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Dentition in cleft palate cases
DENTITION IN CLEFT PALATE CASES* By H. L. D. KIRKHAM, M.D., F.A.C.S., HOUSTON, TEXAS
that cleft palate, so gross a developmental deformity of the I Tjaw, patent often involving as it does the alveolus, should be accompanied by IS
malformations of various types and degrees of the dental elements; however, case analysis shows that the extent of dental defects is not in direct ratio to the maxillary deformity. Taking this as a premise it is at once obvious that while certain of the disturbances of dentition met with in these cases can be attributed to embryologic deficiency, some at least are due to other disturbing elements, and since a larger percentage of disturbed dentition occurs in cases following operations in which the jaw has been penetrated through surgical procedures, it is safe to infer that some of the problems confronting the orthodontist in cleft palate cases are a result of surgical intervention rather than embryologic deviation from the normal. As the defect in the alveolus in complete palate clefts occurs at or near the lateral incisor, it is, therefore, obvious that this tooth shows more embryologic irregularity than all of the others. A study of the variations of the lateral incisors as seen in these cases brings out some very interesting data, true of only academic interest. These data may be of future value in helping to solve some of the problems of mechanism in the etiology of these deformities, which in turn may help to improve the practical side of palate repair. The premaxilla is developed from the frontonasal process and in childrens skulls and some adult skulls is seen to be composed of two portions on each side of the midline. (Fig. 1.) The mesial portions are known as the endognathion, the lateral portions as the mesognathion, and the maxilla proper being known as the exognathion. It has been taught for many years that the premaxilla bears four teeth, however, a study of cleft palate cases shows that this is seldom the case. The lateral incisor on the cleft side is often absent, and when present is more frequently placed on the exognathion rather than the mesognathion side of the cleft. This observation led Albrecht to the opinion that in cleft palate the cleft occurs, not between the mesognathion and exognathion, but rather between the mesognathion and endognathion, associated often with a deficient development of the mesognathion. Observance and study of a case of rare lateral cleft (Fig. 2) tends to bear this out, and also to bring to light additional theories on face development and the vagaries of the lateral incisors. The case in question showed a bilateral cleft of the lip which extended lateral to the nasal ala with a cleft in bone ox: embryonic scarring which extended up to the orbit on both sides. On the left side the orbit was markedly *Read at the Thirtieth Annual Meeting of the American Society of Orthodontists, St. Louis. Mo., April 20-24, 1931.
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Dentition in Cleft Palate Cases
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contracted with an atrophied blind globe; on the right side a globe showing corneal scarring and symblepharon was present. This globe is apparently blind, but may be remedied by iridectomy later. In conjunction with the above, there exists a cleft palate which shows a bridging of tissue across the cleft in front, with a gap in the alveolus, and an extremely wide cleft with an apparent lack of palatal tissue. The premaxilla in this case is very interesting in that it contains four tooth buds, is much wider than the premaxilla in the average bilateral cleft palate and besides shows little or no forward displacement. This raises the question as to whether or not the mesognathion bearing the lateral incisor is so poorly
Endognathl'on JI esognatltion Exognat7tion
Fig. I.-Premaxilla, after Albrecht.
Fig. 2.-Lateral cleft extending Into both orbits.
developed or nondescended in bilateral clefts that the forward displacement of the premaxilla is an apparent rather than an actual forward displacement. Should this be true, it is obvious that it is incorrect to force the premaxilla back into the gap at operation, and as a matter of fact this is proved practically and seen in cases when this replacement has been accomplished by the action of lip muscle pull following repair of the lip over the gap. In these cases the arch is far more normal, to say nothing of preservation of dental structures. (Fig. 3.) Keith in his very comprehensive studies on the mechanism of face growth states: "It is not necessary to go into all the reasons which have led us to regard the alveolar part of the maxillae, the part which lies below the level
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of the hard palate and forms the bony socket of the teeth, as a distinct growth element, a plastic element regulated by its own independent system." Study of cleft palate cases shows that the alveolus though cleft, shows little or no growth disturbance except at the site of the cleft, namely the mesognathion; therefore there should be no special reason why dentition should be disturbed except in the lateral incisor area; unless we include such conditions as supernumerary teeth which, while more common in cleft cases are also seen in otherwise normal mouths and especially in the families of palate and lip clefts.
Fig. 3.-Double cleft palate before and after replacement of premaxilla by muscle pull.
Fig. 4.-Model of unoperated unilateral cleft palate in an adult showing good dentition except at site of cleft.
To determine the influence of palate clefts per se on dentition, it becomes necessary first to study the older cases upon whom no operation has been performed. In this study it is interesting to note that there is invariably no more disturbance in dentition than in the normal mouth of similar age, except as before stated in the region of the lateral incisor. (Fig. 4.) Another interesting observation is that caries is no more frequent in this nonoperative series in the maxilla than in the mandible, tending to show that clefts per se have no bearing or are not a causative factor of caries. (Fig. 5.) Whether lack of calcium or improper diet has a bearing on the causation of caries is a matter to be solved largely by the dentist and has no bearing here except as above stated that cleft palate does not appear to be a causative factor.
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Dentition in Clef t Palate Cases
'I'he study of this se ries fu r ther shows little or no distur ba nce of maxillary grow th exce pt that in volvin g th e mesognathion ; whic h by com parison with the cas e of lateral cleft descr ibed earlier, probabl y is devel oped fr om the nasofrontal pro cess and forms th e alae of the n ose and the n asal pro cess of t he ma xillae, f or in this case t he cleft exten ds t hr oug h th e inf raorb ital canal which it must be r ememb er ed r emains open into th e floor of the or bit in t he newb orn infants. A comparison of t he above ser ies wi th cases up on w hom some sort of jaw pen etration ha s been p er f ormed gives a t otally differ ent picture in regar d to
F ig. 5. -Models of maxllla and m an dible in do u ble lip and pala t e r ep a ir ed w it h out w ir es s ho w in g n o latera I s p r ea d a t tuber osities,
A.
B.
c.
F'i g, 6.-Unilateral palate and lip repaired b y wires . A , B efo r e op era t io n; B, immedi atel y after op eration; and C, eigh t years Inter ; sh ow in g total la ck of develo p men t of m axill a .
failure of development, caries, and misplacemen t of den t al eleme nts . Th e la ck of development is more appare nt in t he alveolus than in t he maxilla proper , and in some instances the alveolar gr owth ha s been comple te ly arrested. (Fig. 6.) The cases whi ch show such ex t re me growth disturbances ar e t hose in which the wire wa s known t o have be en placed too close to th e al veolar border, thus cutting off th e al veolus from t he maxilla . St u dy of seria l sections of a cleft palate case showed such extremel y hi gh p osition of too th buds that it seems almost impossible to insert wires high en oug h t o avoid injury
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to these elements. The lack of development in the alveolus rather than in the maxilla bears out the statements of Keith, and further since the growth centers which largely influence the forward growth of the maxilla are situated in the sphenopterygoid region and along the vomer it would be difficult for wires to damage these centers seriously, therefore, the damage done by wires to development concerns the alveolus rather than the jaw proper, often because the wires are placed too low. However, should they be placed high enough to avoid growth disturbance the wires have a marked damaging effect on the tooth buds and dental elements. Study of the groups of cases in which the wires did not effect alveolar growth shows that caries, absence, or misplacement of premolars and molars invariably occur. (Fig. 7.) Whenever caries of teeth in the maxillae occurs
Fig.
7.~Unllateral
lip and palate repaired by wires. showing disturbed dentition.
Fig. S.-Occluslon In an Incomplete cleft palate with a very wide cleft.
in such cases, it is seldom found that it exists in like ratio in the teeth of the mandible, demonstrating that the existing caries is a result of the damage done to the maxilla and its contained tooth buds. If the results of cases upon whom some form of jaw penetration has been performed are compared with those which have had no penetration, we find a striking improvement in regard to the shape and form of the arch (Fig. 8), development of the maxilla, and still more improvement upon the existence of caries and misplaced teeth. The arch in these nonpenetrated cases more closely resembles the normal, and consequently occlusion, though naturally not perfect, is far better. (Fig. 9.) At the site of the lateral incisor we frequently. find disturbances of development, but this exists without operation
Dentition in Cleft Palate Cases
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and is attributable solely to the deformity. Regarding caries, or missing premolars and molars, we find little or no more irregularity than in the normal jaw of like age. Since so much more frequently the end-results are better when wires or some form of jaw penetration are not used, it is safe to infer that such operative measures are not alone unnecessary, but invariably cause damage of themselves. It is interesting to note that occlusion in the molar region is as good when no penetration has been performed as with it. It can well be asked that if no wires penetrate the jaw what holds it or brings it into position ¥ This is accomplished by the continuous action of the orbicularis oris muscle after repair of the cleft lip; and orthodontic experience with these cases immediately impresses one with the power of this muscle and what a large factor it can be, for better or for worse. In some instances, particularly of double cleft where the premaxilla has been forced too far back, this lip pull is sufficient to counteract orthodontic measures designed to bring the incisors forward. If the principle of lip pull is employed to reform the alveolar arch, it then becomes a matter of personal
A.
B.
Fig. 9.-Complete unilateral palate and lip. A, Before operation; B, after closure by the use of lip pull.
choice as to the method and sequence of the operation by which this is accomplished. Many repair the lip as early as possible, later repairing the palate when the child is a year or so old, thus completing the case in two operations. However, it has been my experience that as good lips were not reconstructed and that frequently a secondary lip operation was necessary when the lip was repaired before the gap was closed, and further, the percentage of holes occurring in the extreme front part of the palate was greater. While of themselves these holes, if small, are not of such vital import, yet if they can be minimized it is advantageous. Before I used the principle of lip pull, it was the practice to repair the front part of the palate first and later, in six or eight weeks, to repair the lip. This has many advantages in that the front and difficult part of the palate is more easily closed before the alveolar border is molded, and furthermore is closed completely; which makes the closure of the posterior part of the palate much easier. Since using the lip pull the following sequence of operations has been followed which has proved very satisfactory: The front part of the palate is closed by utilizing a septal flap; the alveolus is molded to take the spring out of it;
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th e lip is th en undermined an d the edge s a t the top of th e cleft are fresh en ed down t o th e mu scle and two silk worm sut ures are t hen pl aced well ba ck in the chee k so as to coa pt the freshened mu scle of the lip. (F igs . 10 and 11.) Th is almost re constructs t he nostril, though n o attempt at complete lip r epa ir is done. Th e baby is the n all owed t o r est fo r about eig ht wee ks , at which time th e lip has usu ally been conver te d in t o an in complet e clef t with the columella in t he midline, t he gap in t he alveo lus closed and the front part of t he palate close d. Th is conditi on of affairs makes the r epair of the lip at t his tim e mu ch eas ier, and a more satisfactory lip and nostril are r econst r uc te d. (F ig. 12.) L ater when th e child is a year or so old the r emaining pa rt of the palat e is r epaired, which becomes ofte n a compar a tively simple procedure becau se the lip pull ha s furth er narrowed th e cleft until it of te n lies almost in appos it ion. While this procedu r e ha s proved very satisfactory in my hands, it is in no way intended as a criticism of other sequen ces or methods of operation, for so long as th e fu ndamental principles of any operation are adhered to, the details of t echnic mu st be somewhat a
Fig. 10.
F ig . 11.
F ig . 12.
Fig s. 1 0. 11. a n d 1 2.-U n il.a t e r al li p a n d palate at t h e various stages of lip r epair.
ma tter of individual expe rie nce so that a method is worked out which gives the b est r esults; granting t ha t an other might get as good or better r esults by employing another way of accomplishing the sa me end. It might be asked why the lip and front part of the palate are not r epaired at one tim e thus saving an operation ; the answer is because it has been felt that this is a little more than some of t hese babies can safely stand. To summarize: Th er e are certain dental def ormities whi ch can be expe cted as a result of the cleft, chief of which are : displace ment , ab sen ce, or poor dev elopm ent of the la t er al in cisor on t he cleft side; also supernumerary teeth are more frequentl y found in cleft palate cases and in th e families in which clefts occur. Followin g jaw penetration ope rations a larger p ercentage of missing t eeth, misplaced teet h, and caries, is f ound than in those who ha ve had no op eration or have been operated by methods whi ch do not penetrate the jaw. In conclusion it is urged that much damage is don e to the teeth and dental elements by penetration of the maxilla, which damage is largely elimi-
Dentition in Cleft Palate Cases
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nat ed when some m ethod which utilizes the principle of lip pull is employe d. What method is used depends upon the individual prefer enc e of th e op erator, bearing in mind that the fundamental principl es of an y procedure mu st be sound if the end-results are to be u nif ormly those which are so ear nes tl y desir ed. DISCUSSION
Dr. Matthew N. F ederspiel.-Dr. Kirkhams inter est ing paper deal s with a pr oblem t hat is of much conce rn to orthodontists who are treating malposition of t eeth assoc iated with cleft palate. Because of the belief that cleft p al ate is caused by a f ailure of un ion of th e lateral half of the maxilla and prema xilla, surgeons have in a la rge number of ca ses closed th e gap by following the operating procedures known as th e Brophy ope ra tio n. In many eases f ollowing such a n operati on, th ere was a loss of so many tooth buds that th e maxilla r emained st unt ed and f ailed to grow in proportion t o th e devel opment a nd growt h of the mandi bl e. Naturally, the f or ces of masticat ion a nd occlusion were either destroyed or in su ch a pronounced malrela ti on that the end-result wa s an exte nsive malocclusive a nd dcnt of aeial def ormit y. When one studies the embryolog ic development of th e dentofacial area , one ca n a p pre ciate th at a failure of un ion of the various parts th a t mak e up th e lip , t he pr ema xilla ry bon e, a nd the palate, will produce a cleft . Arrested developmen t t o a lar ge degree i s a f act or that pr events the union-especiall y true in a clef t of the alv eolus betw een the en ds a nd mesogn athion. Th e cleft i s du e not only to a failure of union, but al so to th e mesognathion hav in g fail ed t o develop . In such cas es th ere is always a lateral tooth missing. In some ca ses I ha ve obser ved th e endog nathio n an d the mesognatliion st ructures missing, leaving a large alveola r cleft . Wh en this happ ens and the cleft is close d by forcing the la t er al halves togeth er , th ere naturally is a n unharmoni ous rel a tion of the ma xill a ry an d mandibular teet h . Th e mandibular ar ch i s larger and t he maxillary arch smaller. If in snch cases th er e is a loss of a number of t ooth buds fr om passing wir e th r oug h the alveolar structure, then th e deformity is more ex t reme a nd th e ma xill a r esembl es a ll infantile j aw ca lled ma xill ar y micrognathia. It is in such cas es that the patient cons ult s the or t hodont ist f or r eli ef . N aturally such extreme dentofacial deformities with th e loss of a nu mber of maxilla ry teeth , hav e a rather unfavorable prognosis in so far as it r elates t o orthodontic care. Therefore, I have for a number of yea rs di scouraged a ny op eration that closes a cleft by forcing the parts together as performed in the Brophy operation. Su rgeons who manifest a desir e t o give their p atients a well bal an ced fa cial outline shou ld give ser ious consideration to the impor t anee of p reserving t is sue in order not onl y t o close the cleft, but t o establish harmonious relat ion of th e a dj acent struct ur e. Surgery al one does not always offe r to cleft p al ate patients th e r esults hoped f or. Orthodontics when mast ered a nd its principl es un der st ood , offe rs to th e or al surgeon a distinct advantage in the correction of complex and complica te d malformation in cleft pal ate cases. N ot only should the or al surgeon be familiar with ort hodontics, hu t he should kn ow the advantages t hat prosthetics offer in the field of ora l surgery. Many clef t palate cases that fail t o r espond t o plastic surgery d ue to sh ortage of tissue, can be g reatly improved with the insertion of artificial dentures a nd pal a tes th a t give th e patient a remarkable improvement whi ch surgery alone fail s to provide. Therefore a knowledge of the principles and t echni c in surgery, co mb in ed wit h the principles a nd tec hnic in orthodontics and prosthetics, g ives the or al surgeo n the judgm en t whi ch is so nec essary f or the correct ion of p alate and lip clef ts, wh en complica te d with dentof acial def ormities, irregu larit ies of the teet h, and malrelat ion of the dent al ar ches. I f avor Dr. Kirkha ms method of clcsing the lip ea rl y in life. Th e acti on of th e orbiculary muscle will help mold the alveola r structures so th at th ey confo r m t o a better outline.
that cleft palate, so gross a developmental deformity of the I Tjaw, patent often involving as it does the alveolus, should be accompanied by IS
malformations of various types and degrees of the dental elements; however, case analysis shows that the extent of dental defects is not in direct ratio to the maxillary deformity. Taking this as a premise it is at once obvious that while certain of the disturbances of dentition met with in these cases can be attributed to embryologic deficiency, some at least are due to other disturbing elements, and since a larger percentage of disturbed dentition occurs in cases following operations in which the jaw has been penetrated through surgical procedures, it is safe to infer that some of the problems confronting the orthodontist in cleft palate cases are a result of surgical intervention rather than embryologic deviation from the normal. As the defect in the alveolus in complete palate clefts occurs at or near the lateral incisor, it is, therefore, obvious that this tooth shows more embryologic irregularity than all of the others. A study of the variations of the lateral incisors as seen in these cases brings out some very interesting data, true of only academic interest. These data may be of future value in helping to solve some of the problems of mechanism in the etiology of these deformities, which in turn may help to improve the practical side of palate repair. The premaxilla is developed from the frontonasal process and in childrens skulls and some adult skulls is seen to be composed of two portions on each side of the midline. (Fig. 1.) The mesial portions are known as the endognathion, the lateral portions as the mesognathion, and the maxilla proper being known as the exognathion. It has been taught for many years that the premaxilla bears four teeth, however, a study of cleft palate cases shows that this is seldom the case. The lateral incisor on the cleft side is often absent, and when present is more frequently placed on the exognathion rather than the mesognathion side of the cleft. This observation led Albrecht to the opinion that in cleft palate the cleft occurs, not between the mesognathion and exognathion, but rather between the mesognathion and endognathion, associated often with a deficient development of the mesognathion. Observance and study of a case of rare lateral cleft (Fig. 2) tends to bear this out, and also to bring to light additional theories on face development and the vagaries of the lateral incisors. The case in question showed a bilateral cleft of the lip which extended lateral to the nasal ala with a cleft in bone ox: embryonic scarring which extended up to the orbit on both sides. On the left side the orbit was markedly *Read at the Thirtieth Annual Meeting of the American Society of Orthodontists, St. Louis. Mo., April 20-24, 1931.
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Dentition in Cleft Palate Cases
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contracted with an atrophied blind globe; on the right side a globe showing corneal scarring and symblepharon was present. This globe is apparently blind, but may be remedied by iridectomy later. In conjunction with the above, there exists a cleft palate which shows a bridging of tissue across the cleft in front, with a gap in the alveolus, and an extremely wide cleft with an apparent lack of palatal tissue. The premaxilla in this case is very interesting in that it contains four tooth buds, is much wider than the premaxilla in the average bilateral cleft palate and besides shows little or no forward displacement. This raises the question as to whether or not the mesognathion bearing the lateral incisor is so poorly
Endognathl'on JI esognatltion Exognat7tion
Fig. I.-Premaxilla, after Albrecht.
Fig. 2.-Lateral cleft extending Into both orbits.
developed or nondescended in bilateral clefts that the forward displacement of the premaxilla is an apparent rather than an actual forward displacement. Should this be true, it is obvious that it is incorrect to force the premaxilla back into the gap at operation, and as a matter of fact this is proved practically and seen in cases when this replacement has been accomplished by the action of lip muscle pull following repair of the lip over the gap. In these cases the arch is far more normal, to say nothing of preservation of dental structures. (Fig. 3.) Keith in his very comprehensive studies on the mechanism of face growth states: "It is not necessary to go into all the reasons which have led us to regard the alveolar part of the maxillae, the part which lies below the level
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of the hard palate and forms the bony socket of the teeth, as a distinct growth element, a plastic element regulated by its own independent system." Study of cleft palate cases shows that the alveolus though cleft, shows little or no growth disturbance except at the site of the cleft, namely the mesognathion; therefore there should be no special reason why dentition should be disturbed except in the lateral incisor area; unless we include such conditions as supernumerary teeth which, while more common in cleft cases are also seen in otherwise normal mouths and especially in the families of palate and lip clefts.
Fig. 3.-Double cleft palate before and after replacement of premaxilla by muscle pull.
Fig. 4.-Model of unoperated unilateral cleft palate in an adult showing good dentition except at site of cleft.
To determine the influence of palate clefts per se on dentition, it becomes necessary first to study the older cases upon whom no operation has been performed. In this study it is interesting to note that there is invariably no more disturbance in dentition than in the normal mouth of similar age, except as before stated in the region of the lateral incisor. (Fig. 4.) Another interesting observation is that caries is no more frequent in this nonoperative series in the maxilla than in the mandible, tending to show that clefts per se have no bearing or are not a causative factor of caries. (Fig. 5.) Whether lack of calcium or improper diet has a bearing on the causation of caries is a matter to be solved largely by the dentist and has no bearing here except as above stated that cleft palate does not appear to be a causative factor.
1079
Dentition in Clef t Palate Cases
'I'he study of this se ries fu r ther shows little or no distur ba nce of maxillary grow th exce pt that in volvin g th e mesognathion ; whic h by com parison with the cas e of lateral cleft descr ibed earlier, probabl y is devel oped fr om the nasofrontal pro cess and forms th e alae of the n ose and the n asal pro cess of t he ma xillae, f or in this case t he cleft exten ds t hr oug h th e inf raorb ital canal which it must be r ememb er ed r emains open into th e floor of the or bit in t he newb orn infants. A comparison of t he above ser ies wi th cases up on w hom some sort of jaw pen etration ha s been p er f ormed gives a t otally differ ent picture in regar d to
F ig. 5. -Models of maxllla and m an dible in do u ble lip and pala t e r ep a ir ed w it h out w ir es s ho w in g n o latera I s p r ea d a t tuber osities,
A.
B.
c.
F'i g, 6.-Unilateral palate and lip repaired b y wires . A , B efo r e op era t io n; B, immedi atel y after op eration; and C, eigh t years Inter ; sh ow in g total la ck of develo p men t of m axill a .
failure of development, caries, and misplacemen t of den t al eleme nts . Th e la ck of development is more appare nt in t he alveolus than in t he maxilla proper , and in some instances the alveolar gr owth ha s been comple te ly arrested. (Fig. 6.) The cases whi ch show such ex t re me growth disturbances ar e t hose in which the wire wa s known t o have be en placed too close to th e al veolar border, thus cutting off th e al veolus from t he maxilla . St u dy of seria l sections of a cleft palate case showed such extremel y hi gh p osition of too th buds that it seems almost impossible to insert wires high en oug h t o avoid injury
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H. L. D. Kirkham
to these elements. The lack of development in the alveolus rather than in the maxilla bears out the statements of Keith, and further since the growth centers which largely influence the forward growth of the maxilla are situated in the sphenopterygoid region and along the vomer it would be difficult for wires to damage these centers seriously, therefore, the damage done by wires to development concerns the alveolus rather than the jaw proper, often because the wires are placed too low. However, should they be placed high enough to avoid growth disturbance the wires have a marked damaging effect on the tooth buds and dental elements. Study of the groups of cases in which the wires did not effect alveolar growth shows that caries, absence, or misplacement of premolars and molars invariably occur. (Fig. 7.) Whenever caries of teeth in the maxillae occurs
Fig.
7.~Unllateral
lip and palate repaired by wires. showing disturbed dentition.
Fig. S.-Occluslon In an Incomplete cleft palate with a very wide cleft.
in such cases, it is seldom found that it exists in like ratio in the teeth of the mandible, demonstrating that the existing caries is a result of the damage done to the maxilla and its contained tooth buds. If the results of cases upon whom some form of jaw penetration has been performed are compared with those which have had no penetration, we find a striking improvement in regard to the shape and form of the arch (Fig. 8), development of the maxilla, and still more improvement upon the existence of caries and misplaced teeth. The arch in these nonpenetrated cases more closely resembles the normal, and consequently occlusion, though naturally not perfect, is far better. (Fig. 9.) At the site of the lateral incisor we frequently. find disturbances of development, but this exists without operation
Dentition in Cleft Palate Cases
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and is attributable solely to the deformity. Regarding caries, or missing premolars and molars, we find little or no more irregularity than in the normal jaw of like age. Since so much more frequently the end-results are better when wires or some form of jaw penetration are not used, it is safe to infer that such operative measures are not alone unnecessary, but invariably cause damage of themselves. It is interesting to note that occlusion in the molar region is as good when no penetration has been performed as with it. It can well be asked that if no wires penetrate the jaw what holds it or brings it into position ¥ This is accomplished by the continuous action of the orbicularis oris muscle after repair of the cleft lip; and orthodontic experience with these cases immediately impresses one with the power of this muscle and what a large factor it can be, for better or for worse. In some instances, particularly of double cleft where the premaxilla has been forced too far back, this lip pull is sufficient to counteract orthodontic measures designed to bring the incisors forward. If the principle of lip pull is employed to reform the alveolar arch, it then becomes a matter of personal
A.
B.
Fig. 9.-Complete unilateral palate and lip. A, Before operation; B, after closure by the use of lip pull.
choice as to the method and sequence of the operation by which this is accomplished. Many repair the lip as early as possible, later repairing the palate when the child is a year or so old, thus completing the case in two operations. However, it has been my experience that as good lips were not reconstructed and that frequently a secondary lip operation was necessary when the lip was repaired before the gap was closed, and further, the percentage of holes occurring in the extreme front part of the palate was greater. While of themselves these holes, if small, are not of such vital import, yet if they can be minimized it is advantageous. Before I used the principle of lip pull, it was the practice to repair the front part of the palate first and later, in six or eight weeks, to repair the lip. This has many advantages in that the front and difficult part of the palate is more easily closed before the alveolar border is molded, and furthermore is closed completely; which makes the closure of the posterior part of the palate much easier. Since using the lip pull the following sequence of operations has been followed which has proved very satisfactory: The front part of the palate is closed by utilizing a septal flap; the alveolus is molded to take the spring out of it;
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th e lip is th en undermined an d the edge s a t the top of th e cleft are fresh en ed down t o th e mu scle and two silk worm sut ures are t hen pl aced well ba ck in the chee k so as to coa pt the freshened mu scle of the lip. (F igs . 10 and 11.) Th is almost re constructs t he nostril, though n o attempt at complete lip r epa ir is done. Th e baby is the n all owed t o r est fo r about eig ht wee ks , at which time th e lip has usu ally been conver te d in t o an in complet e clef t with the columella in t he midline, t he gap in t he alveo lus closed and the front part of t he palate close d. Th is conditi on of affairs makes the r epair of the lip at t his tim e mu ch eas ier, and a more satisfactory lip and nostril are r econst r uc te d. (F ig. 12.) L ater when th e child is a year or so old the r emaining pa rt of the palat e is r epaired, which becomes ofte n a compar a tively simple procedure becau se the lip pull ha s furth er narrowed th e cleft until it of te n lies almost in appos it ion. While this procedu r e ha s proved very satisfactory in my hands, it is in no way intended as a criticism of other sequen ces or methods of operation, for so long as th e fu ndamental principles of any operation are adhered to, the details of t echnic mu st be somewhat a
Fig. 10.
F ig . 11.
F ig . 12.
Fig s. 1 0. 11. a n d 1 2.-U n il.a t e r al li p a n d palate at t h e various stages of lip r epair.
ma tter of individual expe rie nce so that a method is worked out which gives the b est r esults; granting t ha t an other might get as good or better r esults by employing another way of accomplishing the sa me end. It might be asked why the lip and front part of the palate are not r epaired at one tim e thus saving an operation ; the answer is because it has been felt that this is a little more than some of t hese babies can safely stand. To summarize: Th er e are certain dental def ormities whi ch can be expe cted as a result of the cleft, chief of which are : displace ment , ab sen ce, or poor dev elopm ent of the la t er al in cisor on t he cleft side; also supernumerary teeth are more frequentl y found in cleft palate cases and in th e families in which clefts occur. Followin g jaw penetration ope rations a larger p ercentage of missing t eeth, misplaced teet h, and caries, is f ound than in those who ha ve had no op eration or have been operated by methods whi ch do not penetrate the jaw. In conclusion it is urged that much damage is don e to the teeth and dental elements by penetration of the maxilla, which damage is largely elimi-
Dentition in Cleft Palate Cases
1083
nat ed when some m ethod which utilizes the principle of lip pull is employe d. What method is used depends upon the individual prefer enc e of th e op erator, bearing in mind that the fundamental principl es of an y procedure mu st be sound if the end-results are to be u nif ormly those which are so ear nes tl y desir ed. DISCUSSION
Dr. Matthew N. F ederspiel.-Dr. Kirkhams inter est ing paper deal s with a pr oblem t hat is of much conce rn to orthodontists who are treating malposition of t eeth assoc iated with cleft palate. Because of the belief that cleft p al ate is caused by a f ailure of un ion of th e lateral half of the maxilla and prema xilla, surgeons have in a la rge number of ca ses closed th e gap by following the operating procedures known as th e Brophy ope ra tio n. In many eases f ollowing such a n operati on, th ere was a loss of so many tooth buds that th e maxilla r emained st unt ed and f ailed to grow in proportion t o th e devel opment a nd growt h of the mandi bl e. Naturally, the f or ces of masticat ion a nd occlusion were either destroyed or in su ch a pronounced malrela ti on that the end-result wa s an exte nsive malocclusive a nd dcnt of aeial def ormit y. When one studies the embryolog ic development of th e dentofacial area , one ca n a p pre ciate th at a failure of un ion of the various parts th a t mak e up th e lip , t he pr ema xilla ry bon e, a nd the palate, will produce a cleft . Arrested developmen t t o a lar ge degree i s a f act or that pr events the union-especiall y true in a clef t of the alv eolus betw een the en ds a nd mesogn athion. Th e cleft i s du e not only to a failure of union, but al so to th e mesognathion hav in g fail ed t o develop . In such cas es th ere is always a lateral tooth missing. In some ca ses I ha ve obser ved th e endog nathio n an d the mesognatliion st ructures missing, leaving a large alveola r cleft . Wh en this happ ens and the cleft is close d by forcing the la t er al halves togeth er , th ere naturally is a n unharmoni ous rel a tion of the ma xill a ry an d mandibular teet h . Th e mandibular ar ch i s larger and t he maxillary arch smaller. If in snch cases th er e is a loss of a number of t ooth buds fr om passing wir e th r oug h the alveolar structure, then th e deformity is more ex t reme a nd th e ma xill a r esembl es a ll infantile j aw ca lled ma xill ar y micrognathia. It is in such cas es that the patient cons ult s the or t hodont ist f or r eli ef . N aturally such extreme dentofacial deformities with th e loss of a nu mber of maxilla ry teeth , hav e a rather unfavorable prognosis in so far as it r elates t o orthodontic care. Therefore, I have for a number of yea rs di scouraged a ny op eration that closes a cleft by forcing the parts together as performed in the Brophy operation. Su rgeons who manifest a desir e t o give their p atients a well bal an ced fa cial outline shou ld give ser ious consideration to the impor t anee of p reserving t is sue in order not onl y t o close the cleft, but t o establish harmonious relat ion of th e a dj acent struct ur e. Surgery al one does not always offe r to cleft p al ate patients th e r esults hoped f or. Orthodontics when mast ered a nd its principl es un der st ood , offe rs to th e or al surgeon a distinct advantage in the correction of complex and complica te d malformation in cleft pal ate cases. N ot only should the or al surgeon be familiar with ort hodontics, hu t he should kn ow the advantages t hat prosthetics offer in the field of ora l surgery. Many clef t palate cases that fail t o r espond t o plastic surgery d ue to sh ortage of tissue, can be g reatly improved with the insertion of artificial dentures a nd pal a tes th a t give th e patient a remarkable improvement whi ch surgery alone fail s to provide. Therefore a knowledge of the principles and t echni c in surgery, co mb in ed wit h the principles a nd tec hnic in orthodontics and prosthetics, g ives the or al surgeo n the judgm en t whi ch is so nec essary f or the correct ion of p alate and lip clef ts, wh en complica te d with dentof acial def ormities, irregu larit ies of the teet h, and malrelat ion of the dent al ar ches. I f avor Dr. Kirkha ms method of clcsing the lip ea rl y in life. Th e acti on of th e orbiculary muscle will help mold the alveola r structures so th at th ey confo r m t o a better outline.