATION FOR GLOSSOPEXY? J W Mulder Medisch Centrum Leeuwarden The Netherlands
A patient is described with asphyxia immediately after birth, who had a small median palatal cleft. The tongue slipped into the nasal cavity when she swallowed. The indications for glossopexy are questioned.

10.00 TATTOOING AS AN ADJUNCT TO SURGICAL LIP CORRECTION P H M Spauwen, !1 C S Janssen-Braeks
University Hospital Nijmegen The Netherlands
Tattooing has become increasingly popular in plastic surgery. Intradermal pigmentation placed by traditional tattoo methods and equipment may be used as an adjunct to surgical correction of lip deformities. Cooperation between the surgeon and an experienced skin therapist contributes to improving the end result. Preceding the permanent tattoo, the skin therapist simulates the desired correction using camouflage techniques. We treated patients having scars in the upper lip skin and insufficient height of the vermilion following treatment of cleft lip. Also irregularities of the cutaneo-vermilion junction after burns and dog bites were treated. The procedure will be demonstrated. Results are encouraging.

1O.15 THE NEED FOR ORTHOGNATHIC SURGERY IN PATIENTS BORN WITH COMPLETE CLEFT PALATE OR COMPLETE UNILATERAL CLEFT LIP AND PALATE K Panula, B B J Lovius, O A Pospisil Walton Hospital Liverpool
Few studies have addressed the need for orthognathic surgery in cleft lip and palate patients. The results reported in these studies show wide variation due to differences in criteria for patient selection and requirement for orthognathic surgery.
The need for orthognathic surgery was assessed in 23 patients with complete cleft palate or complete unilateral cleft of lip and palate between the ages of 14 and 20 years. This was based on a subjective assessment of soft tissue morphology, cephalometric analysis, and dental study model analysis. 48% of patients were assessed as requiring orthognathic surgery, 39% did not need orthognathic surgery, and 13% were borderline. Timing and technique of primary surgery and number of operative procedures had no significant effect on subsequent need for orthognathic surgery.
This study demonstrates that approximately half of patients with cleft palate or cleft lip and palate require orthognathic surgery. The implications of this will be discussed in relationship to current practice.

ABSTRACTS : GENERAL SESSION 3

11.0 DYNASTY CHEEKS R A C A Voorsmit University Hospital Nijmegen The Netherlands
Augmentation of the hypoplastic zygoma is one of the most challenging surgical procedures for oral and maxillofacial as well as plastic and reconstructive surgeons. Well-defined prominent cheekbones have always been a classic sign of beauty in our culture. Since Linda Evans and Joan Collins featured on TV in "Dynasty", more women became aware of the fact that well-contoured cheekbones can contribute to the harmony and balance of facial proportions.
It is surprising that the prominence and the shape of the malar regions have received so little attention. Most of the few previous publications concerned insertion of alloplastic or sometimes autogenous materials using a skin incision.
This paper deals with our experiences in augmentation of the cheekbones by means of a sophisticated intra-oral technique. The zygoma is partially osteotomized, a greenstick fracture is created and autogenous bone of the chin is exactly interpositioned to achieve prominent and symmetrical cheekbones. The method has shown only advantages so far, including a predictable result with a harmonious contour, no visible scars and almost no bone resorption due to the sandwich instead of on lay technique. In our opinion this technique is the method of choice for people who have the sneaking desire to have beautiful Dynasty cheeks.

11.15 AUDIT OF PRE-OPERATIVE SWABS IN CLEFT LIP AND PALATE V Cheong, B Bertagne, I Taggart, N Mercer, R W Pigott
Frenchay Hospital Bristol
The practise of pre-operative surveillance swabs is mainly historic without any proven medical advantages. Positive swabs cause considerable organisational disadvantages and patient inconvenience.
A retrospective audit was carried out of all patients undergoing primary repair of cleft lip and palate by one surgeon over a two year period to determine the compliance, the incidence and treatment of post-operative complications. There was no correlation between positive swabs and post-operative complications.

11.30 SPEECH DEVELOPMENT IN CHILDREN WITH CLEFT LIP AND PALATE: CONTINUITY, HETEROGENEITY AND RATE OF CHANGE V J Russell, P Grunwell Birmingham Children's Hospital
This paper presents some of the results of a longitudinal study of the speech development of children with cleft palate from 0.9 to 4.6. The aim was to investigate the extent to which the cleft palate condition affects the nature and chronology of speech development. Eight children's pre-speech and speech development were studied in depth. In the pre-speech data there was evidence of phonetic deviance characteristic of cleft palate speech. These Characteristics were still present in the pronunciation patterns at the early word stage thus revealing a continuity in the speech development of these children. The children resolved these deviant speech patterns at different stages. All the children achieved normal or near normal speech patterns, but the rate of change varied. Whilst there are common tendencies in this population, there is also considerable individual variation. These results confirm the heterogeneous nature of speech development in children with cleft palate.

11.45 GROWING UP WITH A CLEFT E Bradbury Withington Hospital Manchester
This paper examines the psychosocial impact of growing up with a cleft, and the intereaction between parental adjustment and the child's psychological well-being.
As part of a wider study, 13 families of older children with clefts were assessed using detailed interviews and standard psychological measures. The assessment focused on parental adjustment, and on the childrens' self esteem, social experience and behaviour.
It was found that although none of the children were psychologically disturbed, the experience of a cleft was difficult for them. They were less socially competent and more defensive than their peers, and suffered more anxiety, although they were less likely to exhibit difficult behaviour.
There was a significant relationship between parental adjustment and the children's problems. Those whose parents were poorly adjusted experienced more difficulties.
Psychological intervention will be described, and an early screening measure to assist in the identification of poorly adjusted parents
will be presented.

12.00 PSYCHOSOCIAL ADJUSTMENT IN ADULT CLEFT PATIENTS B B J Lovius, D Wilkie P D Slade, M Dewey Liverpool University Dental Hospital
This study used quantitative and qualitative methods to examine various aspects of childhood and adolescent development and subsequent psychosocial adjustment in 10 adults with repaired clefts (mean age 27.9 years). Body satisfaction scale (Slade et al 1990) was used to assess satisfaction/dissatisfaction with 16 body parts. Social Avoidance and Distress (SAD)and Fear of Negative Evaluation (FNE) Scales (Watson and Friend 1969) were used to provide measures of social anxiety. The Hospital Anxiety and Depression Scale (Zigmond and Snaith 1983) and the General Health Questionnaire (Goldberg 1978) were also used. Interviews lasted about 45 minutes and were audio taped. The results showed that in terms of psychosocial adjustment, the individuals were relatively well adjusted, though 30% had GHQ and SAD scores a little raised. The interviews established that in 35% of subjects there was a general lack of confidence with four features common to these subjects, namely teasing, feeling different or isolated from their peer group and difficulty in making friends. The overwhelming view of the sample was the need of a counselling service operating at an informal level.

ABSTRACTS : GENERAL SESSION 4

13.30 CRITERIA FOR THE EVALUATION OF CLEFT LIP SURGERY J W Mulder Medisch Centrum Leeuwarden The Netherlands
In judging the results of our efforts for the patient, we will always subconsciously refer to our concept of people without a cleft. In several studies, a scale for attractiveness is used for comparison of treatment methods. Several artists, surgeons and orthodontists have reported studies on anthropometric maxillofacial esthetic measurements of normal and attractive adults.
The proportion index as described by Farkas was used as a guideline to judge the results of cleft lip surgery. Only the balance of the lower face is taken into account.
A. The height of the upper lip, skin area and red area together should be 30% of the total of the lower face. (too low less than 25%, too high more than 40%)
B. The width of the mouth should not exceed the interpupilar distance, and be wider than the base of the nose.
C. The dimensions of the red upper lip should not exceed those of the lower lip in height, and should not be smaller than 50% of the lower lip.
In a series of 36 patients these criteria are demonstrated.

13.45 A REVIEW OF 350 CONSECUTIVE CLEFT PALATE REPAIRS AT FOUR MONTHS S N Desai Stoke Mandeville Hospital
In any discussion on the surgical repair of cleft palate, one question recurs again and again: at what age should the cleft palate be repaired? - and I would add, what technique to be used? In this Plastic Surgery Unit it is a matter of policy that clefts of the primary palate (cleft lip) should be repaired within 48 hours of birth; cleft palate at the age of 4 months, and wherever possible, pharyngoplasty for VPI before the child reaches 6 years of age. The technique used in our unit is based on Veau repair. Hamulus is always fractured and in complete clefts vomerine flaps are routinely used. 235 cleft palates were repaired up to 1987; this group provides a reliable statistical analysis. 91 had clefts of the primary palate whilst 144 had cleft of the secondary palate. 24 children from this group required pharyngoplasty - Hynes pharyngoplasty.
5 children had poor results, whilst 19 children had accepted intelligibility and speech.
9 children had tonsillectomy prior to pharyngoplasty, this group had better speech results. None of the children had deafness. Details are discussed in the paper.

14.00 OTOPATHOLOGY IN CLEFT PALATE PATIENTS A L Mansbach, P Deltenre, A Demey Children's Hospital Reine Fabiola Brussels Belgium
More than 200 Cleft palate infants between the age of O to 20 months were tested by tympanometry and ABR. Auditory pathologies were found in over 8O % of these children, with median and worst auditory thresholds at about 4O-45 dB and 65 dB, based on a series of 22O ABR measurements. These results did not vary significantly with age or cleft palate repair. We also found a very high incidence of cow milk allergy. Considering the risks inherent in early auditory deprivation, the children were treated before 1 year of age, by insertion of ventilating tubes.

14.15 SOME ENT ASPECTS OF EARLY CLEFT PALATE PATIENTS A L Mansbach, P Deltenre, A Demey
Stoke Mandeville Hospital
A 13 year review has been made of ENT problems in cleft lip and palate children. The middle ear function has been assessed by tympanometry from birth. All of these children had normal aeration of the middle ear at birth and remained normal until complications began to occur at 17 weeks. Closure of the palatal defect is known to reduce middle ear complications and it would appear that closure at, or before 4 months of age, significantly reduces these complications.
If secretory otitis media is present at the time of palatal closure grommets should be inserted. There is a high incidence of multiple grommet insertion associated with fistulae with rhinitis. In these patients if the fistulae are not to be repaired for some time, long term grommets should be inserted.
Sinusitis was uncommon in the children who had early cleft palate repair. The few children who had sinusitis also had fistulae with rhinitis.

ABSTRACTS : CIRCA PRESENTATIONS

09.00 BIOMETRICS 2O00 S Powell, P Wells, J Herold, S Marshall, C Bishop St George's Hospital London, National Engineering Laboratory East Kilbride and AEA Research Laboratories (Harwell)
Craniofacial diagnosis and therapeutics remain essentially empirical at the present time. Much of the theory is based on anecdotal case reports and individual treatment prejudices which, although successful with the individual case, leave much to be desired for the complete range of treatment within the spectrum of variations presenting. Until biometrics are available for the whole of the diagnosis and treatment planning triage and particular typal groups identified based on measured rather than assumed criteria, craniofacial therapeutics will remain essentially empirical.
The Ortho family of software has been formulated and developed at St George's Hospital in conjunction with the National Engineering Laboratory, East Kilbride and AEA Research Laboratories (Harwell). The aim is to present an interlinked package of automated computerised biometrics. For the first time this will give the practising clinician or researcher measured parameters of facial growth, facial appearance, change consequent upon growth or treatment and many developmental typal groups, thus placing the practice of craniofacial surgery on a scientific rather than an empirical basis. The software programme includes:
1. Orthopoint: computerised cephalometrics/anthropometrics.
2. Orthonet: automated computerised landmark capture.
3. Orthomorph: computerised facial topography,
4. Orthobase: computerised clinical case analysis.
These interlinked programmes will be described, emphasising their functionality and clinical and research interface potential.

09.15 MYCOTIC INFECTIONS OF THE CRANIAL BASE J McGlashan, D L G Hill, S E Studholme, T C S Cox, D J Hawkes, A J Strong, J Gleeson Guy's Hospital London (computer imaging paper)

09.30 BIZARRE EYE MOVEMENTS IN CRANIOSYNOSTOSIS: IS THERE AN EXPLANATION? H Cheng*, L Benjamin**
* Oxford Eye Hospital, ** Stoke Mandeville Hospital
Abnormalities of eye movements are common in children with craniofacial disorders. This is especially so in Cruzon's and Apert's syndrome, but also simple plagiocephaly can also result in abnormal orbit and ocular movements. Attempts at explaining these abnormal movements have been made over the years and we have recently looked at alterations in the orbital and extra ocular muscle anatomy in some of these patients, to try to delineate the problem further. MRI and video techniques are employed to image the structures involved and wilt be shown. Another reason for presenting this data is to obtain more information from the Craniofacial Society special interest group, on other techniques that may be available.

O9.45 FACIAL SURFACE REFERENCE POINTS AND THE DETECTION OF THREE-DIMENSIONAL SHAPE CHANGE DURING ORTHODONTIC TREATMENT A Naftel University of Central Lancashire, Preston
In recent years a number of imaging systems have been proposed for capturing 3-D facial surface measurements. However, these systems have yet to be widely adopted by clinicians for the analysis of soft tissue changes during orthodontic treatment
This talk describes work carried out at Preston which aims to develop an objective technique for quantifying these shape changes. The method uses "centres of area" and a statistical "best fit" to match facial surfaces captured at different time intervals. It has low reliance on the designation of anatomical points which are difficult to locate accurately. Deformations induced by swelling, for example, can be evaluated and the results superimposed over the computer-reconstructed face. Facial surface capture is accomplished using a low-cost stereo vision system employing video cameras interfaced to a personal computer. The finished system should be useful to orthodontists and maxillo-facial surgeons planning corrective treatment

10.O0 ORBITAL AND CRANIAL MORPHOLOGY IN CLEFT LIP AND PALATE P D Hodgkinson*, G P Rabey**
* Newcastle General Hospital ** Stoke Mandeville Hospital
The morphology of the orbits and cranium was studied in 164 adults with all types of cleft lip and/or cleft palate. Using morphanalytic techniques including computer graphic spatial statistics, the degree of deformity was accurately quantified and the significant differences from a normal group were identified. Significant lateralisation of the medial but not the lateral parts of the eyes and orbits was found in all groups of patients with any type of cleft lip but not in groups with cleft palate only. These changes were associated with a change in form of the orbit and also with a difference from normal in the position of the structures of the anterior cranial base. Calvarial form was significantly different from normal in cleft lip and palate and isolated cleft palate but to a small degree. No consistent asymmetries of orbital or cranial morphology were found in association with asymmetric cleft deformities.

11.00 THE USES OF 3D IMAGING IN THE TREATMENT OF CRANIOFACIAL PATIENTS J P Moss*, A D Linney**, J Joffe**, S R Grindrod** *The Royal London Hospital ** University College London

11.15 FACE TO FACE WITH 3D LASER SCANNING - AN INITIAL EXPERIENCE P G Budny, M D Poole Radcliffe Infirmary Oxford
A UCL optical surface scanner has been in use as a clinical evaluation tool at the Oxford Plastic and Craniofacial Unit for one year. This computer graphics system is a response to an ever increasing demand for objectivity in the assessment of facial surgery by means of three-dimensional imaging and analysis technology. The method of use of the scanner and its likely potential are discussed with reference to a number of areas of clinical interest.

11.30 LASER IMAGING AND IMAGE RECONSTRUCTION: THEIR APPLICATION IN CRANIOFACIAL MORPHANALYSIS N O Duffy*, G P Rabey**, J Lokier***, R N Bodley** * Heriot-Watt University Edinburgh ** Stoke Mandeville Hospital *** University of Oxford

A method of using scanned laser imaging is described which provides a relatively simple means of capturing 3D surface data for use by craniofacial specialists. The imaging is carried out in such a manner that it provides results in a coordinate frame of reference which ensures compatibility with other imaging modalities such as MR and CT. The incorporation of the laser scanning system into an analytic morphograph is described. The images are converted into a format suitable for use by the Mayo ANALYZE package, for processing and interpretation and for combination and comparison with other images.

11.45 INTERACTING WITH AND MEASURING 3D MEDICAL IMAGES N Robinson CN Software Southwater Sussex

12.00 TOWARDS STANDARDISED AND UNIVERSALLY RELATED CRANIOFACIAL IMAGES: THE CENTRAL PROBLEM AND A SOLUTION G P Rabey*, R N Bodley*, N D Duffy**, J Lokier*** * Stoke Mandeville Hospital ** Herict-Watt University Edinburgh
*** University of Oxford
The current state of craniofacial imaging is briefly summarised, the principal barrier to a new generation of images is described, and a simple solution to the impasse is recommended.

ABSTRACTS : GENERAL SESSION 5

13.3O CLEFT TRIPLETS (17 YEAR FOLLOW UP) W Jaffe, N Waterhouse
Charing Cross Hospital London
The incidence of cleft lip and palate rises with a family history. We present three 17 year olds born to a mother with a cleft lip and palate. All these triplets had one form or another of cleft lip and palate. Their family history and a full description of their surgery is described. To our knowledge this is the only reported case of triplets in which clefting affected all the siblings.

13.45 THE CELLULAR CONTROL OF MANDIBULAR FORM - A REVIEW WITH CLINICAL EXAMPLES J Mew London
While it is widely accepted that mandibular form is under genetic control, it is hard to understand how its shape and direction of growth can vary so widely. This paper presents a review of the literature on the subject exploring the control of growth, at both the macroscopic and cellular level. Clinical examples are given of changes in the direction of facial and mandibular growth, and the associated changes in form that are seen at the pogonion, lower border and ascending ramus. The nature of "these changes will be considered, and possible explanations for them offered.

14.O0 A PRELIMINARY REPORT ON THE DIFFICULTIES ENCOUNTERED DURING NEONATAL CLEFT PALATE IMPRESSIONS, AMONGST UK CONSULTANT ORTHODONTISTS BETWEEN 1983 - 1992 R A C Chate Essex County Hospital Colchester
While presurgical cleft palate treatment with orthopaedic plates remains controversial, neonatal maxillary impressions are still widely performed. This procedure, however, is not without its inherent risks, and as a consequence, a curve y of the United Kingdom Consultant orthodontists was undertaken, to audit any untoward incidents over the last decade.
The data gathered includes the number of "collapses" which required paediatric cardiopulmonary resuscitation, the number of alarming cyanotic episodes, the number of impression material fragmentations which lead to a respiratory obstruction, and the number of occasions when removal of the impression was extremely difficult.
The relative risks for each will be expressed as a percentage of the total number of impressions taken during this period. The associations between the type of impression material used, the positioning of the neonate during the procedure, the different cleft types, and the operator fluency will also be examined, and discussed.

14.15 AN ASSESSMENT OF THE DENTAL ARCH RELATIONSHIP IN THE UNILATERAL COMPLETE CLEFT LIP AND PALATE CASE FOLLOWING NEONATAL PRIMARY REPAIR F 8 Christie*, M Mars** * Stoke Mandeville Hospital ** Hospital for Sick Children London
Introduction - Concern has been expressed about the possible ill effects of the early surgical correction on growth and development of the facial skeleton in cleft cases. This study allows a comparison to be made with the six-centre international study of the treatment outcome, researched in 1992. In these centres conventional timing for primary closure has been practised (Ref CPJ 1992 Vol 29 No 5).
Discussion - 50 Consecutively treated cases have been analysed. The method chosen was the analysis of orthodontic study models using the Goslon Yardstick analysis.
Results - Analysed results indicate that the neonatal group compares favourably with other British groups.
Conclusion - In terns of dental arch relationship, neonatal repair is neither more nor less detrimental to maxillary protrusion in British studies.

14.30 TIMING OF HARD PALATE CLOSURE AND TREATMENT OUTCOME A M Kuijpers-Jagtman*, A E M Noverraz*, M M Mars**
* University of Nijmegen The Netherlands ** Hospital for Sick Children London
In a mixed longitudinal study dental arch relationships of 88 consecutive UCLP patients, treated at the Nijmegen Cleft Palate Centre, were evaluated using the Goslon Yardstick. Four stages of dental development were distinguished: deciduous dentition, first and intertransitional period, second transitional period and permanent dentition. Based on the timing of hard palate closure, the material was divided into 4 groups. Mean age of hard palate closure in group A was 1.5 year, in group B 4.6 year and in group C 9.4 year. In group D the hard palate was still open. Differences between groups were tested with the Chi-square test, one way ANOVA and paired t-tests.
Reproducibility of scoring with the Goslon Yardstick was good for alt stages of dental development. No differences in dental arch relationships were found between the four groups. In 86 percent of the cases, dental arch relationships of UCLP patients, treated in Nijmegen, were acceptable. Pharyngeal flap surgery gave minor unfavourable effects on dental arch relationships.
It was concluded that in this groups of patients timing of hard palate closure was not an important factor with respect to dental arch relationships.

14.45 THE BUCCAL FAT PAD FOR CLOSURE OF ORO-NASAL COMMUNICATIONS IN CLEFT PATIENTS R A C A Voorsmit
University Hospital Nijmegen The Netherlands
Oro-nasal communications in cleft patients are usually closed by transposition of pedicled mucoperiosteal flaps, whether or not in combination with an osteotomy. In secondary cleft surgery we are sometimes dealing with defects which are so large or so scarred by previous surgical interventions that mobilization of the flaps may be difficult and/or vascularization unreliable. Therefore, in those cases it may be hazardous to close the oro-nasal communication the conventional way. Utilization of the buccal fat pad as a pedicled graft to close these defects has proven to be a good alternative on other methods. This paper deals with our experiences in seven patients, four males and three females, with a mean age of almost 30 years and with a mean follow-up of approximately four years. Historical aspects, anatomy, surgical technique and results will be presented and discussed. Surgical advantages of this method include: same area of operation, mobilization of more than enough fatty tissue with a great flexibility, a pedicled and reliable well-vascularized graft with a good epithelialization and no side-effects. No additional bone resections as necessary in some other techniques, and no visible scars and contour deformations are additional advantages for the patient. The method described has shown no disadvantages so far and is, therefore, in some selected cases worth consideration.