Dental Treatment of Predental and Infant Patients with Clefts and Craniofacial Anomalies

The Facial Growth Pattern and the Amount of Palatal Bone Deficiency Relative to Cleft Size Should Be Considered in Treatment Planning

Background:

The aim of this study is to determine the best surgical/orthodontic treatment plan for the complete bilateral and unilateral cleft lip and palate patient to achieve all treatment goals of facial aesthetics, speech, dental function, and psychosocial development.

Methods:

Review of 40 years of serial complete bilateral cleft lip and palate and complete unilateral cleft lip and palate dental casts and photographs from birth to adolescence, with serial cephs starting at 4 years. This was part of a multicenter international 3-dimensional palatal growth study of serial dental casts of patients who developed good speech, occlusion, and facial growth.

Results:

Nasoalveolar molding and gingivoperiosteoplasty were introduced without proven longitudinal benefits. The procedure bodily retruded the premaxilla, which “telescoped” backward causing synostosis at the premaxillary vomerine suture. The resulting midfacial recessiveness with an anterior dental crossbite can only be corrected by midfacial protraction or a Le Fort I surgery.

Conclusions:

Staged orthodontic/surgical treatment limiting premaxillary retraction forces to lip adhesion or forces that cause only premaxillary ventroflexion produce the best results. The palatal cleft should be closed between 18 and 24 months when the ratio of the cleft to the palatal size medial to the alveolar ridge is at least 10%. The protruding premaxilla should only be ventroflexed but never bodily retruded. The facial growth pattern and degree of palatal bone deficiency are the main items to be considered in treatment planning.

Presurgical nasoalveolar molding in patients with unilateral clefts of lip, alveolus and palate. Case study and review of the literature

INTRODUCTION

The case of a newborn female patient with unilateral cleft lip, alveolus and palate is presented with a markedly sunken nasal wing at the cleft side. This finding may lead to a very unsatisfactory aesthetic result after primary cheiloplasty and nasoplasty.

PATIENT AND METHOD

Five months prior to surgery, the patient was treated with a palatal plate and additionally with a nasoalveolar conformer for 4 months thereof. The device consisted of an acrylic pelotte (attached to the maxillary plate with a wire) which lifted the nasal dome and was activated regularly. Under this presurgical treatment, the cleft edges moved closer to each other by 1.8 mm at the alveolar ridge and by 4.5 mm in the palatal area. The nasal wing was lifted by 5 mm. This was enabling elevation of the nasal wing during primary surgery in the case described. Questions are raised as to the remaining effects on nasal symmetry until completion of growth and, on the other hand, as to the chances to reduce postsurgical alar relapse by continued nasal molding beyond primary surgery.

CONCLUSION

Presurgical nasal molding seems to improve aesthetics of the nose in patients with unilateral clefts of lip, alveolus and palate and distinctly flattend nasal wings.

A feeding obturator for a preterm baby with Pierre Robin sequence

The article describes a clinical and laboratory technique for the fabrication of a feeding obturator for a baby with Pierre Robin sequence. Emphasis is placed on the direct fabrication of a preliminary custom tray, preventing thermal trauma to the tissues, and overcoming the danger of airway obstruction or foreign body aspiration. The functional problems associated with a cleft palate and various methods to overcome them are also discussed.

A modified muscle-activated maxillary orthopedic appliance for presurgical nasoalveolar molding in infants with unilateral cleft lip and palate

OBJECTIVE

The purpose of this article is to describe a modified appliance and treatment approach for presurgical nasoalveolar molding in infants with unilateral cleft lip and palate.

METHODS

This approach uses a plate held in with outriggers, which prevents the cleft-widening effect of the tongue, helps with tongue tip placement, and utilizes the functional movements of the facial musculature to guide and relocate the major segment medially to its normal position. Nasal molding is undertaken after most of the lateromedial correction of the alveolar position.

CONCLUSIONS

This technique helps to improve alveolar position, nasal septum alignment, nasal symmetry, and nasal tip projection prior to lip repair.

Orthodontic treatment for patients with clefts

Orthodontic strategies continue to evolve as new methods and treatment concepts more directly address the specific problems of patients who have clefts. By continual review of treatment outcomes and comparing outcomes with patients' problem lists and treatment objectives, clinicians will identify areas of treatment needing improvement and formulate hypotheses for future research.