Importance of timing of treatment in cases of cleft palate

IMPORTANCE OF TIMING OF TREATMENT CASES OF CLEFT PALATE

IN

URIK(I recent years there has Iteen renewed interest. in the c~otnprehcnsivt~ care of the cleft palate ltatiettt. Specialized clinics for the (aare of such patients are h&g formrtl itt trtost of the larger centers of population. However, the principles of treatment antI ihe proper tinting of the various types of therapy are not peneraIIy untIet,stctotI. This presentation is made with the t,hought that the recording of our experiences with the orthodontic prohlents in patients wit,h (aleft palat,e tttay serv(’ to emphasize these principles ant1 lo serve as a guide for the timing of specific treatment. At The New York I losldtal. chiltlreu with vlrft I)alate itrt‘ I)t~o~Sessetl s~~e~‘rt through the plastic surgery c~li~ri~. I’lastic surgectlt, orthodontist,, therapist, dental surgeon. ])sychiai rist, pediatric~iatt, itltd social wc)rker eo(tpet’I~‘Ot*Sf~VetXl ye;llYi I)reviously, Cleft I)ill;ltf’ C’ilSt’S ate in t,hr care of the patictrts. had Iteen cntwl for hy usill, 1)’outsitIt> I)ri\-ate ]tt’;tctitiotlc,t,s for orthotlontic ;ttttl speech problems. Thtls, :t sizahlr hacdklog ot’ patients was avnilahle for ohservation. The orthotlontic pt’oKt*ittlt hils I)eett worketl (lilt hy I>r. JOW~II I). J’:l)y. Dr. E:l~y IICI.S etttljhitconsultant in orthodonticas to The iYew York Hospital. O’ of orthotlontic treattnc~t. sized the importance of corroc:t titttitr, Usually the cleft is tliseo\~eretl ;tt I)irth I:y the attcntlitrg ])hysicialt, ~110 then refers the patient to the plastic surgeott. IXfferettce of opinion exists as to the ideal time to etnploy surgical correctiott OCthe cleft. There is general agreement that, clefts of the lip should Itr ohliteratrcl hy c~heiloplnsty soon after In most clinics this is tlonc at the elec+ivr itge of 1 to 6 weeks. 111 birth. The New York Hospital cleft lip is repairetl imtrrrtliately ilftet* birth. ‘I’h(b The infattt leaves the hospital advantages of this plan wt’c :tlt])nrrtrt at OIIW. at the time of discharge of the utothtbr. Thcrcl is ec~onotny of cost of hospitalizat,ion and the parents are sp;tred the cauriosity OF relatives ant1 friends. The orthodontist examines these ])aticnts as early as possihlt~, since the E;I rly observation structures as ohservrcl itt hit4 h tlC~tt~rlttitttJ $tWWtll ])ilitCt’tlS. of’ the of patients with cleft It;tlatt~ c~ttric~hc~s1hr orihotlotttist ‘s a],l)reciatioo The 0rlh0tl~~tilist atttl sltcrc~h therapist shonld set: nature of the clr-Fortttity.

D

of Ikmtat I+OIII the Departrntmt 01 I’lastic Sur~x:r~ry :,ntt tllc. Ikp:,ttmmt Pork Hospital-Cornell Mectical Cc?nttar. Association This work supportwl by grilnts from The New York StatP Ctritdlren, Inc., and The Vincent .4stor Foundation.

.Su~~gt-vy of TIII.

St:xv

for

c’ripplwl

the patient plan taettt,h inay

1)~ his thirtl

fat* the

patietrt.

tttottth. he

Thus. In

tlentition.

ment

is iritlicatetl.

woul(l

:

vhiltlrrtt

(il)

ittt(l

tiutis

antI

of

the (c)

I)oIII

until

ot~lhc~clot1tic ot’ seVel*e of

these e;rt*ly

~~tl~l’~ll

; (I))

I)ands;

the

1);1l;tiitl

CasW

in

tlurittg

follOWs

ittitial

lttstitutiot1

he tlesitxl)lc~

pt*activc(l

thr

tl1tb l~t~i~tls

SilIll~Itiltl~Y~llS

mixed

This olw+,rv;ltiot~

yw I’.

sit1cc

relative

of

is ~IOIIP

tl~C?iltlll~tlf

cotttt~ac~tion,

is

i hrtxl)y

teeth

ttl?

is ttot

for

tt’rilt-

C~losUlX~ seltlo111

t’or

this

lll~tl~l~t’lll~tlt

suitahlc

(‘ttt*e ;tt 110t11e ilt this

1;1ck of ot*itl

eWly

appliat1ee

tw~sotis

ciahf-

the

cbI)s(‘t*\-:ltiolt lhta stage Of

vet’;

l)y

‘I’he

itt

Ilt’~‘~‘SSilt’V

al)c)nt

xftet. palatitl

it1rtllrtliittely

tl~~~rl0~~11irt11.

tlecitluous

at

i1tttl otdho(lotttiv ;tl)l)lirs (luring

n1;ixillat~~ I lowever,

of

illlt~SthWi~t

shal)e

stlt*lic.;1l

c~spatisiott

eases.

stage

fits in ~~(~11u-it11 I hc sut~~wll’s

t.vl);lit*

Of

its

~Ollll~

I)liIcet11ettt

RIP invites

is

ii w

of

~olrl])li(~:l-

t)rol~lems. A.

Fig. I.-A, The extent of the bitr CIOSIII.~~ is t~~i~t~ncr~t by the (lifficulty in getting a photographic flel~l ; R, nine montlls‘ trcntnlrant \$‘itll a ~.w~t~vwl ~cpper lingual arch has effwte,I marked opening of the bite. ‘I’herefore, eruption

of

tlication

for

crepancies vross-bites. tnasillary c*isors

permanent

the

initiation

is the

with

1) over

incisors

anti

of treatment.

immediate

Appliance ttreit

(Fig.

tt101ar cross-bites

when the

goal. therapy

incisor the

lower

atttl/ot* of the At

this

that is, the consists of

springs ones.

whet1

ittltet.i()t* cross-bites first permanent molars stage,

correction t~ut~retl ne(aess:lr’y

h lowet~

lir1gual

correction

exist, the is the in-

of major

dis-

of molar and anterior lingual arches in the to

,junq)

arch

often

the

upper is placctl

into

If possible. upper illltCl?Ol teeth itivolvetl in the cleft ill'e retairietl during this period of tr*e:Ltment unlt~ they illtrt4Yer.e with surgical therapy, speech. mastication, or are iIT~p~~~;lbl~ (!;trious. It is reillizetl that rtlaJly such teeth lack suficient b0J1y SUPPOI*~ ~VPI’ to serve as l)ridgr ilhutmeuts iltl(l mily have to be sacrificed later. However, their ~~rrseuce pt’e’veuts the tongue from formIf the ing thrusting habits, aids speech, ilIlt{ allows for ljetter appearance. alignment of the teeth ad,jac~cnt to the cleft (‘ill1 IN accomplishetl while other we matters are being attended to, we do so, using il multihanded terhniyue. do not take time at. this stage to treat these teeth slxdically, since the prognosis for their survival is not gtrotl. Ii’ teeth aw missing to such an extent

:I .

c

A.

I?.

('.

Fig. -s.-Diagrammatic sketch of the regional anatomy inwlv~~~l in the one-stage pushThe dottell lines reuresent thr, uosition
Additional palab surgery may he performed if the speech mechanism is faulty despite t,herapy. Palatal push-backs (b’ig. 7) are performetl t,o incwase length of the palate and to effect better closwe of the velo-pharpngeal sphincter. The pharynyeal flap operation (b’igs. 8 ant1 !)I, which utilizes :I flap of the superior posterior pharyngeal wall to join the posterior portion of the soft palate, is performed on occasion to maintain permanently the effect, of the lengthening of the palate. These procedures tend to overcome nasalizaThe results are quite cf’fecti\e ;Itltl. as n result, prost,hetic tion of speech. ob-

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