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Timing of soft tissue surgery in cleft lip and palate patients
A-IV Prevention of Maxillary Deformities in Cleft Patients A-IV Prevention of M a x i l l a r y Deformities in Cleft Patients 1. Effects of Cleft Palate Surgery on Maxillary Growth in the Beagle Model
Takeshi Wada Division for Oral-FacialDisorders, Osaka Univ., Faculty of Dentistry, Osaka, Japan A primary goal :in cleft palate surgery has been to develop surgical methods for doing earlier repairs without interfering with the potential for normal maxillary growth. Most cleft palate surgeries entail leaving areas of denuded bone on the hard palate, and some types of palatal surgery involve surgical trauma to the area of the vomer, both of which may result in diminished postsurgical maxillary growth. In order to prevent the adverse effects of postsurgical contraction, we have developed and tested, in beagles, a ridge-flap (RF) modified surgery which involves medial advancement of mucosa from alveolar ridge, before eruption of deciduous molars. The results indicate that maxillary growth in width is significantly better in the beagle model than when clefts are closed with the more traditional (VY) palatoplasty. Similar studies using beagles, in which we are testing the hypothesis that meticulous resection of the vomer during cleft palate surgery may cause subsequent maxillary growth retardation, is also presented. (Supported by USPHS DE 00853 and N I D R DE 05837)
2. Preoperative Orthopaedic Management in Cleft Lip and Palate Patients Kurita, K.
Department of Oral and Maxillofacial Surgery (2), AichiGakuin University, Nagoya, Japan The aims of preoperative orthopaedic management are 1) to improve intraoral feeding and 2) to guide maxillary growth. In our institute the preoperative orthopaedic management has been used since 1985. The effects of the orthopaedic plate on intraoral feeding and maxillary growth have been evaluated. 1) The effects on intraoral feeding. The volume of the oral intake of milk was compared before and after the wearing of a plate. The sucking speed of milk increased significantly when wearing a plate, the speed increased more in wider clefts. 2) The effects on the maxillary growth. The maxillary growth of 51 unilateral complete cleft lip and palate patients (UCLP) who wore an orthopaedic plate was compared to the maxillary growth of 13 unilateral incomplete cleft lip patients (UCL). The comparison was made by means of three dimensional models. The impression were taken before the start of the orthopaedic management and at the time of lip closure for the UCLR while the impressions
17
for the UCL were also taken on the first visit and at the time of lip closure. The models were compared and it appeared that the maxillary turbinate on the cleft side and the incisive papilla were located significantly more superiorly in UCLP than UCL before orthopaedic management. However, no significant difference was seen at the time of lip closure between UCLP and UCL. The cleft palate width of the UCLP decreased significantly from the start of the orthopaedic management to the time of lip closure. It was likely that this was due to the elimination of tongue pressure in the cleft space.
3. Timing of Soft Tissue Surgery in Cleft Lip and Palate Patients
Ehrenfeld, M. Department of Oral and Maxillofacial Surgery, LudwigMaximilians-University, Miinchen, Germany There is no generally accepted protocol for timing of soft tissue surgery in cleft lip and palate therapy existing. Most authors agree on the fact that cleft lip and palate therapy involves much more than surgery alone and should therefore be performed in a team approach. The nucleus of such a team is usually formed by the operating surgeon, an orthodontist, an otolaryngologist, a pediatrician and a speech therapist. A pediatric dentist, a geneticist, a prosthodontist and a social worker are added to the team if necessary. Help and information through support groups are desirable. Cleft lip and palate malformations come in a variety of different forms and may involve the four subcomponents lip, alveolus and hard as well as soft palate. Deformities involving more than one subcomponent are often closed in more than one operation. One-stage operations in complex deformities require a more extensive mobilisation of the tissues and are supposed to produce results which are inferior compared to those obtained in multi-stage concepts. Complex deformities and such with consequences for breathing or food intake require a preoperative orthodontic therapy. Depending on the type of the deformity removable or fixed orthodontic appliances may be indicated. Surgery starts when the general condition of the child allows an operation without increased perioperative risks. This is usually the case when a newborn has a body weight of 10 pounds and an age of 10 weeks. The most important functional impairments in the early period of life of a CLP-patient originate from the cleft soft palate. It may be the reason for airway obstruction and problems with feeding. In practically all of the cases a cleft palate is the cause for hearing problems and later, if not closed and well functioning at that time, for problems with the articulate speech. Because of that many authors agree that a cleft 's6ff pal'ate should be closed as soon as possible, usually at the age of !approximatly three month. As far as the surgical technique is concerned the construction of a muscle sling in 9hygiological orientation seems to be essential. Lip adtiesions and the closure of the alveolus with mucoperiostal flaps can be performed in the same operation as well as a myringotomy. The final lip operation in complex
18
A-IV Prevention of Maxillary Deformities in Cleft Patients
cases is done in a second operation 6 to 8 weeks after the first. Also in lip surgery the muscle handling and orientation seems to be the most important factor. The closure of the hard palate at the age of 18 to 24 month is the last of the primary operations. We believe that for a normal speech development it is essential that the oral and nasal cavity are completely separated at the end of the second year.
4. Timing of Palatinal Closure and Effects on Maxillary Growth
Gattinger, B.
Department of Oral and Maxillofacial Surgery, Linz, Austria The influence of surgical treatment on the growth in the midface region is obvious in cleft palate patients. The effect on the surrounding tissues e.g. tongue or lips, however, is equally important. The questions which arise from this situation are: what to do and when to do it. A glance at the literature shows that
there is no universally accepted answer, on the contrary, nearly every CLP center takes their own view and follows their own treatment plan. To avoid the consequences of early closure of the cleft palate and to achieve a nearly normal midfacial and palatal growth, a two-stage palatal closure is accepted by many centers. Our own experience relates to two groups of patients: one group operated for palatal closure in a one-stage procedure (Veau technique) and a second group operated with a twostage approach (Widmaier-Perko technique). The results of the two-stage technique showed less disturbance of growth, both sagittally and transversely, as compared to the one-stage technique. The one stage group, however, had much better speech. Since adequate speech is an important factor when considering integration in human society, this factor should play an important role when selecting a treatment protocol. This is particularly relevant when it is realized that therapeutical treatment of speech is limited and mainly effective when carried out before the age of 6 years. On the other hand, present surgical and orthodontic modes of treatment can provide predictable and adequate results when treating maxillofacial skeletal anomalies. These facts tend to support the view that an early one-stage palatal closure is to be preferred.
Takeshi Wada Division for Oral-FacialDisorders, Osaka Univ., Faculty of Dentistry, Osaka, Japan A primary goal :in cleft palate surgery has been to develop surgical methods for doing earlier repairs without interfering with the potential for normal maxillary growth. Most cleft palate surgeries entail leaving areas of denuded bone on the hard palate, and some types of palatal surgery involve surgical trauma to the area of the vomer, both of which may result in diminished postsurgical maxillary growth. In order to prevent the adverse effects of postsurgical contraction, we have developed and tested, in beagles, a ridge-flap (RF) modified surgery which involves medial advancement of mucosa from alveolar ridge, before eruption of deciduous molars. The results indicate that maxillary growth in width is significantly better in the beagle model than when clefts are closed with the more traditional (VY) palatoplasty. Similar studies using beagles, in which we are testing the hypothesis that meticulous resection of the vomer during cleft palate surgery may cause subsequent maxillary growth retardation, is also presented. (Supported by USPHS DE 00853 and N I D R DE 05837)
2. Preoperative Orthopaedic Management in Cleft Lip and Palate Patients Kurita, K.
Department of Oral and Maxillofacial Surgery (2), AichiGakuin University, Nagoya, Japan The aims of preoperative orthopaedic management are 1) to improve intraoral feeding and 2) to guide maxillary growth. In our institute the preoperative orthopaedic management has been used since 1985. The effects of the orthopaedic plate on intraoral feeding and maxillary growth have been evaluated. 1) The effects on intraoral feeding. The volume of the oral intake of milk was compared before and after the wearing of a plate. The sucking speed of milk increased significantly when wearing a plate, the speed increased more in wider clefts. 2) The effects on the maxillary growth. The maxillary growth of 51 unilateral complete cleft lip and palate patients (UCLP) who wore an orthopaedic plate was compared to the maxillary growth of 13 unilateral incomplete cleft lip patients (UCL). The comparison was made by means of three dimensional models. The impression were taken before the start of the orthopaedic management and at the time of lip closure for the UCLR while the impressions
17
for the UCL were also taken on the first visit and at the time of lip closure. The models were compared and it appeared that the maxillary turbinate on the cleft side and the incisive papilla were located significantly more superiorly in UCLP than UCL before orthopaedic management. However, no significant difference was seen at the time of lip closure between UCLP and UCL. The cleft palate width of the UCLP decreased significantly from the start of the orthopaedic management to the time of lip closure. It was likely that this was due to the elimination of tongue pressure in the cleft space.
3. Timing of Soft Tissue Surgery in Cleft Lip and Palate Patients
Ehrenfeld, M. Department of Oral and Maxillofacial Surgery, LudwigMaximilians-University, Miinchen, Germany There is no generally accepted protocol for timing of soft tissue surgery in cleft lip and palate therapy existing. Most authors agree on the fact that cleft lip and palate therapy involves much more than surgery alone and should therefore be performed in a team approach. The nucleus of such a team is usually formed by the operating surgeon, an orthodontist, an otolaryngologist, a pediatrician and a speech therapist. A pediatric dentist, a geneticist, a prosthodontist and a social worker are added to the team if necessary. Help and information through support groups are desirable. Cleft lip and palate malformations come in a variety of different forms and may involve the four subcomponents lip, alveolus and hard as well as soft palate. Deformities involving more than one subcomponent are often closed in more than one operation. One-stage operations in complex deformities require a more extensive mobilisation of the tissues and are supposed to produce results which are inferior compared to those obtained in multi-stage concepts. Complex deformities and such with consequences for breathing or food intake require a preoperative orthodontic therapy. Depending on the type of the deformity removable or fixed orthodontic appliances may be indicated. Surgery starts when the general condition of the child allows an operation without increased perioperative risks. This is usually the case when a newborn has a body weight of 10 pounds and an age of 10 weeks. The most important functional impairments in the early period of life of a CLP-patient originate from the cleft soft palate. It may be the reason for airway obstruction and problems with feeding. In practically all of the cases a cleft palate is the cause for hearing problems and later, if not closed and well functioning at that time, for problems with the articulate speech. Because of that many authors agree that a cleft 's6ff pal'ate should be closed as soon as possible, usually at the age of !approximatly three month. As far as the surgical technique is concerned the construction of a muscle sling in 9hygiological orientation seems to be essential. Lip adtiesions and the closure of the alveolus with mucoperiostal flaps can be performed in the same operation as well as a myringotomy. The final lip operation in complex
18
A-IV Prevention of Maxillary Deformities in Cleft Patients
cases is done in a second operation 6 to 8 weeks after the first. Also in lip surgery the muscle handling and orientation seems to be the most important factor. The closure of the hard palate at the age of 18 to 24 month is the last of the primary operations. We believe that for a normal speech development it is essential that the oral and nasal cavity are completely separated at the end of the second year.
4. Timing of Palatinal Closure and Effects on Maxillary Growth
Gattinger, B.
Department of Oral and Maxillofacial Surgery, Linz, Austria The influence of surgical treatment on the growth in the midface region is obvious in cleft palate patients. The effect on the surrounding tissues e.g. tongue or lips, however, is equally important. The questions which arise from this situation are: what to do and when to do it. A glance at the literature shows that
there is no universally accepted answer, on the contrary, nearly every CLP center takes their own view and follows their own treatment plan. To avoid the consequences of early closure of the cleft palate and to achieve a nearly normal midfacial and palatal growth, a two-stage palatal closure is accepted by many centers. Our own experience relates to two groups of patients: one group operated for palatal closure in a one-stage procedure (Veau technique) and a second group operated with a twostage approach (Widmaier-Perko technique). The results of the two-stage technique showed less disturbance of growth, both sagittally and transversely, as compared to the one-stage technique. The one stage group, however, had much better speech. Since adequate speech is an important factor when considering integration in human society, this factor should play an important role when selecting a treatment protocol. This is particularly relevant when it is realized that therapeutical treatment of speech is limited and mainly effective when carried out before the age of 6 years. On the other hand, present surgical and orthodontic modes of treatment can provide predictable and adequate results when treating maxillofacial skeletal anomalies. These facts tend to support the view that an early one-stage palatal closure is to be preferred.