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Background The authors present outcomes analysis of the nasoalveolar molding treatment protocol in patients with a cleft followed from birth to facial maturity. Methods A single-institution retrospective review was conducted of cleft patients who underwent nasoalveolar molding between 1990 and 2000. Collected data included surgical and orthodontic outcomes and incidence of gingivoperiosteoplasty, alveolar bone grafting, surgery for velopharyngeal insufficiency, palatal fistula repair, orthognathic surgery, nose and/or lip revision, and facial growth. Results One hundred seven patients met inclusion criteria (69 with unilateral and 38 with bilateral cleft lip and palate). Eighty-five percent (91 of 107) underwent gingivoperiosteoplasty (unilateral: 78 percent, 54 of 69; bilateral: 97 percent, 37 of 38). Of those patients, 57 percent (52 of 91) did not require alveolar bone grafting (unilateral: 59 percent, 32 of 54; bilateral: 54 percent, 20 of 37). Twelve percent (13 of 107) of all study patients underwent revision surgery to the lip and/or nose before facial maturity (unilateral: 9 percent, six of 69; bilateral: 18 percent, seven of 38). Nineteen percent (20 of 107) did not require a revision surgery, alveolar bone grafting, or orthognathic surgery (unilateral: 20 percent, 14 of 69; bilateral: 16 percent, six of 38). Cephalometric analysis was performed on all patients with unilateral cleft lip and palate. No significant statistical difference was found in maxillary position or facial proportion. Average age at last follow-up was 20 years (range, 15 years 4 months to 26 years 10 months). Conclusions Nasoalveolar molding demonstrates a low rate of soft-tissue revision and alveolar bone grafting, and a low number of total operations per patient from birth to facial maturity. Facial growth analysis at facial maturity in patients who underwent gingivoperiosteoplasty and nasoalveolar molding suggests that this proposal may not hinder midface growth. Clinical question/level of evidence Therapeutic, IV.

Background Three-dimensionally-printed bioceramic scaffolds composed of β-tricalcium phosphate delivering the osteogenic agent dipyridamole can heal critically sized calvarial defects in skeletally mature translational models. However, this construct has yet to be applied to growing craniofacial models. In this study, the authors implanted three-dimensionally-printed bioceramic/dipyridamole scaffolds in a growing calvaria animal model and evaluated bone growth as a function of geometric scaffold design and dipyridamole concentration. Potential adverse effects on the growing suture were also evaluated. Methods Bilateral calvarial defects (10 mm) were created in 5-week-old (approximately 1.1 kg) New Zealand White rabbits (n = 16 analyzed). Three-dimensionally-printed bioceramic scaffolds were constructed in quadrant form composed of varying pore dimensions (220, 330, and 500 μm). Each scaffold was coated with collagen and soaked in varying concentrations of dipyridamole (100, 1000, and 10,000 μM). Controls consisted of empty defects. Animals were killed 8 weeks postoperatively. Calvariae were analyzed using micro-computed tomography, three-dimensional reconstruction, and nondecalcified histologic sectioning. Results Scaffold-induced bone growth was statistically greater than bone growth in empty defects (p = 0.02). Large scaffold pores, 500 μm, coated in 1000 μM dipyridamole yielded the most bone growth and lowest degree of scaffold presence within the defect. Histology showed vascularized woven and lamellar bone along with initial formation of vascular canals within the scaffold lattice. Micro-computed tomographic and histologic analysis revealed patent calvarial sutures without evidence of ectopic bone formation across all dipyridamole concentrations. Conclusion The authors present an effective pediatric bone tissue-engineering scaffold design and dipyridamole concentration that is effective in augmentation of calvarial bone generation while preserving cranial suture patency.

The authors present an outcomes analysis of mandibular distraction osteogenesis versus tongue-lip adhesion in the surgical treatment of Pierre Robin sequence.A retrospective, 15-year, single-surgeon review was undertaken of all nonsyndromic neonates with Pierre Robin sequence treated with mandibular distraction osteogenesis (2004 to 2009; n = 24) or tongue-lip adhesion (1994 to 2004; n = 15). Outcomes included time of extubation, length of intensive care unit stay, incidence of tracheostomy, and surgical complications. Polysomnography data were collected 1 month and 1 year postoperatively. Sleep study data included changes in oxygen saturation and apnea-hypopnea index.There were no postprocedure tracheostomies in the mandibular distraction osteogenesis group and four tracheostomies in the tongue-lip adhesion group. The preoperative oxygen saturations were significantly lower in the mandibular distraction osteogenesis group compared with tongue-lip adhesion (76.5 percent versus 82 percent; p0.05). Preoperative apnea-hypopnea index was significantly higher in the mandibular distraction osteogenesis group compared with the tongue-lip adhesion group (47 versus 37.6; p0.05). Despite these preoperative differences, patients undergoing mandibular distraction osteogenesis demonstrated significantly higher oxygen saturation levels at 1 month (98.3 percent versus 87.5 percent; p0.05) and 1 year postoperatively (98.5 percent versus 89.2 percent; p0.05) and lower apnea-hypopnea index at 1 month (10.9 versus 21.6; p0.05) and 1 year postoperatively (2.5 versus 22.1; p0.05) compared with tongue-lip adhesion. Surgical complications were comparable between the two groups.In nonsyndromic patients with Pierre Robin sequence, mandibular distraction osteogenesis demonstrates superior outcome measures regarding oxygen saturation, apnea-hypopnea index, and incidence of tracheostomy compared with tongue-lip adhesion.Therapeutic, III.

Frontal sinus cranialization is commonly indicated for posterior table fractures with significant comminution, displacement, or cerebrospinal fluid leaks. This study assessed the clinical outcomes of conservative management.A 10-year retrospective review of all frontal sinus fractures treated at a level 1 trauma center was performed using medical records and radiographic images.A total of 875 patients with frontal sinus fractures were identified, and 68 had posterior table involvement. Nine died within the first 48 hours from other injuries. The remaining 59 patients constituted the study population. Average follow-up approached 1 year (342 days). The more common mechanisms of injury were blunt interpersonal violence (29 percent) and motor vehicle accidents (27 percent). Concurrent central nervous system injury was common (73 percent), and the average Glasgow Coma Scale score was 12.7. Posterior wall fracture pattern was nondisplaced and noncomminuted in 33 patients (54 percent) and comminuted and/or displaced in 27 (46 percent). Cerebrospinal fluid leak was recorded in 11 patients (19 percent). Conservative management was the more common strategy (78 percent), followed by open reduction and internal fixation with sinus preservation (12 percent), obliteration (8 percent), and cranialization (2 percent). Of the 27 patients with comminuted and/or displaced fractures, 16 (59 percent) underwent conservative management, and 11 (41 percent) underwent surgical management, but only one patient (2 percent) underwent cranialization. There was no incidence of intracranial infection, except for one patient who died from encephalitis secondary to a gunshot wound to the head.The vast majority of frontal sinus fractures involving the posterior table, including those with comminution, displacement, or cerebrospinal fluid leaks, can be safely managed without cranialization.Therapeutic, IV.