READERS' FORUM
Letters to the editor* Yuanyuan Jiang Qiaoling Ma Huang Li Nanjing, China
Comprehensive treatment for an adult with bilateral cleft lip and palate
W
ith interest, we read about the comprehensive treatment approach of a patient with bilateral cleft lip and palate in the January 2015 issue of the Journal (Kokai S, Fukuyama E, Sato Y, Hau JC, Takahashi Y, Harada K, et al. Comprehensive treatment approach for bilateral cleft lip and palate in an adult with premaxillary osteotomy, tooth autotransplantation, and 2-jaw surgery. Am J Orthod Dentofacial Orthop 2015;147:11426). We really appreciated the authors' efforts for bringing up this new approach including premaxillary osteotomy combined with alveolar bone grafting and autotransplantation of a tooth with complete root formation to the grafted bone region. However, we have 2 concerns about the study, focusing on the necessity of the 2-jaw surgery. First, the authors mentioned that “her facial profile was concave, with a flat nose and protrusion of the upper and lower lips” but failed to notice that the patient has a straight profile considering the N, Sn, and Pos points on the same line.1 The patient's so-called concave profile is mostly due to her flat nose. Besides, from the pretreatment cephalometric measurements, the patient is skeletal Class I and has a normal angle. We don't think it was necessary to do 2-jaw surgery, and we are curious about the effect of the 2-jaw surgery to dramatically improve the patient's profile. Second, from the facial photographs, the patient's mandibular deviation is not obvious, and the upward canting of her occlusal plane is partly due to her posterior crossbite. The authors mentioned the mandibular deviation toward the right of approximately 8.0 mm before the treatment but failed to show the cephalometric analysis after surgery. What's more, the authors only showed pretreatment radiographs, and readers might mistakenly think that facial asymmetry can't be resolved without surgery. As shown in Figure 5, C and D, the asymmetrical midline of the mandibular arch was already improved to some extent. Was it really necessary to have 2-jaw surgery instead of camouflage? As a bilateral cleft lip and palate patient, she would have already undergone a series of surgeries in childhood, so is it really better for the patient? *The viewpoints expressed are solely those of the author(s) and do not reflect those of the editor(s), publisher(s), or Association.
Am J Orthod Dentofacial Orthop 2015;147:643 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.03.009 REFERENCE 1. Proffit WR, Fields HW Jr, Sarver DM. Contemporary orthodontics. 4th ed. Philadelphia: Elsevier; 2007.
Authors' response
F
irst, we wish to express our appreciation to Drs. Yuanyuan Jiang, Qiaoling Ma, and Huang Li for their insightful comments. We hope that their comments and our reply will remind readers to consider the best treatment option for each particular patient in the future. As pointed out, the patient had a skeletal Class I relationship, not Class III. However, the primary treatment goals for this patient were to “reposition the premaxilla by osteotomy to reduce the size of the alveolar defects and improve the retroclined maxillary incisors” and “reconstruct alveolar defects by bone grafting.” In this case report, the minimal expansion of the posterior segments and the surgical repositioning of the premaxilla enabled us to minimize the alveolar defects, and we observed a sufficient alveolar bone ridge. If we did not perform 2-jaw surgery, including retraction of the mandible, theoretically, the combination of the alternative treatments would require simultaneous expansion of the collapsed posterior segment, repositioning of the retroclined premaxilla, and improvement of the canted occlusal plane. However, these multisegmented osteotomies were associated with a risk of poor blood supply postoperatively. Thus, after a full consultation with the patient, we selected a step-bystep approach, including 2-jaw surgery. We believe that this method of treatment was good in terms of stability of grafted bone, reduction of the surgical risk of the maxilla, stability of the occlusion, and improved facial asymmetry. As shown in Figure 5, C and D, the asymmetry of the mandible was not improved. Also, the molar relationships on both sides were Class I. However, this was 643
Letters to the editor* Yuanyuan Jiang Qiaoling Ma Huang Li Nanjing, China
Comprehensive treatment for an adult with bilateral cleft lip and palate
W
ith interest, we read about the comprehensive treatment approach of a patient with bilateral cleft lip and palate in the January 2015 issue of the Journal (Kokai S, Fukuyama E, Sato Y, Hau JC, Takahashi Y, Harada K, et al. Comprehensive treatment approach for bilateral cleft lip and palate in an adult with premaxillary osteotomy, tooth autotransplantation, and 2-jaw surgery. Am J Orthod Dentofacial Orthop 2015;147:11426). We really appreciated the authors' efforts for bringing up this new approach including premaxillary osteotomy combined with alveolar bone grafting and autotransplantation of a tooth with complete root formation to the grafted bone region. However, we have 2 concerns about the study, focusing on the necessity of the 2-jaw surgery. First, the authors mentioned that “her facial profile was concave, with a flat nose and protrusion of the upper and lower lips” but failed to notice that the patient has a straight profile considering the N, Sn, and Pos points on the same line.1 The patient's so-called concave profile is mostly due to her flat nose. Besides, from the pretreatment cephalometric measurements, the patient is skeletal Class I and has a normal angle. We don't think it was necessary to do 2-jaw surgery, and we are curious about the effect of the 2-jaw surgery to dramatically improve the patient's profile. Second, from the facial photographs, the patient's mandibular deviation is not obvious, and the upward canting of her occlusal plane is partly due to her posterior crossbite. The authors mentioned the mandibular deviation toward the right of approximately 8.0 mm before the treatment but failed to show the cephalometric analysis after surgery. What's more, the authors only showed pretreatment radiographs, and readers might mistakenly think that facial asymmetry can't be resolved without surgery. As shown in Figure 5, C and D, the asymmetrical midline of the mandibular arch was already improved to some extent. Was it really necessary to have 2-jaw surgery instead of camouflage? As a bilateral cleft lip and palate patient, she would have already undergone a series of surgeries in childhood, so is it really better for the patient? *The viewpoints expressed are solely those of the author(s) and do not reflect those of the editor(s), publisher(s), or Association.
Am J Orthod Dentofacial Orthop 2015;147:643 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.03.009 REFERENCE 1. Proffit WR, Fields HW Jr, Sarver DM. Contemporary orthodontics. 4th ed. Philadelphia: Elsevier; 2007.
Authors' response
F
irst, we wish to express our appreciation to Drs. Yuanyuan Jiang, Qiaoling Ma, and Huang Li for their insightful comments. We hope that their comments and our reply will remind readers to consider the best treatment option for each particular patient in the future. As pointed out, the patient had a skeletal Class I relationship, not Class III. However, the primary treatment goals for this patient were to “reposition the premaxilla by osteotomy to reduce the size of the alveolar defects and improve the retroclined maxillary incisors” and “reconstruct alveolar defects by bone grafting.” In this case report, the minimal expansion of the posterior segments and the surgical repositioning of the premaxilla enabled us to minimize the alveolar defects, and we observed a sufficient alveolar bone ridge. If we did not perform 2-jaw surgery, including retraction of the mandible, theoretically, the combination of the alternative treatments would require simultaneous expansion of the collapsed posterior segment, repositioning of the retroclined premaxilla, and improvement of the canted occlusal plane. However, these multisegmented osteotomies were associated with a risk of poor blood supply postoperatively. Thus, after a full consultation with the patient, we selected a step-bystep approach, including 2-jaw surgery. We believe that this method of treatment was good in terms of stability of grafted bone, reduction of the surgical risk of the maxilla, stability of the occlusion, and improved facial asymmetry. As shown in Figure 5, C and D, the asymmetry of the mandible was not improved. Also, the molar relationships on both sides were Class I. However, this was 643
