07-09-2011-13h_david s precious_vitoria
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DDS MSc FRCDC FICD FACD FRCS(Eng) Dhc Dean Emeritus Professor, Oral and Maxillofacial Surgery Dalhousie University, Halifax, Nova Scotia, Canada David S Precious CM Dalhousie University Founded in 1818 Beautiful Scenery Warm and Gracious Colleagues Delicious Food Good Drinks!! I WANT TO BE BRAZILIAN! BRAZILIAN! CLUBE ATLETICO MINEIRO VENCER,VENCER, VENCER!TRANSCRIPT
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
Muito Obrigado