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Orthodontic treatment for the cleft palate patient
ORTHODONTIC
TREATMENT
M. C. JOHNSTON,
FOR THE
L).l).S.,
Jl.Sc.L).,*
CI,EE’T 1’ALATE
PATIENT
TOI
IKTRODU(‘TIoK
T
HE purpose of this article is t,o prosent the principles and p~~md~rc~ employed in the orthodontic treatment of cleft palate patients at the Hospital for Sick Children in Toronto. In 1952, a program of orthodontics for cleft palate patients was initiated at the Hospital for Sick Children by Dr. Egil Harvold. Financial support was received through a NaGonal Health Grant and the Ontario Division of the Junior Red Vross. Many of the treatment) principles which Dr. Harvold derelopcd, as ~011 as the appliances that, he used, will be dcscribcd in this article. In 1955 a generous grant from the Atkinson Charitable Foundation made possible not only continuance of the program but also expansion and inclusion of other services in ortler that the problem might bc approached on a team basis.” Out, of some 450 patients examined by a consultation team, 226 arc presently rccciving orthodontic WW. l’hc orthodontic managcmcnt of cleft palate patients difY’crs considerably from routine orthodontic practice. To appreciate thcsc differcnccs, it, is ncccssary to understand certain basic information about cleft palate. Incidence, Etiology, and ClassificchIo7~ of the Di#erent Types of C’lefts.The terrn cleft 2xxZate is commonly used to describe a wide variety of facial clefts involving the upper lip, maxillary alveolus, and palate. The incidence is fairly constant the world over and gencrall; OCCUJ’S in a ratio approximating one in 750. This incidence has been confirmed for the Province of Ontario.7 Tlittle is known of the cause of the phenomenon. The only cstablishcd etiological factors arc genetic, and thcsc arc not well understood.” A positive: familial history has baen found for appr’osirnatcly one-third of thtl patients we have examined. It is probable t,hxt rnal~y clefts result from crivil~orinle~ltal disturbancq and clefts have been produced by such disturbances in animal espcrilnentation.‘~, I” When the embryologic processes forming the upper lip, maxillary alveolus, and palate unite only partially, or fail to unite at all, clefts result in those areas in which fusion normally would have taken place.” The different forms which these clefts assume may be classified into four primary types (Fig. 1). Clefts of I’rcsented at the fall meetinfi uf the Northeastern Sxicty of Ol‘thodontists. Iluffalo, New York, Oct. 23, 1957. *Director of Orthodontics. Cleft Palate Kesonrch and Treatment Centw, Hospital for Sick Children, Toronto, Ontario. Canada.
Volume 44 Number IO
ORTHODONTIC
TREATMENT
FOR CLEFT
PALATE
PATIENT
751
A. Cleft lip.
B. Cleft palate
C. Unilat era1 cleft lip and pal ate
D. Bilat era1 cl:f:dlip palaf e
,.._ ,’i:,:;‘...‘., ,..’ .
fbb Pre-surgical Fig. I.-illustrations of cal deformities. The segmental trated by schematic diagrams.
the
Post-surgical four prinlary cleft types “collapse” tof the cleft lip
depicting and palate
presurgical and postsurgitypes (C and D) is illus-
752
.JOHNRTON
Am. J. Orthodontks O
195X
the first type are those of the lip (and a,lveolus) and, while they are usually The ilcgrcc of lip clefting is I’(‘unilateral, they are occasionally bilateral. flcctcd in the degree of associated alveolar c1cfting.l” Thus, clefts of this type will vnry in tlogrcc from a notchhing of t,he lip, with little or no associatetl al~~olnr cleft. to the morv complete lip and alvclolar clefts, such as the unil~lt(‘~ill cleft illuStI’ir.tCil in I<‘&. 1 , ;1. (‘lefts 01’ t,he ssccond type arc those oi the palate. They map- merely divide the uvula or, as in Fig. I, R, they may estend I’o~ward into the anterior portion of the hard palate. Where clefts ol’ the above types are continuous with one irrroth(‘r, WV have the unilateral and bilateral I’ornis dcfts of lip and palate. Thcsc constitute thr lasl two typos, the complete of’ which arae illustrated in Fig. 1, f’ ant1 D. The isolatetl clefts, that is, cleft, lip (and alveolus) alone or cleft palate alone, constitute ahout 50 pw cent 01‘ the total, t.he relative frequencies of the (‘lofls of lip (and alvwlus) wit,h associated two types being nhoul the sam(~. calcft, palate const,itutc the other 50 I)c’r c>eM, lhe unilateral cdlel’ts ont,rtumbering the bilateral clefts aplJr,osirn;ltcl~- two to on(a. Genercrl :I(clnn!lel,zent.-‘l‘htr pritncb ol)jcdivcts in the habilitation of the cleft palate patient :II’C the att~a.inmcnt of awcptahlc apltc’araneca and the establishnient of adequate speech and mast icatory fund ion. The complexity of those and associated prohlen~s requires the integrated services of a team which inc~lutl(3 thv petliatrivian, su~~gvori, sp(l(‘cdhth(xt*illJist, tl(hrrtist, i111tl orthodontist. cacdh specialist being tlepcrrtlcnt U~U~Ithe others. Srr~gi~al tarpairs a~(1 cJi1lTid Out t,o obtain Soft tissue CloSur~c~ of t,lr(l clefts. At t,ht> HoslJital for Sick (‘hildrcn, ulcfts of thv lip a~‘(’ ol)et*iLtetl on when the piIt,iPllt is about 1: months 01~1ant1 clefts ot’ t,hc palate when the patient is 1 tl il f(lW c*c!tltPl*S. thc2 latt(~r procctlurc is sometimes iLh(jut 18 rrronths 01~1. tlelayc~l nntil t,hc iIg(l ()I’ 4 OY 5 yt’ilI*s in ;Irr atternl)t to ~tlu~+c restrictions to maxillary growth. In most, MSCS in which speech th(Lr*irl)y or guidance is nrcessa ry, such therapy is prefct*:rbly iustitutcd when spccc*h is in its tlcrclop~rrc~ntal stages. As speech Wficultic~s usually ~csult from inad(~quncdes of the surgically reconstructcd soft pal;rte and tlcformititls of the cltdofacial structures, assistance which the surgwn, orthodontist. or 1Jr~osthotlontist cirrr uffcr may be essential to thr sucwss oi’ the spcrch therapist’s efforts.
There :r~(’ I11;Irkcd diflervncc~s in derrtc)f:~&tl growth and development among the various typcls of vlri’t, ant1 otthotlontic management varies insiderably. .In isolatctl vlcfts 01’ t.hc lip or palate, whtrv the maxilla is not tlividd, maxillary growth irnd tlcvc~lolJlllr,llt a~‘(’ Ilot rr~ar~k~dly affected ant1 consequently the deforrrrity is ncithcr #rcirt nor difficult to treat by the usual 011 th(l <)th(xr hand, growth i111d tlcvelopment are orthodontic ~~t.owtlu~~~s. markedly affevtctl in clefts of the lip and palate (where the nrasilla is divided) , and they rc~quitx~ rather spc4ul orthodontic managc~mc~nt. Treatment of the latter cases has reccivd ronsiderable attention” ant1 is also stressed in this article.
Volume 44 Number IO DENTOFACIAL
ORTHODONTIC
GROWTH
TREATMENT
AND
DEVELOPMENT
FOUR
PRIMARY
FOR
AND TYPES
CLEFT
PALATE
ORTHODONTIC OF
753
PATIENT
MANAGEMENT
OF
THE
CLEFTS
Cleft Lip (and Alveolus).-When the cleft of the lip is slight, no associated alveolar defect may be found. Dental deformity is slight, or absent, and usually orthodontic treatment is not necessary. In more complete “lip” clefts, where the alveolar clefting is more extensive (Fig. 1, A), the localized effects of a cleft passing through the alveolus will be seen without the modifying influence of divided maxillary segments. Usually, any adverse pressures exerted by the repaired lip have little or no effect upon the almost intact maxilla. The localized disturbance occurs in the region of the lateral incisor and is manifested by malformation and rotation of teeth adjacent to the cleft and frequently by the absence of teeth or the presence of supernumerary teeth. Supernumerary teeth are a common finding in the deciduous dentition, while the lateral incisors are very frequently missing (or at least poorly formed) in the permanent dentition. Treatment is straightforward and may be carried out in the mixed or the permanent dentition. It is generally necessary to band the incisors, and WC have successfully used both twin arch and edgewise appliances. The former is particularly applicable in mixed dentition treatment. Retention is often a problem, and in the most severe cases fixed splinting across the cleft region ma.y be indicated. Cleft Palate.-Surgical repair of partial clefts of the soft palate seldom affects dental development in any way. When it becomes necessary to carry the surgical repair onto the hard palate mucosa, however, the resulting scar tissue contraction often manifests itself in a dentoalveolar constriction. This If the cleft constriction is generally localized to the posterior segments. extends appreciably into the hard palate (Fig. 1, B) and the surgical repair underdevelopment is correspondingly more extensive, a general maxillary may result. The underdevclopmcnt is usually slight and insufficient to cause any crowding in the deciduous dentition, but considerable crowding may be present in the mixed and permanent dentitions. Tn order to obtain the most itleal end result, it is generally necessary to treat early, thereby removing any restrictions to maxillary growth imposed by cross-bite relationships. Tn many ways the isolated cleft palate problems resemble noncleft problems closely and may be treated as such. Flxpansion may be accomplished by a number of appliances. Alt.hough the expansion appliance dcvrloped by Harvold, which will be discussed in sonic detail later, is designed primarily for segmental movement, we have also found it to be most efficient for simple dentoalreolar expansion. If the original constriction was not severe, then cuspal interdigitation in the buccal segments and a positive overbite in the incisor segment will usually be sufficient for retention. Occasionally, it may be necessary to use a palatal prosthesis or fixed lingual appliance.
Ilnilateral
(Cleftof
Lip
(and
Alr~eolus)
With
Asocicitetl
('left
Pal&c.-
lZsyrnmeti~y is one 0 1( t,hc most prominent (f~rowth and cl~~~elopnacnt: features of the unilateral clefts of lip and palate.” Anteriorly, the cleft simulat,es t,hat of a complete or extensive unilateral cleft of the lip and alvcolns. Posteriorly, thr pict,urc often varies somewhat from that of an estensivc isolated cleft palate in that the nasal scptutn is genel*ally fused with th(a pal:lt(: on t,hc nonclcft side. I’resurgically the segments of t,lie maxilla are often widely separatctl. Almost invariably, however, they rapidly IIIOYC medially into apposition following rcpa.ir of t,hc lip. This movcmcnt is primarily a rot,ation ilk the horizontal plane about a ])oint approximating the xggonlaticorrl;rsill;lry sutures in the region of the huttresscs (Fig. 1, t’). Some rotation in the frontal plane ma? occur, and this is manifested by a lingual tippin g of the alveolar processes. The dcgrec of medial shifting 01 “collapse” of the srgmt>nts is dcterminctl by the tightness of the lip repair, the dcvelopmcnt of the alveolar procosscs in the region of apposition, and by the contraction forces introduced by the surgical repair of the palate. The development of adequate incisor overbitt, with positive ovc>rjct, may rcducc> the degree of ~ollapsc~ in t,he anterior or prernasillary ;lWil.” is not. symmetrical but rather more The “collapse” ~~ronouttcwl on t,hc cleft side. To atltl to the facial asymmetry, the mandible vclry often deviates laterally in a functional accolllrnotliltioll to the existing occlusion. The reduction of arch length is generally insufficic~nt to ~)rotlu~e crowcling Howcvc~r, the rc~lativcly larger size of the perof the tlcciduous tlcntition. mancnt t&h, coupled with increased masillary constriction with agr (most marked during the transition from mixed to permanent tlcntition), results in considcrablc crowtling. The total growth and development of the maxilla may be affected.“ Thus, ;I. general anteroposterior deficiency may add to a tly premasillary “collapse” to giv(a the mandible a rrlatively propnathous appearance. Also, deficiencies in vertical maxillary growth Illay be~~tr~e ;Il)pt~(&blc with incrcasck in agt~. These arc ca.usc>tlby rcGstanc*cs offcrctl by th(A tongue to the eruption of trcth in constricted or nletlially tlisplaccd It~asillary scgmclnts. J F the reduction of vertical growt,h is g(>ncJr;ll, it, is associatctl with excessive freeway space! at rest, aLIt overclosurc ilt oc(~lusal contact. Ikfioicncitls in vertical growth aw oft(>n lin~itetl to regions in which t,hc “colIaI)se” is marked and are manifested by an oprn-bite in thcsc areas. l’iming of trecltnzent: In the above, there are many indications for earl; treatment. The deformit,y is less in younger patients, and a satisfactory orthodont,ic result is more easily obtainable. If the maxillary segments are carefully repositioned in a symmetrical manner, the mandibular deviations automatically correct themselves in accommodation to occlusion with the corrected maxillary arch. Nxpansion does much to alleviate crowding by irl(m?asing arch length, and early correction of anterior cross-bite tends to lessen anteroposterior
Volume 44 Number IO
ORTHODONTIC
TREATMENT
FOR
CLEFT
PALATE
PATIENT
755
growth discrepancies between the maxilla and the mandible. The problem of vertical maxillary development is not great at lower age levels and can often be avoided if the maxillary segments are moved into normal position before the t,ransition from the mixed dentition to the permanent dentition. In addition to orthodontic considerations, the importance of early treatment in assisting the more normal development of the functions of speech, mastication, and deglut,ition cannot ho ovcrloolrcd. In some children, the psychological implications of growing up with a dentofacial deformity may assume considerable importance. The advantages of early treatment outweigh the disadvantages of multiple periods of active treatment interspersed with long periods of retention. Where some follow-up treatment is necessary in the permanent dentition, it is rarely extensive. Usually the more severe cases benefit most by early treatIn patients in whom the deformity is slight, satisfactory results may ment. be obtained by treatment in the permanent dentition.
Fig. radiograph the base sutures.
X-The “x-line” of a patient crista galli
of
superimposed upon with unilateral cleft at right angles to
the tracing lip and cleft a horizontal
of the posteroanterior palate. The line line joining the
cephalometric is drawn through zygomaticofrontal
Case analysis: In order to determine the asymmetrical position of the segments prior to repositioning, and Ihence guide the relative movement on the two sides, the ‘ ‘ x-line ’ ’ analysis is very helpful59 G It is applied to the anteroposterior cephalometric radiograph, a facial center line being constructed from landmarks in the upper face as shown in Fig. 2. Thus, it is possible t.o assess the lateral position of the maxillary segments and also the lateral position of the mandible and other dentofacial structures.
7% Maxillary exp.,nnsio?z: Various appliances have been used to effect expansion in cleft palate casw, such as th(a t~xpansion scww plate popular in many popular in the United Stat,es. European countries and the Arnold expand&l The appliance whit-h Tlarvold developed specifically fol- segmental movemnt is prcfcrrcttl at the Hospital for Sick (!hildren. It consists of a lingua,1 awh with auxiliary recurve springs. Details of constrnctiolt are shown in Fig. 3.
Fig. 3.-Expansion appliance developed by Harvold. The lingual the auxiliary springs are 0.016 inch in diameter. The ends of the arrh ward to serve as posts. aml the appliance is inserted by placing these tubes and “springing” the arch gingivally to the retention lugs.
arch is O.lJ31 inch and wre bent vertirally upposts into the lingual
Fig:.
and nearing repositioning.
I.--Study pletion
models of a unilateral cleft of orthodontic treatment)
of lip and demonstrating
palate (before segmental
the
rom-
The expansion appliance dcvclopc~l by Harvoltl may be NOactivated as to control the rwultant. rtlovwncwt awnratclly. The auxiliary springs function differently, dcpcntling upon the region and nature of adjustment. i&O, where neccwary, th(b main arch may hc ac*tivatcd for expansion. and variation in the hnccolingual angulat,ion of the posts, t,hrough their torque action, way
he employed to assist in cont,rolJing the relative
cspuuion
on the two sides.
If t,hc expansion force is correctly applktl, the repositioning of the maxillary The scgrllclnts is very rapid, usually being completed in thrw to six months. repositioning is the direct reverse of the collapse movement, (Fig. 4).
Volume 41 Number
IO
ORTHODONTIC TREATMENT FOR CLEFT PALATE PATIENT
757
Following expansion, it is necessary to employ some form of retention in order to maintain the corrected position of the maxillary segments. Such precautions must be taken both during and between subsequent periods of active treatment. “Interim” retention appliances may consist of a plain lingual arch or maxillary prosthesis (Fig. 5, D). Modifications may sometimes be necessary in order to permit the eruption of individual permanent teeth lingual to the line of the deciduous arch. Anterior cross-bite correction in the Correction of anterior cross-bite: deciduous dentition may do much to assist in establishing a more normal growth pattern. It may be contraindicated, however, for many cases nearing the mixed dentition stage. This is because correction in the deciduous dentition does not ensure labial eruption of the permanent incisors and, in fact, decidnous root movement may tip the permanent incisors even further lingually. E’or these reasons, anterior cross-bite correction is frequently delayed until the permanent incisors have completed their eruption. A.
B.
Fig. 5.-Anterior cross-bite correction, in the mixed dentition, for a patient with a uniA, Maxillary expansion completed and the mandibular deciduous lateral cleft of lip and palate. cuspids extracted. B, Initial appliances for anterior cross-bite correction. 0, Anterior crossbite corrected and incisors aligned. The mandibular flrst cleciduous molars have been exD, Interim retention prosthesis. tracted.
A lingual arch with finger springs is quite efficient for the initial alignment and labial movement of crowded, lingually placed maxillary incisors. Rowever, excessive use tends to tip the anchor teeth distally. In addition to preventing this tipping a labial appliance with banded incisors is more efficient for
758 correcting rotations, handling necessary root movements, and ensuring adequate overbite for retention. The twin arch is pa,rticularly well suited although a modified edgewise appliance, or at least it,s braeke& may be used. Some form of mandibular bite block or bite plane may be necessary when the overbite is considerable. If eventual rnandibular premolar extraction is deerned necessary to relieve a t,ooth size problem or to compensate for a mnsilla deficient in anterior growth, the mandibular deciduous cuspids may bc cst,racted and an anterior elastic added to t,he bite block t,o retract, the incisors (Fig. 5). Center-line correction may sometimes be a problem. Excessive movement toward the cleft may dt~nud~ a large part, of the root, surface of the tooth adjaccnt to the cleft. In most cases, howtrrcr, t,he growth potential of the alvcolnr l)one is ntlcqunto, and a suitable result may be attained (E’ig. 5).
Fig-. 6.-Applimwe designed by Harvoltl velopment. The arms extending from the round wire and are activated occlusally.
to correct deficiencies pal&al prosthesis are
in of
nmxillary 0.029 inch
vertical de(diameter)
Correction of deficiencies ix m~xillnr~y l)erticnl development: Where segmental collapse is rnarked and repositionin g of these segments is delayed until the permanent, dentition, problems of deficient masillar,v vertical development, a rise. To aid in t,hc solution of these problems, Harvold designed an cffectivc appliance>. As illustrated in Fig. 6, arms from a palatal prosthesis (lxtend gingivally to lugs on banded maxillary teeth. Occlusal activation of the arms stimulates the eruption of the tet~th. The appliance may bc usctl to best advantage following li1tWd expansion of the maxillary segments and prior to any anterior cross-bite correction (Fig. 7 1). ~etailud positi(J?zin{/ of tpeth in the permanent dcntitim~: It, will be necessary to finish many C:IWS with ;I Illultibantl ;lppliall(x~, such as the edgewise. Multiband appliances arc: inc,ficient in controlling scgmc~ntal mo\:(1tILent, atltl precautions shoultl be t,aken to maintain the proper position of the seglrtt:nts already attained while moving t,eeth within them. If’ the arch is of propel ln those proform and its length fixed, little difficulty will be encountered. however, 0~1~ IllLIst cedures involving space closu~ (decrease in arch length)? take care to cnsurc’ suffcicnt rigitlit,y and prol)cr arc+h fornt ia order to I,“+ Vent ‘irecollapsc” of the segments.
Volume 44 Number
ORTHODONTIC
TREATMENT
FOR
CLEFT
PALBTE
PATIENT
IO
759
B.
A. PATIENT R .F. PATIENT R.F.
PRE-TREATMENT
PRE-TREATMENT CS-6-5614CCLUSAL
PATIENT
R.F.
POST-TREATMENTCIS-
(S-6-%,-REST
CONTACT
g-571 -0CCLUSAL CONTACT
PATIENT RF. POST-TREATMENT
(18 9 57) 4 REST
Fig. ‘I.-Tracings of the cephalometric radiographs of a patient with unilateral cleft l!P and cleft palate before and after flfteen months of orthodonfic treatment. A period of maxlllary expansion was followed by correction of deficient maxillary ,vertKal developm+t (usmg the appliance illustrated in Fig. 6). the remaining teeth then bemg banded to faclhtate anThe tracings demonstr?te an Improvement In terior cross-bite correction and tooth alignment. profile at occlusal contact and 8 more normal freeway space at rest poSltlon.
Volume 44 Number IC
ORTHODONTIC
TKEXTME
ST
FOR
(‘LEFT
I’ATATE
PATIENT
761
Retention prostheses: To finish t,hese cases, some kind of permanent maintainer must be constructed. This may take the form of a simple partial denture replacing any missing teeth and, by careful clasping, rotations may bc stabilized and the recurrence of open-bite prevented (Fig. 8), Eventually we anticipate splinting a large number of our cases. These splints are constructed across the cleft, an>- missing teeth being replaced as pontics. They require two abutment teeth on either side of the cleft and have been used successfully in riorway.’ Also, any lack of adequate bony support, for teeth adjacent to the cleft may be supplemented in this manner. Bilnteral (‘left of Lip (and ~llveolus) With Associated Cleft Palate.-In complete bilateral clefts of the lip a,nd palat,e, the premaxillarp segment is separated from the two lateral maxillary segments and suspended from the nasal septum (Fig. 1, D) . It would appear that this segment, consists simply of teeth and alveolar bone. The more teeth it contains, the larger the segment, and if these teeth are lost the remaining segment resorbs almost completely. Before lip surgery the premaxillary segment is carried forward at an ‘ ‘ uninhibited ’ ’ rat,c by growth in the nasal septum. The repaired lip subsequently retards this forward growth, and gradually the premaxillary segment is brought into a more normal relationship with the remainder of the maxilla. Thcx crowns of the teeth are “molded back,” and by the time the permanent, incisors erupt they are generally tipped posteriorly about 15 degrees, wit,h their crowns in linguoversion. The anteroposterior position of the premaxillarp segment is an important determining factor in the degree and nature of the collapse of the lateral seg1ncnts. The more posterior its position, tho more efficiently it prevents the medial movement of the lateral segment. The “collapse” movements and the wedging action of the premaxillary segment, are depicted in Fig. 1, fi. As with the unilateral clefts of lip and palate, it is generally conceded that early trtatrncnt is prefcrablc. However, orthodontic management of the bilateral clefts differs from that of unilateral clefts in the unique problems associated with the prcmaxillary scgmcnt and in tho fact that asymmetry is 110 longer a dominating factor. It has been our experience that in all but the most severe protrusions the prcmaxillary segment and contained t&h should be maintained in as normal a position as possible until the age: of 12 to 13 years, when most of the pcrmancnt dcntition has cruptctl. Then a tlecision may be made as t,o whethe]: or not the teeth in this segment are to be retained. Other reasons for their removal (bcsides position) include hyl)oplasia and hypocalcification. The mechanics of orthodontic treatment arc much the same as ,For the unilateral clefts of lip and palat,c. Even though anterio I’ cross-bite and maxillilry center-lint correction arc essentially scgrnental movements, appliance therapy does not differ greatly. Interim retention by removable prosthesis is generally preferable, due to the high incidence of residual anterior palatal and alveolar openings into the nasal cavities which may be covered in this manner.
retention of these cases is almost always provider1 by a rcprosthesis. ldcally, it should be placetl over splints across the clefts. cases in which the maxillary incisors are removed, it may he necessary out certain surgical proccdurcs, such as trimming or even surgical of t,he premaxillarp segment, before a prosthesis is inserted.
I'ermanrnt
movable In those to carry removal
IJIMITATIONS
OF
ORTHODOXTIC
TRFXT.\IENT
We have already seen some of the limitations in handling severe cases of bilateral clefts of the lip and palate without the aid of’ the surgeon and prosthodontist. Also, undt:rdevclopnlcrlt of the maxilla nray bc quit,c severe in unilateral or bilateral clefts of lip and pala,te, or cvcbn in cases of isolated cleft palate. If this underdevelopmcnt is associated with a well-dcvclopcd or overdeveloped mandible, it. may bc very tlifficult, or ittlpossiblc to rcclncc tltc anteroposterior discrepancy by orthotlontic trcatmcnt alone. I’rosthrt,ic IV placement of the maxillary incisors or anterior teeth nlay be sufficient in some cases, whereas in others surgical corr&ion of mandibular prognathism is indicated. In most cases, however, as those illust,ratcd of orthodontic treatment are very good.
iI1 Ii’ig. 8, the potentialities
The diagnostic ant1 treatment concepts employed by the orthodontists working in the Cleft Palate Research and Treatment (‘entre at the Hospital for Sick Children in Toronto have been presentctl. Many of these concepts were introduced by Dr. Egil Rarvold. Dentofacial growt,h and tlcveloprnent, orthodontic ma~lageltle~~t, and prosthctic retention have been described for each of the four funtlamcntal types of clefts: (1) cleft lip (and alveolus). (2) cleft palate, (ii) unilateral cleft lil) (and alveolus) with associated cleft palate, and (1) l)ilateral cleft lip (ant1 alveolus) with associated cleft palate. Some of the limitations of orthodontic trra.tmcnt, particularly thosr Wlated to severe deficiencies in anterior growth of the maxilla, wc:r(L discussctl. In recent years numerous advances have been made in the habilitation of cleft palate patients. It is holed that,, with continuc4 inr],rovelncnts in treatment, an cvcr-increasing number of these handicapped childrcln may pt’oteed to adulthood with an acceptable appearance, undt!rstandable speech, and a healthy mental outlook. REFERENCES
1. Rohn,
A.:
Retention Construction Following l)r. Harvold’s hfethotl of Repositioning the Maxillary Complex in Cleft Palate Cases, Tr. European Orthodontic Societ?, pp. 219-221, 1951. 2. Cox, M. A., Lindsay, W. K., Whnley, J. H., C’urtis, B. .J., Spence, H. J., and J,ewis, Rnth: Syrnposiurn on Cleft Palate Research and Treatment, .J. Canad. Dent. A. 23: 563. 588, 1957. 3. Fogh-hndersen? Peal: Inheritance of Hare-Lip and Cleft Palate, Copenhagen, 194!!, Nyt Nor&Sk ForlagAmold Busk, p. 226. 4. Graber, T. M.: The Congenital Cleft Palate Deformity, J. Am. Dent. A. 48: 375395, 1954.
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Number IO
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TREATMENT
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PALATE
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5. Harvold, 6. 7. 8. 9.
Egil: A Roentgen Study of the Post-Natal Morphogenesis of the Facial Skeleton in Cleft Palate, Oslo, 1954, A. W. Dreggers Boktyrherei A/S, p. 102. Harvold. EPil: Cleft Lin and Palate. AM. J. ORTHODONTICS 90: 493-506. 1954. Hixon, B.: m A Study of Lthe Incidenck of Cleft Lip and Cleft Palate ih Ontario, Canad. J. Pub. Health 42: 508-511 1951. Orban, Balint: Oral Histology and Embryology (chapter on The Development of the Oral Cavity), ed. 3, St. Louis, 1953, The C. V. Mosby Company, p. 364. Posen, A. L.: Some Principles Involved in Orthodontic Treatment of Operated TJnilateral and Bilateral Complete Cleft Palate, Angle Orthodontist 27: 109.113, 19.57.
10. Pruzansky, Samuel: Description, Classification and Analysis of Unoperatetl Clefts of the Liu and Palate. AM. J. OELTHODONTICS38: 590-611.1953. The Importance of Early Orthodontic ‘Treatment in Cleft Palate 11. Subtelny, J. “D.: Planning, Angle Orthodontist 27: 148-158, 1957. 1“I. Walker B E - Experimental Production of Cleft Palate in Animals, Cleft Palate Bill. i: s:9, 1957. Etiology of Congenital Malformations, In Advances in Pediatrics, 13. Waranky, Josef: Chicago, 1947, Year Book Publi-ihers, Inc., vol. 2, pp. l-59.
555 UWIVERSITY AVE.
TREATMENT
M. C. JOHNSTON,
FOR THE
L).l).S.,
Jl.Sc.L).,*
CI,EE’T 1’ALATE
PATIENT
TOI
IKTRODU(‘TIoK
T
HE purpose of this article is t,o prosent the principles and p~~md~rc~ employed in the orthodontic treatment of cleft palate patients at the Hospital for Sick Children in Toronto. In 1952, a program of orthodontics for cleft palate patients was initiated at the Hospital for Sick Children by Dr. Egil Harvold. Financial support was received through a NaGonal Health Grant and the Ontario Division of the Junior Red Vross. Many of the treatment) principles which Dr. Harvold derelopcd, as ~011 as the appliances that, he used, will be dcscribcd in this article. In 1955 a generous grant from the Atkinson Charitable Foundation made possible not only continuance of the program but also expansion and inclusion of other services in ortler that the problem might bc approached on a team basis.” Out, of some 450 patients examined by a consultation team, 226 arc presently rccciving orthodontic WW. l’hc orthodontic managcmcnt of cleft palate patients difY’crs considerably from routine orthodontic practice. To appreciate thcsc differcnccs, it, is ncccssary to understand certain basic information about cleft palate. Incidence, Etiology, and ClassificchIo7~ of the Di#erent Types of C’lefts.The terrn cleft 2xxZate is commonly used to describe a wide variety of facial clefts involving the upper lip, maxillary alveolus, and palate. The incidence is fairly constant the world over and gencrall; OCCUJ’S in a ratio approximating one in 750. This incidence has been confirmed for the Province of Ontario.7 Tlittle is known of the cause of the phenomenon. The only cstablishcd etiological factors arc genetic, and thcsc arc not well understood.” A positive: familial history has baen found for appr’osirnatcly one-third of thtl patients we have examined. It is probable t,hxt rnal~y clefts result from crivil~orinle~ltal disturbancq and clefts have been produced by such disturbances in animal espcrilnentation.‘~, I” When the embryologic processes forming the upper lip, maxillary alveolus, and palate unite only partially, or fail to unite at all, clefts result in those areas in which fusion normally would have taken place.” The different forms which these clefts assume may be classified into four primary types (Fig. 1). Clefts of I’rcsented at the fall meetinfi uf the Northeastern Sxicty of Ol‘thodontists. Iluffalo, New York, Oct. 23, 1957. *Director of Orthodontics. Cleft Palate Kesonrch and Treatment Centw, Hospital for Sick Children, Toronto, Ontario. Canada.
Volume 44 Number IO
ORTHODONTIC
TREATMENT
FOR CLEFT
PALATE
PATIENT
751
A. Cleft lip.
B. Cleft palate
C. Unilat era1 cleft lip and pal ate
D. Bilat era1 cl:f:dlip palaf e
,.._ ,’i:,:;‘...‘., ,..’ .
fbb Pre-surgical Fig. I.-illustrations of cal deformities. The segmental trated by schematic diagrams.
the
Post-surgical four prinlary cleft types “collapse” tof the cleft lip
depicting and palate
presurgical and postsurgitypes (C and D) is illus-
752
.JOHNRTON
Am. J. Orthodontks O
195X
the first type are those of the lip (and a,lveolus) and, while they are usually The ilcgrcc of lip clefting is I’(‘unilateral, they are occasionally bilateral. flcctcd in the degree of associated alveolar c1cfting.l” Thus, clefts of this type will vnry in tlogrcc from a notchhing of t,he lip, with little or no associatetl al~~olnr cleft. to the morv complete lip and alvclolar clefts, such as the unil~lt(‘~ill cleft illuStI’ir.tCil in I<‘&. 1 , ;1. (‘lefts 01’ t,he ssccond type arc those oi the palate. They map- merely divide the uvula or, as in Fig. I, R, they may estend I’o~ward into the anterior portion of the hard palate. Where clefts ol’ the above types are continuous with one irrroth(‘r, WV have the unilateral and bilateral I’ornis dcfts of lip and palate. Thcsc constitute thr lasl two typos, the complete of’ which arae illustrated in Fig. 1, f’ ant1 D. The isolatetl clefts, that is, cleft, lip (and alveolus) alone or cleft palate alone, constitute ahout 50 pw cent 01‘ the total, t.he relative frequencies of the (‘lofls of lip (and alvwlus) wit,h associated two types being nhoul the sam(~. calcft, palate const,itutc the other 50 I)c’r c>eM, lhe unilateral cdlel’ts ont,rtumbering the bilateral clefts aplJr,osirn;ltcl~- two to on(a. Genercrl :I(clnn!lel,zent.-‘l‘htr pritncb ol)jcdivcts in the habilitation of the cleft palate patient :II’C the att~a.inmcnt of awcptahlc apltc’araneca and the establishnient of adequate speech and mast icatory fund ion. The complexity of those and associated prohlen~s requires the integrated services of a team which inc~lutl(3 thv petliatrivian, su~~gvori, sp(l(‘cdhth(xt*illJist, tl(hrrtist, i111tl orthodontist. cacdh specialist being tlepcrrtlcnt U~U~Ithe others. Srr~gi~al tarpairs a~(1 cJi1lTid Out t,o obtain Soft tissue CloSur~c~ of t,lr(l clefts. At t,ht> HoslJital for Sick (‘hildrcn, ulcfts of thv lip a~‘(’ ol)et*iLtetl on when the piIt,iPllt is about 1: months 01~1ant1 clefts ot’ t,hc palate when the patient is 1 tl il f(lW c*c!tltPl*S. thc2 latt(~r procctlurc is sometimes iLh(jut 18 rrronths 01~1. tlelayc~l nntil t,hc iIg(l ()I’ 4 OY 5 yt’ilI*s in ;Irr atternl)t to ~tlu~+c restrictions to maxillary growth. In most, MSCS in which speech th(Lr*irl)y or guidance is nrcessa ry, such therapy is prefct*:rbly iustitutcd when spccc*h is in its tlcrclop~rrc~ntal stages. As speech Wficultic~s usually ~csult from inad(~quncdes of the surgically reconstructcd soft pal;rte and tlcformititls of the cltdofacial structures, assistance which the surgwn, orthodontist. or 1Jr~osthotlontist cirrr uffcr may be essential to thr sucwss oi’ the spcrch therapist’s efforts.
There :r~(’ I11;Irkcd diflervncc~s in derrtc)f:~&tl growth and development among the various typcls of vlri’t, ant1 otthotlontic management varies insiderably. .In isolatctl vlcfts 01’ t.hc lip or palate, whtrv the maxilla is not tlividd, maxillary growth irnd tlcvc~lolJlllr,llt a~‘(’ Ilot rr~ar~k~dly affected ant1 consequently the deforrrrity is ncithcr #rcirt nor difficult to treat by the usual 011 th(l <)th(xr hand, growth i111d tlcvelopment are orthodontic ~~t.owtlu~~~s. markedly affevtctl in clefts of the lip and palate (where the nrasilla is divided) , and they rc~quitx~ rather spc4ul orthodontic managc~mc~nt. Treatment of the latter cases has reccivd ronsiderable attention” ant1 is also stressed in this article.
Volume 44 Number IO DENTOFACIAL
ORTHODONTIC
GROWTH
TREATMENT
AND
DEVELOPMENT
FOUR
PRIMARY
FOR
AND TYPES
CLEFT
PALATE
ORTHODONTIC OF
753
PATIENT
MANAGEMENT
OF
THE
CLEFTS
Cleft Lip (and Alveolus).-When the cleft of the lip is slight, no associated alveolar defect may be found. Dental deformity is slight, or absent, and usually orthodontic treatment is not necessary. In more complete “lip” clefts, where the alveolar clefting is more extensive (Fig. 1, A), the localized effects of a cleft passing through the alveolus will be seen without the modifying influence of divided maxillary segments. Usually, any adverse pressures exerted by the repaired lip have little or no effect upon the almost intact maxilla. The localized disturbance occurs in the region of the lateral incisor and is manifested by malformation and rotation of teeth adjacent to the cleft and frequently by the absence of teeth or the presence of supernumerary teeth. Supernumerary teeth are a common finding in the deciduous dentition, while the lateral incisors are very frequently missing (or at least poorly formed) in the permanent dentition. Treatment is straightforward and may be carried out in the mixed or the permanent dentition. It is generally necessary to band the incisors, and WC have successfully used both twin arch and edgewise appliances. The former is particularly applicable in mixed dentition treatment. Retention is often a problem, and in the most severe cases fixed splinting across the cleft region ma.y be indicated. Cleft Palate.-Surgical repair of partial clefts of the soft palate seldom affects dental development in any way. When it becomes necessary to carry the surgical repair onto the hard palate mucosa, however, the resulting scar tissue contraction often manifests itself in a dentoalveolar constriction. This If the cleft constriction is generally localized to the posterior segments. extends appreciably into the hard palate (Fig. 1, B) and the surgical repair underdevelopment is correspondingly more extensive, a general maxillary may result. The underdevclopmcnt is usually slight and insufficient to cause any crowding in the deciduous dentition, but considerable crowding may be present in the mixed and permanent dentitions. Tn order to obtain the most itleal end result, it is generally necessary to treat early, thereby removing any restrictions to maxillary growth imposed by cross-bite relationships. Tn many ways the isolated cleft palate problems resemble noncleft problems closely and may be treated as such. Flxpansion may be accomplished by a number of appliances. Alt.hough the expansion appliance dcvrloped by Harvold, which will be discussed in sonic detail later, is designed primarily for segmental movement, we have also found it to be most efficient for simple dentoalreolar expansion. If the original constriction was not severe, then cuspal interdigitation in the buccal segments and a positive overbite in the incisor segment will usually be sufficient for retention. Occasionally, it may be necessary to use a palatal prosthesis or fixed lingual appliance.
Ilnilateral
(Cleftof
Lip
(and
Alr~eolus)
With
Asocicitetl
('left
Pal&c.-
lZsyrnmeti~y is one 0 1( t,hc most prominent (f~rowth and cl~~~elopnacnt: features of the unilateral clefts of lip and palate.” Anteriorly, the cleft simulat,es t,hat of a complete or extensive unilateral cleft of the lip and alvcolns. Posteriorly, thr pict,urc often varies somewhat from that of an estensivc isolated cleft palate in that the nasal scptutn is genel*ally fused with th(a pal:lt(: on t,hc nonclcft side. I’resurgically the segments of t,lie maxilla are often widely separatctl. Almost invariably, however, they rapidly IIIOYC medially into apposition following rcpa.ir of t,hc lip. This movcmcnt is primarily a rot,ation ilk the horizontal plane about a ])oint approximating the xggonlaticorrl;rsill;lry sutures in the region of the huttresscs (Fig. 1, t’). Some rotation in the frontal plane ma? occur, and this is manifested by a lingual tippin g of the alveolar processes. The dcgrec of medial shifting 01 “collapse” of the srgmt>nts is dcterminctl by the tightness of the lip repair, the dcvelopmcnt of the alveolar procosscs in the region of apposition, and by the contraction forces introduced by the surgical repair of the palate. The development of adequate incisor overbitt, with positive ovc>rjct, may rcducc> the degree of ~ollapsc~ in t,he anterior or prernasillary ;lWil.” is not. symmetrical but rather more The “collapse” ~~ronouttcwl on t,hc cleft side. To atltl to the facial asymmetry, the mandible vclry often deviates laterally in a functional accolllrnotliltioll to the existing occlusion. The reduction of arch length is generally insufficic~nt to ~)rotlu~e crowcling Howcvc~r, the rc~lativcly larger size of the perof the tlcciduous tlcntition. mancnt t&h, coupled with increased masillary constriction with agr (most marked during the transition from mixed to permanent tlcntition), results in considcrablc crowtling. The total growth and development of the maxilla may be affected.“ Thus, ;I. general anteroposterior deficiency may add to a tly premasillary “collapse” to giv(a the mandible a rrlatively propnathous appearance. Also, deficiencies in vertical maxillary growth Illay be~~tr~e ;Il)pt~(&blc with incrcasck in agt~. These arc ca.usc>tlby rcGstanc*cs offcrctl by th(A tongue to the eruption of trcth in constricted or nletlially tlisplaccd It~asillary scgmclnts. J F the reduction of vertical growt,h is g(>ncJr;ll, it, is associatctl with excessive freeway space! at rest, aLIt overclosurc ilt oc(~lusal contact. Ikfioicncitls in vertical growth aw oft(>n lin~itetl to regions in which t,hc “colIaI)se” is marked and are manifested by an oprn-bite in thcsc areas. l’iming of trecltnzent: In the above, there are many indications for earl; treatment. The deformit,y is less in younger patients, and a satisfactory orthodont,ic result is more easily obtainable. If the maxillary segments are carefully repositioned in a symmetrical manner, the mandibular deviations automatically correct themselves in accommodation to occlusion with the corrected maxillary arch. Nxpansion does much to alleviate crowding by irl(m?asing arch length, and early correction of anterior cross-bite tends to lessen anteroposterior
Volume 44 Number IO
ORTHODONTIC
TREATMENT
FOR
CLEFT
PALATE
PATIENT
755
growth discrepancies between the maxilla and the mandible. The problem of vertical maxillary development is not great at lower age levels and can often be avoided if the maxillary segments are moved into normal position before the t,ransition from the mixed dentition to the permanent dentition. In addition to orthodontic considerations, the importance of early treatment in assisting the more normal development of the functions of speech, mastication, and deglut,ition cannot ho ovcrloolrcd. In some children, the psychological implications of growing up with a dentofacial deformity may assume considerable importance. The advantages of early treatment outweigh the disadvantages of multiple periods of active treatment interspersed with long periods of retention. Where some follow-up treatment is necessary in the permanent dentition, it is rarely extensive. Usually the more severe cases benefit most by early treatIn patients in whom the deformity is slight, satisfactory results may ment. be obtained by treatment in the permanent dentition.
Fig. radiograph the base sutures.
X-The “x-line” of a patient crista galli
of
superimposed upon with unilateral cleft at right angles to
the tracing lip and cleft a horizontal
of the posteroanterior palate. The line line joining the
cephalometric is drawn through zygomaticofrontal
Case analysis: In order to determine the asymmetrical position of the segments prior to repositioning, and Ihence guide the relative movement on the two sides, the ‘ ‘ x-line ’ ’ analysis is very helpful59 G It is applied to the anteroposterior cephalometric radiograph, a facial center line being constructed from landmarks in the upper face as shown in Fig. 2. Thus, it is possible t.o assess the lateral position of the maxillary segments and also the lateral position of the mandible and other dentofacial structures.
7% Maxillary exp.,nnsio?z: Various appliances have been used to effect expansion in cleft palate casw, such as th(a t~xpansion scww plate popular in many popular in the United Stat,es. European countries and the Arnold expand&l The appliance whit-h Tlarvold developed specifically fol- segmental movemnt is prcfcrrcttl at the Hospital for Sick (!hildren. It consists of a lingua,1 awh with auxiliary recurve springs. Details of constrnctiolt are shown in Fig. 3.
Fig. 3.-Expansion appliance developed by Harvold. The lingual the auxiliary springs are 0.016 inch in diameter. The ends of the arrh ward to serve as posts. aml the appliance is inserted by placing these tubes and “springing” the arch gingivally to the retention lugs.
arch is O.lJ31 inch and wre bent vertirally upposts into the lingual
Fig:.
and nearing repositioning.
I.--Study pletion
models of a unilateral cleft of orthodontic treatment)
of lip and demonstrating
palate (before segmental
the
rom-
The expansion appliance dcvclopc~l by Harvoltl may be NOactivated as to control the rwultant. rtlovwncwt awnratclly. The auxiliary springs function differently, dcpcntling upon the region and nature of adjustment. i&O, where neccwary, th(b main arch may hc ac*tivatcd for expansion. and variation in the hnccolingual angulat,ion of the posts, t,hrough their torque action, way
he employed to assist in cont,rolJing the relative
cspuuion
on the two sides.
If t,hc expansion force is correctly applktl, the repositioning of the maxillary The scgrllclnts is very rapid, usually being completed in thrw to six months. repositioning is the direct reverse of the collapse movement, (Fig. 4).
Volume 41 Number
IO
ORTHODONTIC TREATMENT FOR CLEFT PALATE PATIENT
757
Following expansion, it is necessary to employ some form of retention in order to maintain the corrected position of the maxillary segments. Such precautions must be taken both during and between subsequent periods of active treatment. “Interim” retention appliances may consist of a plain lingual arch or maxillary prosthesis (Fig. 5, D). Modifications may sometimes be necessary in order to permit the eruption of individual permanent teeth lingual to the line of the deciduous arch. Anterior cross-bite correction in the Correction of anterior cross-bite: deciduous dentition may do much to assist in establishing a more normal growth pattern. It may be contraindicated, however, for many cases nearing the mixed dentition stage. This is because correction in the deciduous dentition does not ensure labial eruption of the permanent incisors and, in fact, decidnous root movement may tip the permanent incisors even further lingually. E’or these reasons, anterior cross-bite correction is frequently delayed until the permanent incisors have completed their eruption. A.
B.
Fig. 5.-Anterior cross-bite correction, in the mixed dentition, for a patient with a uniA, Maxillary expansion completed and the mandibular deciduous lateral cleft of lip and palate. cuspids extracted. B, Initial appliances for anterior cross-bite correction. 0, Anterior crossbite corrected and incisors aligned. The mandibular flrst cleciduous molars have been exD, Interim retention prosthesis. tracted.
A lingual arch with finger springs is quite efficient for the initial alignment and labial movement of crowded, lingually placed maxillary incisors. Rowever, excessive use tends to tip the anchor teeth distally. In addition to preventing this tipping a labial appliance with banded incisors is more efficient for
758 correcting rotations, handling necessary root movements, and ensuring adequate overbite for retention. The twin arch is pa,rticularly well suited although a modified edgewise appliance, or at least it,s braeke& may be used. Some form of mandibular bite block or bite plane may be necessary when the overbite is considerable. If eventual rnandibular premolar extraction is deerned necessary to relieve a t,ooth size problem or to compensate for a mnsilla deficient in anterior growth, the mandibular deciduous cuspids may bc cst,racted and an anterior elastic added to t,he bite block t,o retract, the incisors (Fig. 5). Center-line correction may sometimes be a problem. Excessive movement toward the cleft may dt~nud~ a large part, of the root, surface of the tooth adjaccnt to the cleft. In most cases, howtrrcr, t,he growth potential of the alvcolnr l)one is ntlcqunto, and a suitable result may be attained (E’ig. 5).
Fig-. 6.-Applimwe designed by Harvoltl velopment. The arms extending from the round wire and are activated occlusally.
to correct deficiencies pal&al prosthesis are
in of
nmxillary 0.029 inch
vertical de(diameter)
Correction of deficiencies ix m~xillnr~y l)erticnl development: Where segmental collapse is rnarked and repositionin g of these segments is delayed until the permanent, dentition, problems of deficient masillar,v vertical development, a rise. To aid in t,hc solution of these problems, Harvold designed an cffectivc appliance>. As illustrated in Fig. 6, arms from a palatal prosthesis (lxtend gingivally to lugs on banded maxillary teeth. Occlusal activation of the arms stimulates the eruption of the tet~th. The appliance may bc usctl to best advantage following li1tWd expansion of the maxillary segments and prior to any anterior cross-bite correction (Fig. 7 1). ~etailud positi(J?zin{/ of tpeth in the permanent dcntitim~: It, will be necessary to finish many C:IWS with ;I Illultibantl ;lppliall(x~, such as the edgewise. Multiband appliances arc: inc,ficient in controlling scgmc~ntal mo\:(1tILent, atltl precautions shoultl be t,aken to maintain the proper position of the seglrtt:nts already attained while moving t,eeth within them. If’ the arch is of propel ln those proform and its length fixed, little difficulty will be encountered. however, 0~1~ IllLIst cedures involving space closu~ (decrease in arch length)? take care to cnsurc’ suffcicnt rigitlit,y and prol)cr arc+h fornt ia order to I,“+ Vent ‘irecollapsc” of the segments.
Volume 44 Number
ORTHODONTIC
TREATMENT
FOR
CLEFT
PALBTE
PATIENT
IO
759
B.
A. PATIENT R .F. PATIENT R.F.
PRE-TREATMENT
PRE-TREATMENT CS-6-5614CCLUSAL
PATIENT
R.F.
POST-TREATMENTCIS-
(S-6-%,-REST
CONTACT
g-571 -0CCLUSAL CONTACT
PATIENT RF. POST-TREATMENT
(18 9 57) 4 REST
Fig. ‘I.-Tracings of the cephalometric radiographs of a patient with unilateral cleft l!P and cleft palate before and after flfteen months of orthodonfic treatment. A period of maxlllary expansion was followed by correction of deficient maxillary ,vertKal developm+t (usmg the appliance illustrated in Fig. 6). the remaining teeth then bemg banded to faclhtate anThe tracings demonstr?te an Improvement In terior cross-bite correction and tooth alignment. profile at occlusal contact and 8 more normal freeway space at rest poSltlon.
Volume 44 Number IC
ORTHODONTIC
TKEXTME
ST
FOR
(‘LEFT
I’ATATE
PATIENT
761
Retention prostheses: To finish t,hese cases, some kind of permanent maintainer must be constructed. This may take the form of a simple partial denture replacing any missing teeth and, by careful clasping, rotations may bc stabilized and the recurrence of open-bite prevented (Fig. 8), Eventually we anticipate splinting a large number of our cases. These splints are constructed across the cleft, an>- missing teeth being replaced as pontics. They require two abutment teeth on either side of the cleft and have been used successfully in riorway.’ Also, any lack of adequate bony support, for teeth adjacent to the cleft may be supplemented in this manner. Bilnteral (‘left of Lip (and ~llveolus) With Associated Cleft Palate.-In complete bilateral clefts of the lip a,nd palat,e, the premaxillarp segment is separated from the two lateral maxillary segments and suspended from the nasal septum (Fig. 1, D) . It would appear that this segment, consists simply of teeth and alveolar bone. The more teeth it contains, the larger the segment, and if these teeth are lost the remaining segment resorbs almost completely. Before lip surgery the premaxillary segment is carried forward at an ‘ ‘ uninhibited ’ ’ rat,c by growth in the nasal septum. The repaired lip subsequently retards this forward growth, and gradually the premaxillary segment is brought into a more normal relationship with the remainder of the maxilla. Thcx crowns of the teeth are “molded back,” and by the time the permanent, incisors erupt they are generally tipped posteriorly about 15 degrees, wit,h their crowns in linguoversion. The anteroposterior position of the premaxillarp segment is an important determining factor in the degree and nature of the collapse of the lateral seg1ncnts. The more posterior its position, tho more efficiently it prevents the medial movement of the lateral segment. The “collapse” movements and the wedging action of the premaxillary segment, are depicted in Fig. 1, fi. As with the unilateral clefts of lip and palate, it is generally conceded that early trtatrncnt is prefcrablc. However, orthodontic management of the bilateral clefts differs from that of unilateral clefts in the unique problems associated with the prcmaxillary scgmcnt and in tho fact that asymmetry is 110 longer a dominating factor. It has been our experience that in all but the most severe protrusions the prcmaxillary segment and contained t&h should be maintained in as normal a position as possible until the age: of 12 to 13 years, when most of the pcrmancnt dcntition has cruptctl. Then a tlecision may be made as t,o whethe]: or not the teeth in this segment are to be retained. Other reasons for their removal (bcsides position) include hyl)oplasia and hypocalcification. The mechanics of orthodontic treatment arc much the same as ,For the unilateral clefts of lip and palat,c. Even though anterio I’ cross-bite and maxillilry center-lint correction arc essentially scgrnental movements, appliance therapy does not differ greatly. Interim retention by removable prosthesis is generally preferable, due to the high incidence of residual anterior palatal and alveolar openings into the nasal cavities which may be covered in this manner.
retention of these cases is almost always provider1 by a rcprosthesis. ldcally, it should be placetl over splints across the clefts. cases in which the maxillary incisors are removed, it may he necessary out certain surgical proccdurcs, such as trimming or even surgical of t,he premaxillarp segment, before a prosthesis is inserted.
I'ermanrnt
movable In those to carry removal
IJIMITATIONS
OF
ORTHODOXTIC
TRFXT.\IENT
We have already seen some of the limitations in handling severe cases of bilateral clefts of the lip and palate without the aid of’ the surgeon and prosthodontist. Also, undt:rdevclopnlcrlt of the maxilla nray bc quit,c severe in unilateral or bilateral clefts of lip and pala,te, or cvcbn in cases of isolated cleft palate. If this underdevelopmcnt is associated with a well-dcvclopcd or overdeveloped mandible, it. may bc very tlifficult, or ittlpossiblc to rcclncc tltc anteroposterior discrepancy by orthotlontic trcatmcnt alone. I’rosthrt,ic IV placement of the maxillary incisors or anterior teeth nlay be sufficient in some cases, whereas in others surgical corr&ion of mandibular prognathism is indicated. In most cases, however, as those illust,ratcd of orthodontic treatment are very good.
iI1 Ii’ig. 8, the potentialities
The diagnostic ant1 treatment concepts employed by the orthodontists working in the Cleft Palate Research and Treatment (‘entre at the Hospital for Sick Children in Toronto have been presentctl. Many of these concepts were introduced by Dr. Egil Rarvold. Dentofacial growt,h and tlcveloprnent, orthodontic ma~lageltle~~t, and prosthctic retention have been described for each of the four funtlamcntal types of clefts: (1) cleft lip (and alveolus). (2) cleft palate, (ii) unilateral cleft lil) (and alveolus) with associated cleft palate, and (1) l)ilateral cleft lip (ant1 alveolus) with associated cleft palate. Some of the limitations of orthodontic trra.tmcnt, particularly thosr Wlated to severe deficiencies in anterior growth of the maxilla, wc:r(L discussctl. In recent years numerous advances have been made in the habilitation of cleft palate patients. It is holed that,, with continuc4 inr],rovelncnts in treatment, an cvcr-increasing number of these handicapped childrcln may pt’oteed to adulthood with an acceptable appearance, undt!rstandable speech, and a healthy mental outlook. REFERENCES
1. Rohn,
A.:
Retention Construction Following l)r. Harvold’s hfethotl of Repositioning the Maxillary Complex in Cleft Palate Cases, Tr. European Orthodontic Societ?, pp. 219-221, 1951. 2. Cox, M. A., Lindsay, W. K., Whnley, J. H., C’urtis, B. .J., Spence, H. J., and J,ewis, Rnth: Syrnposiurn on Cleft Palate Research and Treatment, .J. Canad. Dent. A. 23: 563. 588, 1957. 3. Fogh-hndersen? Peal: Inheritance of Hare-Lip and Cleft Palate, Copenhagen, 194!!, Nyt Nor&Sk ForlagAmold Busk, p. 226. 4. Graber, T. M.: The Congenital Cleft Palate Deformity, J. Am. Dent. A. 48: 375395, 1954.
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Number IO
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5. Harvold, 6. 7. 8. 9.
Egil: A Roentgen Study of the Post-Natal Morphogenesis of the Facial Skeleton in Cleft Palate, Oslo, 1954, A. W. Dreggers Boktyrherei A/S, p. 102. Harvold. EPil: Cleft Lin and Palate. AM. J. ORTHODONTICS 90: 493-506. 1954. Hixon, B.: m A Study of Lthe Incidenck of Cleft Lip and Cleft Palate ih Ontario, Canad. J. Pub. Health 42: 508-511 1951. Orban, Balint: Oral Histology and Embryology (chapter on The Development of the Oral Cavity), ed. 3, St. Louis, 1953, The C. V. Mosby Company, p. 364. Posen, A. L.: Some Principles Involved in Orthodontic Treatment of Operated TJnilateral and Bilateral Complete Cleft Palate, Angle Orthodontist 27: 109.113, 19.57.
10. Pruzansky, Samuel: Description, Classification and Analysis of Unoperatetl Clefts of the Liu and Palate. AM. J. OELTHODONTICS38: 590-611.1953. The Importance of Early Orthodontic ‘Treatment in Cleft Palate 11. Subtelny, J. “D.: Planning, Angle Orthodontist 27: 148-158, 1957. 1“I. Walker B E - Experimental Production of Cleft Palate in Animals, Cleft Palate Bill. i: s:9, 1957. Etiology of Congenital Malformations, In Advances in Pediatrics, 13. Waranky, Josef: Chicago, 1947, Year Book Publi-ihers, Inc., vol. 2, pp. l-59.
555 UWIVERSITY AVE.