XXI COBRAC

Vitória-ES 2011

David S Precious CM

DDS MSc FRCDC FICD FACD FRCS(Eng) Dhc

Dean Emeritus

Professor, Oral and Maxillofacial Surgery

Dalhousie University,

Halifax, Nova Scotia, Canada

Dalhousie UniversityFounded in 1818

Beautiful Scenery

Warm and Gracious Colleagues

Delicious Food

Good Drinks!!

I WANT TO BE

BRAZILIAN!BRAZILIAN!

CLUBE ATLETICOMINEIRO

VENCER,VENCER, VENCER!

CLEFT LIP IS REALLY CLEFT-LIP-NOSE

David S Precious CM

DDS MSc FRCDC FICD FACD FRCS(Eng) Dhc

Dean Emeritus

Professor, Oral and Maxillofacial Surgery

Dalhousie University,

Halifax, Nova Scotia, Canada

GOAL

TO CONVINCE YOU THAT PRIMARY SURGERY FOR MANAGEMENT OF CLEFT

LIP AND PALATE IS LIP AND PALATE IS SURGERY OF MUSCLES.

Breach of Superficial Facial Muscles

Breach of Deep Muscles

PHYSIOLOGIC SURGERY FOR CLEFT LIP AND PALATE

�� The congenital gap is not the result of The congenital gap is not the result of agenesis, but of failure of the facial agenesis, but of failure of the facial processes to fuseprocesses to fuse

�� The muscles of the divided lipThe muscles of the divided lip--nose and nose and soft palate are present on the sides of the soft palate are present on the sides of the cleftcleft

�� The quality of the surgical repair depends The quality of the surgical repair depends on the quality of the reconstitution of the on the quality of the reconstitution of the muscles. muscles.

ANATOMY

GROWTH

DEFINE PROBLEM

3-D FUNCTIONAL 3-D FUNCTIONAL ANANTOMY

NASAL NASAL SEPTUMSEPTUM

NASAL SEPTUM IS ACTIVE GROWTH CENTRE OF THE FACE

Delaire, J. and Precious, D.S.:

The Influence of the Nasal Septum on Maxillonasal Septum on Maxillonasal Growth in Congenital Labio-Maxillary Clefts.

Cleft Palate Journal, 23:270-277, 1986.

Human Fetus21 weeks

NASAL SEPTUM

MEDIAL CRUSLOWER LATERALCARTILAGE

NASAL SEPTUM

PREMAXILLA

NASAL SEPTUM-PREMAXILLA SUBJECT TO MUSCLE

DISSYMMETRY

Delaire, J. and Precious,D.S.:

Interaction of the Interaction of the Development of the Nasal Septum, the Nasal Pyramid and the Face.

Int. Jour. of Ped. Otorhinolaryngology,

12:311-326, 1987.

DISSYMMETRIC MUSCLES = CROOKED FACE

Precious, D.S., and Delaire, J.:

Balanced Facial Growth. Balanced Facial Growth.

Oral Surg. Oral Med. Oral Path., 63:637-650, 1987.

Deviation of the Face

Non-Cleft Human Fetus (21 weeks)

CLEFT HUMAN FETUS (21WEEKS)Cleft at birth is not new

Septum

Tongue

Septum

ANS

NASAL SEPTUM

CONVEX SIDEMore and Larger Chondrocytes

CONCAVE SIDEFewer and Smaller Chondrocytes

More and Larger Chondrocytes

Precious, D.S.: Cleft Lip and Palate, in: Fonseca Oral and Maxillofacial Surgery, 7 Volumes. Ed. Fonseca. Vol 6, W.B. Saunders Company. Philadelphia. 2000

Cleft Side

Non-Cleft Side

PRIMARY SURGERY FOR LIP,NOSE,SOFT PALATE AT 5-6 MONTHS OF AGE

Primary Soft Palate at time of Primary Soft Palate at time of Primary Lip Primary Lip RepairRepair

Hard Palate, by about 1 year of ageHard Palate, by about 1 year of age

Precious, D.S: Effective Surgery for Cleft Lip in Current Experimental Study for Treatment of Cleft Lip and Palate. Editors:

N Natsume, T Kawai, D Precious, Quintessence. Chicago, Berlin, Tokyo, London. 2008

MUSCULAR IMBALANCE DISTORTS BOTH SKIN AND MUCOSA

Delaire, J., and Precious, D.: Surgical Considerations of

Mucocutaneous Anomalies in Cleft Lip and Palate.

Scand. J. Plast. Reconstr. Surg. 23:55-72, 1989.

Muscle Surgery >> Skin Surgery

THE THE BIG FIVE

THE BIG 5

Primary lip/nose surgery must achieve THE BIG 51. Straight septum2. Symmetrical N/L muscles3. No vestibular fistula4. Patent, functional nostril5. Symmetrical soft palate muscles

MILLARDMILLARD

DELAIREDELAIRE

How?How?

�� Primary Lip Repair at 5Primary Lip Repair at 5--6 months6 months

How?How?

�� Primary Lip Repair at 5Primary Lip Repair at 5--6 months6 months

How?How?

�� Primary Lip Repair at 5Primary Lip Repair at 5--6 months6 months

How?How?

�� Primary Lip Repair at 5Primary Lip Repair at 5--6 months6 months

x

x

x

How?How?

�� Primary Lip Repair at 5Primary Lip Repair at 5--6 months6 months

The Advantage of Wide

Subperiosteal Exposure in Primary

Surgical Correction of Labial

Maxillary Clefts

Delaire J, Precious D, Geordeff ADelaire J, Precious D, Geordeff AUniversity of Nantes, France and

Dalhousie University Halifax, Nova Scotia

Scand J Plastic Reconstr Surg 22:147, 1988

Reduction of Midfacial Periosteal

Perfusion Failure by Subperiosteal

Versus Supraperiosteal Dissection

Martin Rucker, Thomas Binger, Martin Rucker, Thomas Binger,

Kristina Deltcheva, Michael MengerUniversity of Saarland, Homberg, Germany

J Oral Maxillofac Surg 63:87-92 2005

Note integrity of maxillarylabial frenum

Waterproof closure of nasal mucosa and functional airway

Septo-premaxillary TractionSystem

Septo-premaxillary TractionSystemSystem

Precious, D. S.: Primary Unilateral Cleft Lip/Nose Repair via the Delaire Technique. Atlas of the Oral and Maxillofacial Clinics of North America. ed G.

Ghali. Elsevier, Philadelphia, 17:125-135, 2009.

Muscle Surgery >> Skin Surgery

Precious, D. S.: Primary Bilateral Cleft Lip/Nose Repair via the Delaire Technique. Atlas of the Oral and Maxillofacial Clinics of North

America. ed G. Ghali. Elsevier, Philadelphia, 17:137-146, 2009.

6 months of age

16 years of age

Precious D.S.: Orthognathic Surgery for Patients with Cleft Lip and Palate.Current Therapy in Oral and Maxillofacial Surgery ed R Bell et al. Elsevier, Philadelphia 2011

LH6 mos1988

LH 16 yrs2007

LH 16 yrs2007

Thank you for your kind attention

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