Orthodontics and Periodontally Assisted Osteogenic Orthodontics
What is cleft lip and cleft palate?
Cleft lip and cleft palate is a facial malformations in which with sides of the face and skull that form the upper lip and mouth remain separated, instead of ‘stitching’ together in very early gestational development. These splits can also occur in the roof of the mouth, which is called the bony or hard palate.
Though the defect occurs in early fetal development, in the majority of cases, the cause is associated to genetic and environmental influence that exposures during pregnancy.
Aside from aesthetics, this defect can affect people in even more serious ways, such as difficulty eating, speech, ear infections, dental problems in the primary and permanent dentition.
How is CLP treated?
Infancy: Presurgical orthopedics
Presurgical infant orthopedics is sometimes used to relocate the segments of the cleft in maxilla prior to lip repair. A custom-fitted orthodontic appliance is applied to bring the parts of the lips, upper jaw, to bring them closer, while at the same time improving the nose shape, size and projection. This is called Nasoalveolar Molding (NAM). These appliances can make lip closure easier at time of surgical repair.
Nasoalveolar Molding (NAM)
Nasoalveolar Molding is a pre-surgical method of reshaping the gums, lips, and nose before cleft lip and palate surgery, to lessen the severity of the cleft. NAM is used mainly for children with large clefts and the technique has revolutionized cleft repair. It is part of a field of sub-specialty referred to as Craniofacial Orthodontics, which is part of a larger specialty of Craniofacial Orthopedics, which is in turn part of the overall treatment for CLP.
The goals of repair of cleft lip and palate are to:
- help patients to develop normal speech;
- restore dentition and oral functions;
- improve hearing;
- minimize facial difference;
- attain social acceptability of cleft individuals
- increase assimilation into society (psychological support); and
- restore/reconstruct facial and oral anatomy.
Since the CLP patient will be under interdisciplinary care, it is the opinion of this practice that any advantage gained for the patient is worthwhile. But, parents of the CLP infant should be well-informed and allowed to make the best decision for them and their child.
What exactly does NAM do?
[Excerpt from “Presurgical cleft lip and palate orthopedics: an overview” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5459959/ ]
‘NAM is a technique utilizing a nasal stent attached to the intra-oral mouth plate, and is designed to improve nasolabial anatomy. It is reported that columella (the portion of septum that extends beyond the edge of the nostril) lengthening, reduction in alar asymmetry (the nostril roundness), and recovery of nasal tip projection can be achieved. The use of nasal stents in bilateral CLP in combination with lip tapes and elastics can lengthen the deficient columella. It has been proven that NAM improved surgical outcome for cleft patient, as it is effective in reducing hard and soft tissue deformity.’
[ Excerpt from “Cleft Lip and Palate Patients: Diagnosis and Treatment” https://www.intechopen.com/books/designing-strategies-for-cleft-lip-and-palate-care/cleft-lip-and-palate-patients-diagnosis-and-treatment ]
During primary dentition
Midfacial deficiency (gaps) is a common feature of cleft lip and palate patients due to scar tissue of the lip and palate closure. During deciduous (‘baby teeth’) dentition; orthopedic, orofacial myofunctional therapy and speech therapy are recommended at tis developmental stage.
During mixed dentition
Early orthopedic treatment in cleft palate children is essential because the maxillary bones and their component parts may be moved and altered in young children with relative ease and thereby creating a more functional dental arch.
It is during this stage of a CLP patient’s life that the most effective and long-lasting results will be achieved using advanced orthodontic techniques and periodontally assisted osteogenic orthodontics.
Comprehensive fixed appliance therapy (brackets) usually occurs in the permanent dentition stage with the aim of preparing for alveolar bone graft that can be done by an oral surgeon. This phase usually involves the alignment of malposed maxillary incisors. Reverse pull headgear or face mask therapy, expansion of maxillary arch may be continued during this time period. Final alignment of teeth is carried over with or without extraction. Orthodontic management is limited after eruption of permanent dentition. The established malocclusion and discrepancy between the upper and lower arch often require orthognathic surgery. This is also an excellent stage for periodontally assisted osteogenic orthodontics, to reshape and allow teeth to have bone structure to support their movement.
Cleft is the most common craniofacial malformation that an orthodontist may encounter, and involves a complex treatment plan spanning the patient’s life from infancy into adulthood.
The orthodontist’s role in the cleft lip and palate team requires close relationship with the other team members all working to achieve the best outcome for the patient. The most common specialties involved in the care of a child with a cleft are: Maxillofacial surgeon, plastic surgeon, craniofacial orthodontist, orofacial myofunctional therapist, general dentist, otolaryngologist, speech therapist, pediatrician, and prosthodontist.
Thanks to NAM and other advances in surgical and orthodontic treatments, a child born with a cleft now has excellent chance of living a normal life, and enjoying more their childhood than before.
For further reading on the topic, please see the links below.
Facial and Airway Development Center
11490 Commerce Park Dr #430
Reston, VA 20191