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CLINICAL STUDY

A Digital Assessment of the Maxillary Deformity

Correction in Infants With Bilateral Cleft Lip and Palate
Using Computer-Aided Nasoalveolar Molding
Xin Gong, MS, Jun Zhao, PhD, Jiawei Zheng, PhD,y and Quan Yu, PhD
and palate cases present variation in severity and form. Wider clefts
Objectives: To evaluate the maxillary alveolar repositioning of the with nasolabial deformity have more deficient hard and soft tissue
infants with bilateral cleft lip and palate (BCLP) undergoing elements, which present a surgical challenge to achieve valuable
computer-aided nasoalveolar molding (CAD-NAM). function and aesthetic. The outcomes of bilateral repairs have
Methods: A total of 19 BCLP infants undergoing CAD-NAM were historically been dissatisfactory due to the resultant deformity or
recruited as the treatment group, and 21 nonpresurgically treated new problems of malfunction. The deformities include wide phil-
BCLP patients served as controls. The upper alveolar morphology trum, a tight upper lip, broad and flat nose, widened scars, and
was measured and evaluated. Changes in all variables between pre- whistle deformities.2 Minimal cleft deformities may have better
and post-CAD-NAM were compared. treatment outcomes. The aim of presurgical nasoalveolar molding
Results: By the end of CAD-NAM, significant difference was (PNAM/NAM) is to reduce the severity of initial cleft deformity.
However, the benefits of presurgical premaxilla positioning with an
found in the P-A, P’-A’, and L-ideal midline (P < 0.01); in the
intraoral device remain controversial because of the possible pro-
sagittal dimensions, significant difference was found in the P-TT’, blems of maxillary growth inhibition.1
P’-TT’, I-TT’, A-X, and A’-X’ (P < 0.01), while in the vertical Since the 1960s, presurgical orthopedic therapy has been widely
dimensions, significant difference was found in the alveolus height used around the world as a noninvasive option for improving nasal
in the bilateral canine regions (P < 0.01). symmetry before primary repair of a cleft lip, and a series of
Conclusion: Computer-aided nasoalveolar molding can effectively presurgical approaches have been developed. Latham device was
reduce the cleft gap, correct the alveolar midline deviation, and developed to actively reposition the lateral alveolar cleft segments
retract the projection and outward rotation of the premaxilla and retract the protruded premaxilla.3 Grayson and Cutting devel-
segment, and normalize the contour of the alveolus. oped a contemporary PNAM appliance, a device different from the
traditional intraoral alveolar molding equipments.4 Orthodontists
have to adjust the acrylic appliance by differential addition or
Key Words: Bilateral cleft lip and palate, nasoalveolar molding, removal of the leading edge of the maxillary segments at weekly
reverse engineering, three-dimensional analysis appointments. The nasal stents create a ‘‘tissue expander’’ effect on
the length of the columella. Presurgical nasoalveolar molding
(J Craniofac Surg 2017;00: 00–00) therapy is considered effective for the treatment of wide bilateral
cleft lip and palate (BCLP). Innovations of this technology have

C left lip and palate deformities are the most common congenital
abnormalities of the head and neck.1 Advancements in the
various multidisciplinary fields involved in cleft management have
generated a variety of techniques for medical imaging such as laser
surface scanning and three-dimensional (3D) virtual model con-
struction in recent years.5 In our previous study, we modified the
substantially improved functional and aesthetic outcomes. Cleft lip Grayson NAM therapy and designed a computer-aided NAM
(CAD-NAM) procedure using reverse engineering and rapid pro-
totyping technique.6 The aim of the current study was to introduce
From the Department of Orthodontics; and yDepartment of Oral and the CAD-NAM therapy and evaluate its effectiveness on the
Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong maxillary alveolar repositioning in infants with BCLP.
University School of Medicine, Shanghai Key Laboratory of Stomatol-
ogy, Shanghai, China. METHODS
Received September 11, 2016.
Accepted for publication March 16, 2017.
Address correspondence and reprint requests to Quan Yu, PhD, Department Subjects
of Orthodontics, Ninth People’s Hospital, Shanghai Jiao Tong In the present study 19 infants with complete BCLP were
University School of Medicine, Shanghai Key Laboratory of Stoma- enrolled as the treatment group. The subjects included 11 males
tology, 639 Zhi-Zao-Ju Road, Shanghai 200011, China; and 8 females, and had a mean age of 11.6 days. Twenty-one infants
E-mail: quanyu122@vip.sina.com; Jiawei Zheng, PhD, Department of with complete BCLP who did not undergo any presurgical ortho-
Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao
pedic treatments were recruited as controls. The controls included
Tong University School of Medicine, Shanghai Key Laboratory of
Stomatology, 639 Zhi-Zao-Ju Road, Shanghai 200011, China; 15 males and 6 females, and had a mean age of 185.3 days. A
E-mail: davidzhengjw@sjtu.edu.cn maxillary impression was taken by an orthodontist aided by a
This study received financial support from the National Natural Science surgeon at the first examination as soon as possible after birth.
Foundation of China (grant no. 81271182) and Shanghai Summit and
Plateau Disciplines, China. Ethical Statement
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD This research was approved by the Ethics Review Committee of
ISSN: 1049-2275 Shanghai Ninth People’s Hospital affiliated to Shanghai Jiao Tong
DOI: 10.1097/SCS.0000000000003812 University, School of Medicine, and the protocol of treatment was in

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Gong et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

accordance with the Declaration of Helsinki. Photographs and

participation in the study were authorized by the patients’ parents.
Informed consent was obtained from all participants with a detailed
description of the purpose and benefits from the study.

Computer-Aided Nasoalveolar Molding

Treatment Procedure
Stone cast date was acquired by a Vivid910 3D laser scanner
(Konica Minolta Holdings, Tokyo, Japan). The digital geometrical
3D model was judged by the geometric data using a Rapid Form
XOR3 reverse engineering software system (Inus Technology,
Seoul, South Korea) (Fig. 1). The whole NAM procedure was
designed and divided into 16 to 20 steps in the Rapid Form
XOR3 with the treatment objectives. A scale model was printed
by the rapid prototyping system when the treatment protocol was
formulated. Then, the whole series of appliances were created. Each
pair of the NAM device consisted of a 2 mm dental plate and 2
retentive buttons. Orthodontic elastics (0.25 inch and 3.5 oz) are
secured around the retentive buttons and to the cheek with adhesive FIGURE 2. The nasal molding started after the premaxilla has been returned to
tape. The infants’ parents were required to change 1 step of the the keystone position.
appliances each week. Subsequently, the nasal molding phase
started after the premaxilla was retracted to the keystone position
within the maxillary arch (Fig. 2). The NAM and columella Statistical Analysis
elongation required 5 to 6 months of active treatment prior to lip All measurement data were expressed as mean, standard devi-
repair.7 ation, and all statistical analyses were performed using the statisti-
cal software SPSS version 15.0 (SPSS Inc, Chicago, IL).
Differences in all variables between pre- and post-CAD-NAM were
Measurement Method tested for statistical significance using paired t test, and the differ-
A 3D laser scanner was employed to capture the objective and ences between the treatment and control groups before the lip repair
quantitative data of the physical characteristics of the cleft maxilla surgery were compared with the independent samples t test. The
in infants with BCLP. All parameters were measured by 2 inde- differences between measurement and mean values were used
pendent orthodontists. The linear measurements were determined to determine the method error according to Dahlberg formula
using a modified protocol as previously described by Seckel et al.8,9 (d2 ¼ Sd2/2n). Error estimation using the method error according
The landmarks were defined as follows: I, incisory point; P, most to Dahlberg was less than the reference value of 1.0 mm for all
lateral points of the premaxilla; A, most anterior points of the measurement values. A P value <0.05 was considered statistically
alveolus; C, lateral sulcus point; Q, point where the lateral sulcus significant.
intersects the gingival groove; T, tuberositas point of the alveolus.
The horizontal reference plane was confirmed based on 3 points,
including the vestibular groove bottom of the upper lip frenum, the RESULTS
left lateral vestibular groove bottom of the alveolar ridge, and The subjects in both groups had a similar gender distribution. The
the right lateral vestibular groove bottom of the alveolar ridge. infant with CAD-NAM started treatments at a mean age of 11.6 days.
These 3 points constituted the horizontal reference plane. All linear Descriptive statistical analysis for all variables is displayed in Table 2,
measurements are illustrated in Figure 3. The landmarks designated and comparison of all parameters in the treatment group before and
to indicate the changes of the maxillary alveolar shape and position
between pre- and post-CAD-NAM are shown in Table 1 and Figures
3 and 4.

FIGURE 1. The digital model of the maxillary alveolar was analyzed by the FIGURE 3. The landmarks of the maxillary alveolar tissue morphology
Rapidform XOR3 software. measurements were described in Table 1.

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 Maxillary Deformity Correction

TABLE 1. Definition of Landmarks and Measurements

Abbreviation Definition

Landmarks
I The crest of the ridge on the line drawn from labial frenum to
the incisive papilla (incisory point).
P/P’ Most lateral point of the premaxilla.
A/A’ Most anterior point of the alveolus.
C/C’ Lateral sulcus point
Q/Q’ Point where the lateral sulcus intersects the gingival groove.
T/T’ The tuberosity and the crest of the ridge were outlined on the
model, and the junction of these lines was called T and T’. FIGURE 4. The 2 patients of the measurement A to X. If alveolar border of the
L The labial frenum point. lateral segment is positioned anterior to the premaxilla segment, this
F/F’(Canine points) Canine points are the intersection of the groove of the lateral measurement is negative; otherwise, positive measurement should be
labial frenum and the crest of the ridge. If the infant does anticipated.
not have any buccal frenum at the area of deciduous
canine, we took the crest of the alveolar bridge in
deciduous canine region as the position of canine point.
A-T/A’-T’ The crest of the alveolar ridge. DISCUSSION
X/X’ Intersection of the transverse line from point A (parallel to Bilateral cleft lip and palate is recognized as a condition in which
the T-T’) with the perpendicular from the T-T’ to point P. the premaxilla is suspended from the tip of the nasal septum and the
M/M’ A perpendicular was erected from the T-T’ to the point I, at lateral alveolar segments and lip elements remain behind. The
the level of the bisection of this distance, a line parallel to severe anterior projection of the premaxilla and footplates of
the base line was drawn, reaching the crest of the alveolar
ridges of both segments. The intersections of this the medial crura, combined with tethering of the lateral crura, pulls
transverse line with the outlines of the alveolar crest on the nasal domes widely apart, and down into the lip. The lateral
both sides were labeled points M and M’, respectively. displacement of the alar cartilage domes contributes to a widened
Measurements alar base, flattened nose, and a short or absent columella. Finally,
Transverse dimensions the muscle-free prolabium seems to draw the foreshortened colu-
P-X Transverse and oblique width of anterior cleft, which is the mella down, widening and distorting the nostrils.10–12 Although
transverse relation of pre- and lateral maxilla segment. many protocols for treating infants with cleft lip and palate have
When segments are separated at alveolar cleft and A is
farther from Y than X, reading is positive. In situation been successful, the severely wide deformities often require a
where lateral segment overlaps cleft segment, that is, X is multidisciplined team approach.13
farther from Y than A’, reading is negative. Continued advancement in the comprehensive care of children
P-A (cleft gap) Distance between point P and A. with cleft lip and palate has resulted in numerous innovative
M-M’ Middle arch width. treatment approaches. The cooperation of multidisciplinary spe-
L-ideal midline Transverse distance of the labial frenum deviation. cialties has continued to expand the options for treatment of patients
Sagittal dimensions with difficulty in cure. Due to many different treatment philos-
P/P’-TT’ Anteriorposterior maxilla alveolar length of the bilateral ophies, the presurgical orthopedic (PSO) treatment interventions
segments. are considerably variable among cleft centers.14– 16 Facial taping
I-TT’ Anterioposterior length of the whole maxilla alveolar. with elastic devices may be used for the application of selective
A-X Anterioposterior relation of the premaxilla segment to the external pressure, and may allow for improvement of lip and nasal
bilateral segments. If alveolar border of the lateral
segment is positioned anterior to the premaxilla segment, position before the lip repair procedure. Such a technique has
this measurement is negative; otherwise, positive greater impact in patients of wide BCLP, in which manipulation
measurement should be anticipated. of the premaxilla segment may make primary repair technically
Vertical dimensions easier. Some surgeons prefer PSO appliances rather than lip taping
I height The maxilla arch height in the incisor region, distance from to achieve similar goals. Presurgical orthopedic appliances are
point I to the horizontal reference plane. composed of a custom-made acrylic base plate that provides
F height The maxilla arch height in the canine region, distance from improved anchorage in the molding of lip, nasal, and alveolar
point F’ to the horizontal reference plane.
structures during the presurgical phase of treatment. Presurgical
orthopedic also add significant cost and time to treatment early in
the child’s life. Frequent appointments are necessary for monitoring
of the anatomic changes and periodic appliance adjustment. The
after CAD-NAM is shown in Table 3. In the transverse dimensions, Grayson NAM appliance has become popular with some centers
significant difference was found in the P-A, P’-A’, and L-ideal with attempts to manipulate the segments without pin retention
midline (P < 0.01); in the sagittal dimensions, significant difference before lip and nose repair.17 The NAM appliance is adjustable by
was found in the P-TT’, P’-TT’, I-TT’, A-X, and A’-X’ (P < 0.01), removing or adding acrylic and manipulating protrusive elements
while in the vertical dimensions, significant difference was found in that attempt to mold the nasal cartilages. By orderly restoration of
the alveolus height in the bilateral canine regions (P < 0.01). By the nasoalveolar anatomy, the craniofacial surgeon can avoid alar rim
end of CAD-NAM treatment, the 3 alveolar segments were reposi- overexpansion. The intraoral appliances used to move the alveolar
tioned in a proper arch form in most patients. The posterior lateral segments together. This is purported to lead to improved nasal
alveolar segments were aligned and the premaxilla was retracted to a appearance, limited maxillary growth disturbance, and fewer forth-
normal position. Table 4 presents the comparison of independent- coming procedures. The use of NAM is a valuable tool in treating
samples t test results between the CAD-NAM treatment group and the the wide unilateral and BCLP. The benefits of NAM include
control group. Figure 5 shows a typical patient from the CAD-NAM nonsurgical columellar elongation, definition of the nostril aper-
treatment group and the changes in the lip and the maxillary cast tures, stretching of the intranasal lining to permit tension-free
during the course of treatment. approximation of the dome cartilage in the midline, and provision

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TABLE 2. The Descriptive Statistics Analysis of the Digital Model Measurement

Treatment Group Pretreatment (n ¼ 19) Treatment Group Posttreatment (n ¼ 19) Control Group Presurgery (n ¼ 21)

Mean Std. Deviation Min Max Mean Std. Deviation Min Max Mean Std. Deviation Min Max

Age (d) 11.632 8.706 3.000 35.000 194.053 16.910 161.000 232.000 185.273 14.192 169.000 208.000
Transverse dimensions
P-X 4.848 4.097 2.524 14.617 2.646 3.432 0.000 11.313 3.122 3.312 0.699 11.275
P’-X’ 3.600 3.197 0.937 12.019 2.838 2.043 0.000 7.253 3.140 2.284 1.293 6.829
P-A 13.176 2.931 9.355 21.267 6.678 5.143 0.000 15.241 11.727 2.703 8.302 18.189
P’-A’ 14.705 2.654 9.765 19.941 9.108 4.294 0.000 14.877 12.570 2.149 7.610 14.767
M-M’ 40.138 2.212 36.459 43.983 40.274 3.759 28.165 48.213 39.900 2.355 36.800 44.536
L-ideal midline 3.495 1.600 1.401 6.865 1.352 0.798 0.000 3.263 2.792 1.159 1.731 4.981
Sagittal dimensions
P-TT’ 30.655 2.506 25.970 33.637 26.533 3.362 21.451 33.358 29.430 2.553 24.897 33.005
P’-TT’ 32.167 3.014 25.856 36.694 27.611 3.260 22.401 33.708 30.985 2.096 27.099 33.300
I-TT’ 32.568 2.045 27.913 36.198 27.867 2.331 23.754 32.184 31.688 2.602 26.897 34.746
A-X 10.915 2.980 4.437 16.012 5.422 4.107 0.000 10.950 10.191 2.856 5.304 13.997
A’-X’ 13.199 2.733 7.764 17.525 7.743 3.839 0.000 12.179 11.882 2.297 7.039 15.005
Vertical dimensions
I height 5.957 1.304 3.748 8.483 5.606 1.739 4.122 11.031 6.869 2.347 3.641 10.683
F height 5.531 1.009 3.811 7.642 4.649 0.745 3.369 6.571 5.630 1.510 3.090 7.979
F’ height 5.387 1.168 2.967 7.904 4.574 1.239 2.241 7.428 5.753 1.076 3.974 7.455

of convexity to the lateral crura of the lower lateral cartilages.18 By dental plate and a nasal stent. The remolding force is realized
approximating the nostril apices, nasoalveolar molding produces through the tissue surface of the appliance. Digitally based man-
additional columella elongation by recruitment of nasal apex skin ufacturing provides consistency, fine quantitative control, and
inside the nasal tip, forming a soft triangle. Nasoalveolar molding is speed over manual methods.6,7 The purpose of this applied research
reported to ideally begin before 6 weeks of age to utilize the early was to develop a digital system for designation and production of
plasticity of the nasal cartilages.19–21 the NAM therapy, and evaluate the effectiveness of CAD-NAM
In a previous report, we modified the Grayson NAM therapy and therapy on the maxillary alveolar repositioning in infants with
designed a CAD-NAM procedure, and the appliances consisted of a BCLP. Treatment plan and appliance design were accomplished
with a CAD technique, which enabled accurate analysis of the
amount of movement in multiple planes. The digital 3D model of
TABLE 3. The Paired-Samples t Test of the Variables in the Treatment Group the upper denture was constructed using laser scanning to make the
(Pretreatment Versus Posttreatment) diagnosis and measurement of the upper alveolar morphology. By
95% Confi- applying the laser scanning device, objective and quantifiable data
dence Interval pertaining to the physical characteristics of the cleft maxilla in
of the BCLP infants were captured. The digital geometrical 3D model was
Difference judged using the Rapid Form XOR3 software system. The assess-
Standard ments revealed that the CAD-NAM therapy significantly corrected
Mean Deviation Lower Upper t Sig. (2-Tailed) the deformity of the maxillary alveolus and arch. In the transverse
dimensions, the changes of the P-A, P’-A’, and L-ideal midline
Transverse dimensions
indicated that the width of the alveolar cleft decreased with NAM,
P-X 4.848 4.097 0.241 4.163 2.359 0.03
and the outward rotation of the premaxillary segment was corrected.
P’-X’ 3.600 3.197 0.692 2.215 1.101 0.285
The upper denture midline deviation was also corrected, and our
P-A 13.176 2.931 3.973 9.021 5.408 0.000y
findings are similar to previous studies.4,17,19 In the sagittal dimen-
P’-A’ 14.705 2.654 3.944 7.251 7.113 0.000y
sions, the decreases of P-TT’, P’-TT’, I-TT’, A-X, and A’-X’
M-M’ 40.138 2.212 1.820 1.548 0.170 0.867
indicated that the sagittal arch length of the anterior arch decreased
L-ideal midline 3.495 1.600 1.310 2.976 5.406 0.000y
and the projection of the premaxilla segment was retracted signifi-
Sagittal dimensions
cantly. The contour of the alveolus was normalized without collapse
P-TT’ 30.655 2.506 2.635 5.607 5.826 0.000y
of the alveolar segments. In terms of transverse dimension, to
P’-TT’ 32.167 3.014 3.482 5.630 8.913 0.000y
compensate for the widening of alveolar width as patients continued
I-TT’ 32.568 2.045 3.766 5.635 10.563 0.000y
to grow, the CAD-NAM procedure was designed not only to
A-X 10.915 2.980 3.417 7.569 5.560 0.000y
maintain the width of the maxilla, but also to compensate for the
A’-X’ 13.199 2.733 4.026 6.884 8.023 0.000y
alveolar growth in each appliance. The arch width grew slightly
Vertical dimensions
from posttreatment (M-M’) in the treatment group. Since the
I height 5.957 1.304 0.467 1.168 0.901 0.380
maxillary alveolus of BCLP cases may originate with alveolar
F height 5.531 1.009 0.574 1.188 6.035 0.000y
tissue defects, the goal of NAM treatment is only to correct
F’ height 5.387 1.168 0.385 1.240 3.994 0.001y
the alveolar segments as a normal arc and not intentional to reduce
 the cleft gap, so as not to have a deleterious effect on the transverse
P < 0.05.
y
P < 0.01.
growth of the alveolus. In the vertical dimension, the alveolus
height of the bilateral canine regions declined significantly

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TABLE 4. The Independent-Samples t Test of the Variables Between the Treatment Group (Posttreatment) and Control Group (Presurgery)

Treatment Group Posttreatment Control Group Presurgery Independent Sig.

(n ¼ 19) (n ¼ 21) Samples t (2-Tailed)

Mean Standard Deviation Mean Standard Deviation

Transverse dimensions
P-X 2.646 3.432 3.122 3.312 0.371 0.714
P’-X’ 2.838 2.043 3.140 2.284 0.374 0.711
P-A 6.678 5.143 11.727 2.703 3.009 0.005y
P’-A’ 9.108 4.294 12.570 2.149 2.487 0.019
M-M’ 40.274 3.759 39.900 2.355 0.296 0.769
L-ideal midline 1.352 0.798 2.792 1.159 4.029 0.000y
Sagittal dimensions
P-TT’ 26.533 3.362 29.430 2.553 2.468 0.020
P’-TT’ 27.611 3.260 30.985 2.096 3.072 0.005y
I-TT’ 27.867 2.331 31.688 2.602 4.148 0.000y
A-X 5.422 4.107 10.191 2.856 3.394 0.002y
A’-X’ 7.743 3.839 11.882 2.297 3.241 0.003y
Vertical dimensions
I height 5.606 1.739 6.869 2.347 1.686 0.103
F height 4.649 0.745 5.630 1.510 2.392 0.024
F’ height 4.574 1.239 5.753 1.076 2.631 0.014


P < 0.05.
y
P < 0.01.

posttreatment. But there was no significant difference in the incisor

region, indicating that the vertical growth of the lateral segments
was inhibited during the CAD-NAM procedure. The inhibition is
likely to result from vertical component forces of the retention tapes
during the treatment period. It is a temporary growth inhibition.
The alveolus may continue to grow vertically when the forces
were removed. The alveolus height may return to normal when the
deciduous canines erupt.
This characteristic differs from the situation in patients with
UCLP.22 It is therefore suggested that the inhibition of the alveolar
growth is mainly present in the canine regions of BCLP infants.
Such an inhibition on upper alveolar growth may be an inevitable
complication. This disadvantageous effect is believed to be a
temporary growth inhibition. The alveolus may continue to grow
vertically following the lip repair surgery. However, the long-term
effect of the NAM on upper alveolar growth remains unclear.
Although PNAM using a CAD technique simplifies the conven-
tional presurgical orthopedic therapy, it depends on the modifi-
cation of the surgical procedure to repair the cleft.

CONCLUSIONS
This study evaluated the changes of maxillary alveolar morphology
seen in BCLP infants undergoing CAD-NAM. The assessments
indicated that CAD-NAM could effectively reduce the cleft gap,
correct deviation of the alveolar midline, and retract the premax-
illary segment. In addition, the projection and outward rotation of
the premaxillary segment was corrected, and the contour of the
alveolus was normalized. Computer-aided nasoalveolar molding
allows repositioning of the maxillary alveolus and the surrounding
soft tissues which make it possible that nonsurgical approximation
of the cleft lip segments may limit wound tensions and result in less
surgical scar. However, CAD-NAM may inhibit the alveolar growth
in the upper canine regions. The multidisciplinary management
FIGURE 5. A typical case of a 10-day-old boy with complete bilateral cleft lip
should be emphasized as the aesthetic and functional management
and palate, pre and postpresurgical computer-aided nasoalveolar molding often includes much more than surgical cleft repair alone.
treatment. Computer-aided nasoalveolar molding is therefore considered an

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Gong et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

excellent addition to a cleft lip and palate team’s armamentarium 10. Broadbent TR, Woolf RM. Cleft lip nasal deformity. Ann Plast Surg
although extremely challenging. Further studies to evaluate the 1984;12:216–234
permanence of improvement in maxillary alveolar morphology and 11. Millard DR Jr. Embryonic rationale for the primary correction of
soft tissue appearance using CAD-MAN seem justified. classical congenital clefts of the lip and palate. Ann R Coll Surg Engl
1994;76:150–160
12. Stenstrom SJ, Oberg TR. The nasal deformity in unilateral cleft lip.
ACKNOWLEDGMENTS Some notes on its anatomic bases and secondary operative treatment.
Many thanks are delivered to all participants joining in this study. Plast Reconstr Surg Transplant Bull 1961;28:295–305
13. Millard DR Jr. Closure of bilateral cleft lip and elongation of
columella by two operations in infancy. Plast Reconstr Surg 1971;
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6 # 2017 Mutaz B. Habal, MD

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