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XXI COBRAC Vit贸ria-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 University Founded in 1818


Beautiful Scenery


Warm and Gracious Colleagues


Delicious Food


Good Drinks!!


I WANT TO BE BRAZILIAN!


CLUBE ATLETICO MINEIRO 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 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 agenesis, but of failure of the facial processes to fuse



The muscles of the divided liplip-nose and soft palate are present on the sides of the cleft



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


ANATOMY GROWTH


DEFINE PROBLEM

3-D FUNCTIONAL ANANTOMY


NASAL SEPTUM


NASAL SEPTUM IS ACTIVE GROWTH CENTRE OF THE FACE Delaire, J. and Precious, D.S.: The Influence of the Nasal Septum on Maxillonasal Growth in Congenital LabioMaxillary Clefts. Cleft Palate Journal, 23:270277, 1986.


Human Fetus 21 weeks


MEDIAL CRUS LOWER LATERAL CARTILAGE

NASAL SEPTUM


PREMAXILLA


NASAL SEPTUM-PREMAXILLA SUBJECT TO MUSCLE DISSYMMETRY Delaire, J. and Precious,D.S.: 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. 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 ANS Tongue


NASAL SEPTUM

CONCAVE SIDE Fewer and Smaller Chondrocytes

CONVEX SIDE 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 Lip Repair


Hard 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 BIG FIVE


THE BIG 5

Primary lip/nose surgery must achieve THE BIG 5 1. 2. 3. 4. 5.

Straight septum Symmetrical N/L muscles No vestibular fistula Patent, functional nostril Symmetrical soft palate muscles


MILLARD


DELAIRE


How? 

Primary Lip Repair at 55-6 months


How? 

Primary Lip Repair at 55-6 months


How? 

Primary Lip Repair at 55-6 months


How? 

Primary Lip Repair at 55-6 months x x


How? 

Primary Lip Repair at 55-6 months


The Advantage of Wide Subperiosteal Exposure in Primary Surgical Correction of Labial Maxillary Clefts Delaire J, Precious D, Geordeff A University 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, Kristina Deltcheva, Michael Menger University of Saarland, Homberg, Germany

J Oral Maxillofac Surg 63:87-92 2005


Note integrity of maxillary labial frenum Waterproof closure of nasal mucosa and functional airway


Septo-premaxillary Traction System


Septo-premaxillary Traction System


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


LH 6 mos 1988


LH 16 yrs 2007


LH 16 yrs 2007


Thank you for your kind attention

Muito Obrigado


07-09-2011-13H_DAVID S PRECIOUS_VITORIA