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The responsibility of the orthodontist in the cleft palate problem
THE
RESPONSIBILITY CLEFT H. K.
COOPER,
OF THE ORTHODONTIST PALATE PROBLEM D.D.S., F.A.C.D.,”
IN THE
PA.
LANCASTER,
N ORDER to discuss this subject properly it is first of all essential that we agree on the category in which the cleft palate patient belongs. Before either the orthodontist or any other member of the allied professions can assume a responsibility, it is obviously necessary to arrive at some conclusion as to their particular individual liability. At the present time the problem of orientation seems to this essayist to be the confusing issue and when once clarified should immediately simplify and expedite the solution of our individual problems. In 1840 when the first dental college was founded, separating the training of dental students from medical students, some factors of greater import took place than they at that time ever dreamed could happen. I am referring specifically to the place dentistry occupies in the field of public health and its position in relation to those problems. For those results culminating from the independent stand of dentistry were long and far-reaching. For too many years the importance and need of good dentistry were forgotten factors in t,he public health program. One has only to take the statistics compiled from this last war to realize how devastating that separation became and how completely overlooked was the part dentistry must play. When one considers the dental situation generally and realizes that in the Army alone approximately 3,000,OOO dentures were made for our young men, the cream of American manhood, the ones who were our school children only yesterday, one sees the significant fact that dentistry had been neglected by those responsible for our public health structure. At the present time clinics are established in the United States for practically every ailment to which the human being falls heir, but the figures resultant from this last war show a poor solution to our dental problems, completely out of proportion to the magnitude of the needs. So in like manner in the field of orthodontics this separation in thinking has produced still more startling conditions, precluding any satisfactory solution of its problems and hindering its function in fulfilling public health demands. What is orthodontics? Is it not dental facial orthopedics? If so, should not the crippled children’s programs include the service of orthodontics? Or are the facial cripples to be neglected? Until a place can be found to orient these unfortunates properly, nothing can really be assumed as a responsibility
I
Read before the Academy *Director, Lancaster Rotary
of Cleft
Club
Palate
C!eft
Prosthesis, Speech
Palate 67’5
iipril 10, Clinic.
1946.
676
H. K. Cooper
by any one branch of the healing arts. JOURNAL
OF ORTHODONTICS
In a paper? published
in the
AMERICAN
AND ORAL SURGERY in 1942, I wrote as follows:
As time goes on we are more and more frequently impressed with the realization that although orthopedics and orthodontics are so closely related, yet in the practical application of treatment of deformities, orthodonti& and orthopedics are completely severed. It seems unusually singular that although we have such a great common meeting ground in Wolff’s Law, nevertheless one is forced to face the question with alarming frequency, “Why cannot the treatment of facial deformities be carried out as any other branch of orthopedics?”
In attempting a solution are to be met I continue :
to the problem
of how and where these needs
To help a facial cripple properly and serve him scientifically requires just as much of a well-rounded dental staff as is required by the orthopedist. When we consider the need of the worst of these cases, the cleft palate patient, we face such a severe deformity and extreme condition that the task is tremendous; and a successful result can be accomplished only when given the proper opportunity and assistance. An adequate dental staff should consist, first of all, of a qualibed oral surgeon; a dentist who will do the best dentistry possible for these patients; a trained orthodontist; a prosthodontist especially taught for this department; the speech eorreetionist and finally the psychologist. This group working together is just as important as those before mentioned in the general orthopedic department and is essential to the smooth functioning of successful treatment. This orthopedic to see to formities our facial
is not a plea for socialized treatment any more than we can setup socialized medicine. But it is a plea for a clear look it that state funds and private funds set aside for the treatment are also made available for those involving facial deformities; cripples will get the same consideration and on the same’basis.
call the present into the future; of general dethat eventually
It has always been very difficult to understand why we continually hear the statement made that there are no funds set aside for the treatment of these facial deformity cases. Evidently they are not considered true deformities, for we do not require separate funds to treat a right or left arm nor separate funds for a leg or a back. It seems singular that any deformity which requires treatment by an orthodontist must come from a particular fund for that purpose and very rarely is there any available. This, to me, is the greatest illustration resulting from that long ago event in 1840 when we separated the It seems we training. of the dental student from that of the medical student. now try,to separate the body because of that confusion in our thinking.. In order to illustrate let us consider Figs. 1 and 2. Fig. 1 shows a boy with anterior poliomyelitis. That disease is in reality a disease of the nervous system, and because of it the innervating influence to his one leg was disturbed. Consequently the leg has become deformed causing him to become a “crippled child.” In Fig. 2 we have a boy with an early temporomandibular ankylosis. According to Thoma and others, we know that them’growth of the mandible is influenced more by muscle function than is the maxilla. It has been demonstrated that the growth of the maxilla is influenced by atmospheric pressure, whereas in the mandible, muscle function is the greater factor. But in both cases the same fundamental causative factor exists
Responsibility
of
Orthodontist
in
Palate
Cleft
677
to produce a definite deformity. If the boy in Fig. 1 is a crippled child,, what are we to call the boy in Fig. 2 ? In the United States today we have funds set aside for crippled children’s programs which adequately care for the leg of the one boy, but except in a very few instances completely overlook the jaw of the other boy. So also in studying textbooks relating to general bone deformities we have noticed the space devoted to the cause and treatment of conditions, but, except for wryneck, no reference is made to any of the malformations of the jaws and facial bones. One could almost ask the question, “When is a crippled child not a cripple?” And be answered immediately with, “When he has the deformity above the neck. ”
Fig. 1. Fig. l.-Lack of development Orthopedic Surgery, by permission Fig. 2.-Lack of development (Courtesy Dr. Kurt H. Thoma.)
of left leg resulting from of Lea & Febiger.) of the mandible resulting
Fig. anterior from
2. poliomyelitis.
temporomandibular
(Whitman: ankylosis.
To return to the definition of orthodontics, Angle in 1900 defined orthodontia as that science which has for its object the prevention and correction of malocclusions of the teeth. Strang5 later elaborated on that by this statecan hope to practice his profession in an intelligent ment : “No orthodontist and efficient manner until he has grasped this vision in all the bigness and broadness of its true meaning. . . . This field is not a limited one by any means but reaches out to touch and influence the entire range of facial anatomy as well as that of the neck and the thorax.” XalzmanrP states in his recent book : “Orthodontics comprises the science and art ,which deal with the dlevelopmental and positional anomalies of the teeth and jaws. . . . Orthodontics is based on anthropdliigy? anthropometrics, phylogenetics, biometrics, gnathostatics, endocrinology, pediatrics; ‘dietetics, clinical medicine and dentistry, and most if not all of the basic -biologic medical and dental sciences.” Orthodontics
678
H. K. Cooper
also has been called dental facial orthopedics, and until we eventually arrive at some conclusions as to what position dentistry in general and orthodontics in particular will occupy in health thinking, it is difficult to discuss the responsibility that the orthodontist must assume as his in the complete program. That the orthodontist must assume a great share of responsibility in the treatment of cleft palate cases is assuredly a fact. Textbooks have been mentioning this, but the present general setup for handling of these cases has been so insufficient and poorly coordinated as to discourage most orthodontists who felt the results obtained were not worth the effort. The orthodontist as an orthopedic dentist, by training in biological sciences and by his use of appliance technique, should be in an ideal position to recognize the needs and treatment necessary for these people. In fact, I have often felt that just as in the orthopedic hospital the head of the staff is the general orthopedist, so the day should eventua,lly arrive when the head of the dental staff in that same institution will be the orthodontist. I will admit that the present state of orthodontics is not up to this idealistic attitude, but the future of dentistry as a profession depends upon some of its specialties finally assuming more than the role of technicians. Since orthodontics is the study of the growth and development of the face and jaws and the functions relating to these structures, it surely seems t,hat the responsibility of the orthodontist is extremely great and challenging. The orthodontist of the future by virtue of his training and interest will have to consider it his duty to assume more responsibility as& be willing to strike out and lead in these matters. Many cases would be imyneasurably improved in later years if we had only attempted to do long ago what we are trying to do at this meeting today. To see how far surgery will and can go, and to make sure that the orthodontist continues the treatment with the feeling of?closest +& cooperation will enable the two specialties to accomplish so much more than has been done. In considering the establishment of separate clinics for the treatment of cleft palate patients it seems only logical to include those of other great facial deformities. I feel that such cases are an equal responsibility but one which the orthodontist hesitates to assume before he has been authorized to do so. All deformities of the face or teeth, those either with or without a speech and psychological problem, would loom as equal in importance with the cleft palate. Fig. 3 shows a case of a boy with cleft palate with resultant facial deformity. He has a speech and psychological problem. Fig. 4 shows a case of extreme mutilated distoclusion. His deformity is His speech and psychological problem, although not quite as also great. severe as the boy in Fig. 3, is still obvious. How are we going to separate these two boys so far as treatment in a clinic is concerned? In the Lancaster Rotary Club Cleft Palate Speech Clinic we are constantly faced with such patients. They are for the most part patients with unusual deformities and speech problems who quite confidently apply for service, thereby At one time we are criticizing the putting us in a most peculiar position.
Responsibility
of Orthodontist
in Cleft
Palate
67-9
handling of cripples generally and know and feel that a great group have been discriminated against, and yet we turn about and advocate, if we are not careful, the same thing in our facial deformity cases. We cannot separate these people. By what manner of logic do we take a person who. has a cleft palate with a speech defect and refuse a patient with a disfiguring distoclusion or mesioelusion deformity which very often presents a speech a,nd psychological problem also ?
Fig. Fig. Fig.
3.-Deformity 4.-Deformity
3. resulting resulting
Fig. from from
4.
cleft palate. distoclusion.
Six years ago a baby boy was referred to me who suffered from a partial absence of-the tongue. We have watched the case closely through the years to the present time. His tongue has grown some but not nearly enough to stimulate proper development of the mandible which is also the lower border of his face. His speech naturally is influenced by this and is the’ reason for his presentation today for your consultation and discussion. Another very rare case was referred to our clinic, a patient with cleft palate and harelip associated with complete anodontia. The deformity is terrible and will grow worse as the child develops. ‘We hope to present a complete case report of this patient at some future time. Suffice it here to sa,y that there are many more cases of other facial deformities that are constantly applying for treatment. It is difficult to provide treatment for the cleft palate patient with or without a speech and psychological problem and neglect the other patient whose deformity and psychological handicap is just as grea,t. The program must be all-embracing. We are handicapped in our clinic very often because cases come tlo us too late for ideal treatment. Too often compromise treatment must be undertaken. Surgery has been done for them, but that represents the sum total of the treatment received. I hope I will not be misunderstood on making the statement that too often the surgery was only mediocre, usually done by one
680
H. K. Cooper
trained in abdominal surgery, with aptitude or special training in this particular field. Here also is represented a very severe problem, for where poor lip surgery has been $erformed the orthodontist is given no chance to produce good facial contours. There must be the closest cooperation between the orthodontist’and the surgeon for we know that proper muscle pressure is a necessary part of treatment for a final permanent result. I am not now referring to the artists, t.he trained, scientifically minded surgeons, represented here today. I am referring to the great group of general surgeons who have been doing these operations in their respective communities because they felt there was nothing to do but make the attempt. The fault probably lies even deeper in the fact that there has never been any program outlined and established to orient these patients and place them in their proper category. Dr. Linwood Grace2 in a statistical study states that 1 out of 800 live births suffers from a cleft palate. Using the same statistics of 1 in 800, the ratio of poor people in that group is bound to be high, so usually it becomes necessary for the parents to resort to charity, which in turn forms the reason for the attempt by the abdominal surgeon. It is the best surgery available .under the circumstances. The orthodontist, too, is greatly handicapped in his treatment of cleft palate patients because they have not been sent to him at an early age. In the Lancaster Rotary Club Clinic where the cost of extensive treatment would not prohibit the ideal handling of a case, the time element proves to be a problem. There the wisdom, experience, and judgment of t.he orthodontist must stand him in good stead, for sometimes a compromise treatment proves to be the best. The proper cleft palate treatment requires a thorough over-all view of the problem and in some cases it is obviously impossible to take one, two, or three years for orthodontic treat,ment when the total rehabilitation problem of the patient is demanding immediate attention. The orthodontist must decide when the compromise is justified’ for the problem at hand. The short treatment can be done with operative’dentistry in the form of jacket crowns, thimble crowns, etc., plus unusual prosthetic measures, so that the speech clinician and the psychologist can work with us in helping to solve the total rehabilitation of the patient. If a program is eventually developed in which these people who have been operated on as infants can be constantly contacted and watched so that proper dentistry will be done on the deciduous teeth and orthodontic treatment given at the proper time, then and then only will the orthodontist be able to function in his ideal capacity. On the other hand, we see many cases in our clinic where orthodontics is of paramount importance and where tr’eatment can be accomplished successfully in a very short time. Models of one of these cases are demonstrated in Figs. 5 to 9. Figs. 5 and 6 show right and left view of the malocclusion still remaining after much lip and palate surgery was done. There still remains an opening on the left side well into the palate connecting with the nose. Figs. 7 and 8 show the case after orthodontic treatment.
Responsibility
Fig.
Fig.
of Orthodontist
5.
in Cleft
Fig.
7.
Palate
6.
Fig.
Fig.
9.
8.
681
it?. X.
Cooper
Fig. 9 shows the restoration that carries a soft acrylic attachment to make a seal of the opening into the nose. It also carries an acrylic obturator into the pharynx. This restoration has improved the patient’s occlusion and appearance. It also $Ctsas‘a retaining appliance. She is having speech retaining and psycholpgical * ment help in our Rotary Club Clinic at the present time. Of the cases we have treated there are some in which the upper anterior teeth still remaining are in lingual version to the lower anteriors similar to that shown in Fig. 5. _ These can be brought over the bite into proper occlusion and become a great a’fd,in establishing facial harmony and better speech. Here a word of warning is very necessary for we. have found that in types 3 and 4 cleft palate patients where one or more of’ the;*teeth are in $se proximity to the cleft, the problem of retention is so severe as to preclude any possibility of a good result. Therefore we have been removing such teeth and using artificial substitutes because relapse means more than the loss of teeth in the greater danger of holding back the entire program for the patient’s total rehabilitation. This conclusion ‘and decision have been reached after various experiences in the past years in which we found ourselves too concerned with a tooth instead of a total personality. There is another type of case which presents a full complement of teeth in the mandible but due to the cleft palate will never get the same number of teeth in the maxilla (Fig. 3). Here we have best illust,rated one of the forces of occlusion, namely, harmony in the size of the arches. So from the orthodontic standpoint we feel that the compromise treatment of the removal of a lower premolar on each side of the arch helps us to produce another deformity to conform to the original deformity which in turn produces an illusion of a better facial balance. In the more adult patient we do not feel that it is always advisable to do extensive orthodontic treatment where the danger of relapse is too evident, because, should the relapse take place, the entire program is greatly retarded and in many instances the results are entirely defeated. We must realize we are dealing with human beings who must be educated and inspired to persevere in achieving the results we now dream of for all the patients. In conclusion, I might remind you of Dr. Wm. J. Gies’ report3 following his study for the Carnegie Foundation, for this statement, though well known to all of you, bears repeating: “Whether dentistry now is or ever will be a branch of medicine is not the point, but that dentistry is a part of public health of equal importance to the respective branches of medicine is a fact.” We have not yet accomplished too much to justify that statement but we should never cease trying to make it known by action. Our potential strength in the public health picture is stupendous if used properly with the complete cooperation of all the allied professions. If dentistry continues to be too highly a specialized and separated group and, within its boundaries, orthodontics a still more specialized unit, a danger lies in the fact that we may lose sight of the complete picture of our public health worth.
Responsibility
of
Orthodontist
in Cleft
Palate
683
REFERENCES. 1. Cooper, 2. Grace, 3. 4. 5. 6.
H. K.: Crippled Children? AX J. ORTHODONTICS AXD ORAL SURG. 28: 35, 1942. Linwood G.: Frequency of Occurrence of Cleft Palates and Har”elips, - , J. Dent. ‘Research 22: 495, 1543. ” Gies, Wm. J.: Dental Education in the United States and Canada, Carnegie Foundation for the Advancement of Teaching, Bulletin No. 19,1926. Salzmann, J. A.: Principles of Orthodontics, Philadelphi?, 1943, J. B. Lippincott Co. Strang, R. H. W.: Textbook of Orthodontia, Philadelphia, 1933, Lea & Febiger. Thoma, Kurt RI.: Principal Factors Controlling Development of Mandible and Maxilla, AM.J. ORTHODONTICS AND ORAL SURG.~~: 171,l935. 26 N.
LIME
STREET
RESPONSIBILITY CLEFT H. K.
COOPER,
OF THE ORTHODONTIST PALATE PROBLEM D.D.S., F.A.C.D.,”
IN THE
PA.
LANCASTER,
N ORDER to discuss this subject properly it is first of all essential that we agree on the category in which the cleft palate patient belongs. Before either the orthodontist or any other member of the allied professions can assume a responsibility, it is obviously necessary to arrive at some conclusion as to their particular individual liability. At the present time the problem of orientation seems to this essayist to be the confusing issue and when once clarified should immediately simplify and expedite the solution of our individual problems. In 1840 when the first dental college was founded, separating the training of dental students from medical students, some factors of greater import took place than they at that time ever dreamed could happen. I am referring specifically to the place dentistry occupies in the field of public health and its position in relation to those problems. For those results culminating from the independent stand of dentistry were long and far-reaching. For too many years the importance and need of good dentistry were forgotten factors in t,he public health program. One has only to take the statistics compiled from this last war to realize how devastating that separation became and how completely overlooked was the part dentistry must play. When one considers the dental situation generally and realizes that in the Army alone approximately 3,000,OOO dentures were made for our young men, the cream of American manhood, the ones who were our school children only yesterday, one sees the significant fact that dentistry had been neglected by those responsible for our public health structure. At the present time clinics are established in the United States for practically every ailment to which the human being falls heir, but the figures resultant from this last war show a poor solution to our dental problems, completely out of proportion to the magnitude of the needs. So in like manner in the field of orthodontics this separation in thinking has produced still more startling conditions, precluding any satisfactory solution of its problems and hindering its function in fulfilling public health demands. What is orthodontics? Is it not dental facial orthopedics? If so, should not the crippled children’s programs include the service of orthodontics? Or are the facial cripples to be neglected? Until a place can be found to orient these unfortunates properly, nothing can really be assumed as a responsibility
I
Read before the Academy *Director, Lancaster Rotary
of Cleft
Club
Palate
C!eft
Prosthesis, Speech
Palate 67’5
iipril 10, Clinic.
1946.
676
H. K. Cooper
by any one branch of the healing arts. JOURNAL
OF ORTHODONTICS
In a paper? published
in the
AMERICAN
AND ORAL SURGERY in 1942, I wrote as follows:
As time goes on we are more and more frequently impressed with the realization that although orthopedics and orthodontics are so closely related, yet in the practical application of treatment of deformities, orthodonti& and orthopedics are completely severed. It seems unusually singular that although we have such a great common meeting ground in Wolff’s Law, nevertheless one is forced to face the question with alarming frequency, “Why cannot the treatment of facial deformities be carried out as any other branch of orthopedics?”
In attempting a solution are to be met I continue :
to the problem
of how and where these needs
To help a facial cripple properly and serve him scientifically requires just as much of a well-rounded dental staff as is required by the orthopedist. When we consider the need of the worst of these cases, the cleft palate patient, we face such a severe deformity and extreme condition that the task is tremendous; and a successful result can be accomplished only when given the proper opportunity and assistance. An adequate dental staff should consist, first of all, of a qualibed oral surgeon; a dentist who will do the best dentistry possible for these patients; a trained orthodontist; a prosthodontist especially taught for this department; the speech eorreetionist and finally the psychologist. This group working together is just as important as those before mentioned in the general orthopedic department and is essential to the smooth functioning of successful treatment. This orthopedic to see to formities our facial
is not a plea for socialized treatment any more than we can setup socialized medicine. But it is a plea for a clear look it that state funds and private funds set aside for the treatment are also made available for those involving facial deformities; cripples will get the same consideration and on the same’basis.
call the present into the future; of general dethat eventually
It has always been very difficult to understand why we continually hear the statement made that there are no funds set aside for the treatment of these facial deformity cases. Evidently they are not considered true deformities, for we do not require separate funds to treat a right or left arm nor separate funds for a leg or a back. It seems singular that any deformity which requires treatment by an orthodontist must come from a particular fund for that purpose and very rarely is there any available. This, to me, is the greatest illustration resulting from that long ago event in 1840 when we separated the It seems we training. of the dental student from that of the medical student. now try,to separate the body because of that confusion in our thinking.. In order to illustrate let us consider Figs. 1 and 2. Fig. 1 shows a boy with anterior poliomyelitis. That disease is in reality a disease of the nervous system, and because of it the innervating influence to his one leg was disturbed. Consequently the leg has become deformed causing him to become a “crippled child.” In Fig. 2 we have a boy with an early temporomandibular ankylosis. According to Thoma and others, we know that them’growth of the mandible is influenced more by muscle function than is the maxilla. It has been demonstrated that the growth of the maxilla is influenced by atmospheric pressure, whereas in the mandible, muscle function is the greater factor. But in both cases the same fundamental causative factor exists
Responsibility
of
Orthodontist
in
Palate
Cleft
677
to produce a definite deformity. If the boy in Fig. 1 is a crippled child,, what are we to call the boy in Fig. 2 ? In the United States today we have funds set aside for crippled children’s programs which adequately care for the leg of the one boy, but except in a very few instances completely overlook the jaw of the other boy. So also in studying textbooks relating to general bone deformities we have noticed the space devoted to the cause and treatment of conditions, but, except for wryneck, no reference is made to any of the malformations of the jaws and facial bones. One could almost ask the question, “When is a crippled child not a cripple?” And be answered immediately with, “When he has the deformity above the neck. ”
Fig. 1. Fig. l.-Lack of development Orthopedic Surgery, by permission Fig. 2.-Lack of development (Courtesy Dr. Kurt H. Thoma.)
of left leg resulting from of Lea & Febiger.) of the mandible resulting
Fig. anterior from
2. poliomyelitis.
temporomandibular
(Whitman: ankylosis.
To return to the definition of orthodontics, Angle in 1900 defined orthodontia as that science which has for its object the prevention and correction of malocclusions of the teeth. Strang5 later elaborated on that by this statecan hope to practice his profession in an intelligent ment : “No orthodontist and efficient manner until he has grasped this vision in all the bigness and broadness of its true meaning. . . . This field is not a limited one by any means but reaches out to touch and influence the entire range of facial anatomy as well as that of the neck and the thorax.” XalzmanrP states in his recent book : “Orthodontics comprises the science and art ,which deal with the dlevelopmental and positional anomalies of the teeth and jaws. . . . Orthodontics is based on anthropdliigy? anthropometrics, phylogenetics, biometrics, gnathostatics, endocrinology, pediatrics; ‘dietetics, clinical medicine and dentistry, and most if not all of the basic -biologic medical and dental sciences.” Orthodontics
678
H. K. Cooper
also has been called dental facial orthopedics, and until we eventually arrive at some conclusions as to what position dentistry in general and orthodontics in particular will occupy in health thinking, it is difficult to discuss the responsibility that the orthodontist must assume as his in the complete program. That the orthodontist must assume a great share of responsibility in the treatment of cleft palate cases is assuredly a fact. Textbooks have been mentioning this, but the present general setup for handling of these cases has been so insufficient and poorly coordinated as to discourage most orthodontists who felt the results obtained were not worth the effort. The orthodontist as an orthopedic dentist, by training in biological sciences and by his use of appliance technique, should be in an ideal position to recognize the needs and treatment necessary for these people. In fact, I have often felt that just as in the orthopedic hospital the head of the staff is the general orthopedist, so the day should eventua,lly arrive when the head of the dental staff in that same institution will be the orthodontist. I will admit that the present state of orthodontics is not up to this idealistic attitude, but the future of dentistry as a profession depends upon some of its specialties finally assuming more than the role of technicians. Since orthodontics is the study of the growth and development of the face and jaws and the functions relating to these structures, it surely seems t,hat the responsibility of the orthodontist is extremely great and challenging. The orthodontist of the future by virtue of his training and interest will have to consider it his duty to assume more responsibility as& be willing to strike out and lead in these matters. Many cases would be imyneasurably improved in later years if we had only attempted to do long ago what we are trying to do at this meeting today. To see how far surgery will and can go, and to make sure that the orthodontist continues the treatment with the feeling of?closest +& cooperation will enable the two specialties to accomplish so much more than has been done. In considering the establishment of separate clinics for the treatment of cleft palate patients it seems only logical to include those of other great facial deformities. I feel that such cases are an equal responsibility but one which the orthodontist hesitates to assume before he has been authorized to do so. All deformities of the face or teeth, those either with or without a speech and psychological problem, would loom as equal in importance with the cleft palate. Fig. 3 shows a case of a boy with cleft palate with resultant facial deformity. He has a speech and psychological problem. Fig. 4 shows a case of extreme mutilated distoclusion. His deformity is His speech and psychological problem, although not quite as also great. severe as the boy in Fig. 3, is still obvious. How are we going to separate these two boys so far as treatment in a clinic is concerned? In the Lancaster Rotary Club Cleft Palate Speech Clinic we are constantly faced with such patients. They are for the most part patients with unusual deformities and speech problems who quite confidently apply for service, thereby At one time we are criticizing the putting us in a most peculiar position.
Responsibility
of Orthodontist
in Cleft
Palate
67-9
handling of cripples generally and know and feel that a great group have been discriminated against, and yet we turn about and advocate, if we are not careful, the same thing in our facial deformity cases. We cannot separate these people. By what manner of logic do we take a person who. has a cleft palate with a speech defect and refuse a patient with a disfiguring distoclusion or mesioelusion deformity which very often presents a speech a,nd psychological problem also ?
Fig. Fig. Fig.
3.-Deformity 4.-Deformity
3. resulting resulting
Fig. from from
4.
cleft palate. distoclusion.
Six years ago a baby boy was referred to me who suffered from a partial absence of-the tongue. We have watched the case closely through the years to the present time. His tongue has grown some but not nearly enough to stimulate proper development of the mandible which is also the lower border of his face. His speech naturally is influenced by this and is the’ reason for his presentation today for your consultation and discussion. Another very rare case was referred to our clinic, a patient with cleft palate and harelip associated with complete anodontia. The deformity is terrible and will grow worse as the child develops. ‘We hope to present a complete case report of this patient at some future time. Suffice it here to sa,y that there are many more cases of other facial deformities that are constantly applying for treatment. It is difficult to provide treatment for the cleft palate patient with or without a speech and psychological problem and neglect the other patient whose deformity and psychological handicap is just as grea,t. The program must be all-embracing. We are handicapped in our clinic very often because cases come tlo us too late for ideal treatment. Too often compromise treatment must be undertaken. Surgery has been done for them, but that represents the sum total of the treatment received. I hope I will not be misunderstood on making the statement that too often the surgery was only mediocre, usually done by one
680
H. K. Cooper
trained in abdominal surgery, with aptitude or special training in this particular field. Here also is represented a very severe problem, for where poor lip surgery has been $erformed the orthodontist is given no chance to produce good facial contours. There must be the closest cooperation between the orthodontist’and the surgeon for we know that proper muscle pressure is a necessary part of treatment for a final permanent result. I am not now referring to the artists, t.he trained, scientifically minded surgeons, represented here today. I am referring to the great group of general surgeons who have been doing these operations in their respective communities because they felt there was nothing to do but make the attempt. The fault probably lies even deeper in the fact that there has never been any program outlined and established to orient these patients and place them in their proper category. Dr. Linwood Grace2 in a statistical study states that 1 out of 800 live births suffers from a cleft palate. Using the same statistics of 1 in 800, the ratio of poor people in that group is bound to be high, so usually it becomes necessary for the parents to resort to charity, which in turn forms the reason for the attempt by the abdominal surgeon. It is the best surgery available .under the circumstances. The orthodontist, too, is greatly handicapped in his treatment of cleft palate patients because they have not been sent to him at an early age. In the Lancaster Rotary Club Clinic where the cost of extensive treatment would not prohibit the ideal handling of a case, the time element proves to be a problem. There the wisdom, experience, and judgment of t.he orthodontist must stand him in good stead, for sometimes a compromise treatment proves to be the best. The proper cleft palate treatment requires a thorough over-all view of the problem and in some cases it is obviously impossible to take one, two, or three years for orthodontic treat,ment when the total rehabilitation problem of the patient is demanding immediate attention. The orthodontist must decide when the compromise is justified’ for the problem at hand. The short treatment can be done with operative’dentistry in the form of jacket crowns, thimble crowns, etc., plus unusual prosthetic measures, so that the speech clinician and the psychologist can work with us in helping to solve the total rehabilitation of the patient. If a program is eventually developed in which these people who have been operated on as infants can be constantly contacted and watched so that proper dentistry will be done on the deciduous teeth and orthodontic treatment given at the proper time, then and then only will the orthodontist be able to function in his ideal capacity. On the other hand, we see many cases in our clinic where orthodontics is of paramount importance and where tr’eatment can be accomplished successfully in a very short time. Models of one of these cases are demonstrated in Figs. 5 to 9. Figs. 5 and 6 show right and left view of the malocclusion still remaining after much lip and palate surgery was done. There still remains an opening on the left side well into the palate connecting with the nose. Figs. 7 and 8 show the case after orthodontic treatment.
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Fig. 9 shows the restoration that carries a soft acrylic attachment to make a seal of the opening into the nose. It also carries an acrylic obturator into the pharynx. This restoration has improved the patient’s occlusion and appearance. It also $Ctsas‘a retaining appliance. She is having speech retaining and psycholpgical * ment help in our Rotary Club Clinic at the present time. Of the cases we have treated there are some in which the upper anterior teeth still remaining are in lingual version to the lower anteriors similar to that shown in Fig. 5. _ These can be brought over the bite into proper occlusion and become a great a’fd,in establishing facial harmony and better speech. Here a word of warning is very necessary for we. have found that in types 3 and 4 cleft palate patients where one or more of’ the;*teeth are in $se proximity to the cleft, the problem of retention is so severe as to preclude any possibility of a good result. Therefore we have been removing such teeth and using artificial substitutes because relapse means more than the loss of teeth in the greater danger of holding back the entire program for the patient’s total rehabilitation. This conclusion ‘and decision have been reached after various experiences in the past years in which we found ourselves too concerned with a tooth instead of a total personality. There is another type of case which presents a full complement of teeth in the mandible but due to the cleft palate will never get the same number of teeth in the maxilla (Fig. 3). Here we have best illust,rated one of the forces of occlusion, namely, harmony in the size of the arches. So from the orthodontic standpoint we feel that the compromise treatment of the removal of a lower premolar on each side of the arch helps us to produce another deformity to conform to the original deformity which in turn produces an illusion of a better facial balance. In the more adult patient we do not feel that it is always advisable to do extensive orthodontic treatment where the danger of relapse is too evident, because, should the relapse take place, the entire program is greatly retarded and in many instances the results are entirely defeated. We must realize we are dealing with human beings who must be educated and inspired to persevere in achieving the results we now dream of for all the patients. In conclusion, I might remind you of Dr. Wm. J. Gies’ report3 following his study for the Carnegie Foundation, for this statement, though well known to all of you, bears repeating: “Whether dentistry now is or ever will be a branch of medicine is not the point, but that dentistry is a part of public health of equal importance to the respective branches of medicine is a fact.” We have not yet accomplished too much to justify that statement but we should never cease trying to make it known by action. Our potential strength in the public health picture is stupendous if used properly with the complete cooperation of all the allied professions. If dentistry continues to be too highly a specialized and separated group and, within its boundaries, orthodontics a still more specialized unit, a danger lies in the fact that we may lose sight of the complete picture of our public health worth.
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REFERENCES. 1. Cooper, 2. Grace, 3. 4. 5. 6.
H. K.: Crippled Children? AX J. ORTHODONTICS AXD ORAL SURG. 28: 35, 1942. Linwood G.: Frequency of Occurrence of Cleft Palates and Har”elips, - , J. Dent. ‘Research 22: 495, 1543. ” Gies, Wm. J.: Dental Education in the United States and Canada, Carnegie Foundation for the Advancement of Teaching, Bulletin No. 19,1926. Salzmann, J. A.: Principles of Orthodontics, Philadelphi?, 1943, J. B. Lippincott Co. Strang, R. H. W.: Textbook of Orthodontia, Philadelphia, 1933, Lea & Febiger. Thoma, Kurt RI.: Principal Factors Controlling Development of Mandible and Maxilla, AM.J. ORTHODONTICS AND ORAL SURG.~~: 171,l935. 26 N.
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