[Therapeutic approach to cleft lip-maxilla-palate: for normal facial growth. A protocol and various technics to restore nasal respiration].

By contrast with the poor maxillary growth following primary surgery in infancy, unoperated adult cleft lip and palate subjects are known to have good facial growth. There is a strong consensus to consider that scarring from primary surgery is the main cause of this problem, particularly scarring from secondary epithelialization of denuded palatal bone, or of closure of the cleft in one layer. In an attempt to improve the outcome of facial growth, a lot of protocols have developed but, currently, none of them appears more valid and the differences between them are more in favor of the personal influence of each surgeon and his team. We are not in agreement with the widely spread opinion attributing the poor results to a severe hypoplasia which could explain the cleft itself. Actually, these patients have a normal potential of growth, but they need normal functions to show it. We think that oral breathing, so frequent among these patients, is enough to explain their poor growth. Over the past 22 years, we have tried to restore, with encouraging results, a nasal breathing mode, as early as 6 years of age, through precise secondary surgery of the nostril and the septum. But with experience, we have concluded that changing the first habit of oral breathing into a nasal one is particularly difficult in cleft patients, and that a nasal mode of breathing should be established once the primary surgery, in order to avoid compensation mechanisms and their consequences. For the last 6 years, our current protocol has allowed to achieve consistently this objective, with an evident influence on the outcome of the growth of the maxilla in complete unilateral and bilateral clefts. A longer follow-up is necessary to confirm it, but henceforth, all those who know the essential role of nasal breathing for a normal facial growth should endorse this process.