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Presurgical orthopaedic treatment using hard plates
2
J. Cranio-Max.-Fac. Surg. 17 (1989)
J. Cranio-Max.-Fac.Surg. 17 (1989) 2-4 © GeorgThiemeVertagStuttgart • New York
Presurgical Orthopaedic Treatment Using Hard Plates Walter Hochban, Karl-Heinz Austermann Dept. of Oral and Maxillo-FacialSurgery(Head:Prof. K.H. Austermann, M.D., D.M.D.),Philipps-University,Marburg,West Germany
Introduction It is well established that the deviation of maxillary clefts can be overcome to a high degree, by orthopaedic appliances in early infancy (Huddart, 1973; Huddart and Crabb, 1977; Sauer et al., 1977; Shaw, 1978; Hotz and Gnoinski, 1979; Huddart, 1986; Sarnds et al., 1986). Our own experiments with different types of appliance resulted in one simple form which we have been applying for four and a half years to all our children with clefts of lip, alveolus and palate.
W. Hochban, K.-H. Austermann Summary Our concept in the treatment of unilateral clefts of lip, alveolus and palate includes early maxillary orthopaedic treatment starting immediately after birth until the end of the first year of life and the surgical closure of the lip at three months and of the soft palate at twelve months. Hard palate and alveolus are closed after three years by secondary osteoplasty in the alveolar region. The appliance is made of hard acrylic resin and is adjusted monthly to allow for growth. It thus encourages passive orthopaedic guidance of maxillary growth. The local compatibility of the plate was excellent and the acceptance by the children created no problems until tooth eruption. Follow-up studies were conducted on twenty children treated in this way until three years of age. After the first year results show a good and harmonious arch alignment without any collapse of the alveolar segments. The cleft narrows and the steepness of the palatal slope flattens. This maxillary development is arrested after suspension of orthopaedic treatment, and a slight collapse of the alveolar segments is observed. Key words Cleft lip, alveolus and palate - Presurgical orthopaedic treatment
Methods of Treatment We have been using a thin acrylic appliance without active elements and without any soft acrylic parts. A model of the maxilla is taken with Kerr Permelastic® on a semi-individual impression tray. Thereafter an appliance of hard acrylic resin is molded on the plaster cast. Because of the appliance, the maxillary growth is influenced passively, as the power of lip, cheek and tongue will either be used or abandoned. In cases of unilateral clefts of lip, alveolus and palate, this means that the lesser segment is spared labiobuccally and the greater segment is influenced in the anterior part on the palatal side. Vertical differences and the rims of the palatal cleft are also spared. The treatment is likely to start immediately after birth. Every four weeks the appliance is renewed to adapt to the proceeding growth. After lip closure in the third month of life, the vestibular part of the appliance in the premaxillary region is removed in order to mold a rest protrusion of the premaxilla by the now actively restored lip. The treatment will be finished after closure of the soft palate at ten to twelve months. At age three, there will be the final closure of the alveolus and palate by secondary osteoplasty. Material and Method of Evaluation The basis of this investigation consists of the follow-up of twenty children treated in the manner described. The orthopaedic effectiveness of the appliance was judged by both acceptance and compatibility. Therefore, the maxillary casts of the twenty patients were evaluated in a horizontal and frontal coordinate system. Reference lines were the interconnection line between the two tuberosities and
the perpendicular line from the centre of it. Facebow recordings were not taken. The recorded points are shown in the two drawings (Fig. 1 and 2). Results The local compatibility of the appliance was excellent; sensitivity reactions or fungal infection did not occur. The appliance was tolerated well in all cases until about the eighth month of life, thereafter half the children did not tolerate the appliance well. The development of the maxilla during the treatment is shown by means of average values in Fig. 3 and 4. Around the canine points B and F (Fig. 3) there is an harmonious development within the first months of life both in the sagittal and transverse directions. Later a decrease in the transverse development with continuing sagittal growth occurs in association with a corresponding "collapse" of the two alveolar segments. At the alveolar cleft, the end of the lateral segment E develops only sagittally. The end of the medial alveolar segment D develops sagittally as well as transversely in the direction of the cleft. The incisal point C makes a similar movement whereby the sagittal development predominates over the transverse. The palatal cleft - cross-sectionally shown in Fig. 4 - narrows during the treatment by more than half. The steepness of the palatal slope flattens until the end of the first year of life, as can be seen by the diminution in the angles a and b. Afterwards the cleft narrows continuously, but the flattening of the palate does not increase.
PresurgicaIOrthopaedicTreatmentUsingHard Plates
Cranio-Max.-Fac.Surg. 17 (1989)
3
E
1
1F
Fig.1 Recordings of the maxilla sagittally and transversely A and G: Tuberosity points B and F: Canine points C: Incisal point D: End of the medial alveolar segment E: End of the lateral alveolar segment
~
/ ~ . 'r /
/!/] i!
Fig.2 Recordings of the maxilla cross-sectionally 2-3: Width of the palatal cleft a: Steepness of the palatal slope on the cleft side b: Steepness of the palatal slope on the non-cleft side
E
/
~
~
"-4,~, F
month" 3 6 .
,, ,,
",,
I ~,,-,\
\',\\
12 6 1 -
'
/i"i/\ -
/i'ii\
Fig.3 Maxillary development sagittally and transversely at 1.3, 6, 12 and 36 months of life (average values),
Discussion and Conclusions We tried to simplify the presurgical orthopaedic treatment of the infants as much as possible without at the same time risking compromising the orthopaedic effectiveness. These conditions are fulfilled by the appliance, but as soon as eruption of the teeth begins, the well-known problems of acceptance occur (Huddart, 1986). The orthopaedic effectiveness of the appliance must be judged positively, since harmonious growth in the desired direction until the end of the first year of life can be observed in all the patients. After cessation of the orthopaedic treatment, we saw a slight collapse of the segments in the anterior region of the palatal cleft and the flattening of the palate occurring during the orthopaedic treatment did cease as well. Although the continuation of the orthopaedic treatment would be desirable until the closure of
,,
]
Fig.4 Development of the palatal cleft and the steepness of the palatal slope cross-sectionally.
the alveolus and the hard palate, this often fails because of the progressing eruption of teeth and the diminishing acceptance of the treatment with increasing age. References
Hotz, M.M., W.M. Gnoinski:Effects of early maxillary orthopaedics in coordination with delayed surgery for cleft lip and palate. J. Max.-Fac. Surg. 7 (1979) 201-210 Huddart, A.G.:An evaluation of pre-snrgical treatment. Brit. J. Orthodont. 1 (1973) 21-25 Huddart, A.G.:Arch alignment and presurgical treatment - the West Midlands approach. In: Hotz,M. M. et al. (eds): Early treatment of cleft lip and palate, Huber, Bern 1986 Huddart, A.G.,J.J. Crabb:The effect of presurgical treatment on palatal tissue area in unilateral cleft lip and palate subjects. Brit. J. Orthodont. 4 (1977) 181-185
4
J. Cranio-Max.-Fac. Surg. 17 (1989)
W. Hochban, K.-H. Austermann: Presurgical Orthopaedic Treatment
Sarnds, K.-V., B. Rune, S. Jacobsson: Changes in maxillary alveolar arch morphology in complete unilateral cleft lip and palate from birth to 19 months of age. In: Hotz, M. M. et al. (eds): Early treatment of cleft lip and palate. Huber, Bern 1986 Sauer, H., H. Lithe, H. Scbiile: Untersuchungen iiber das Kieferwachstum bei priioperativer kieferorthop/idischer Behandlung yon Lippen-, Kiefer-, Gaumenspalten. Dtsch. Zahn~irztl. Z. 32 (1977) 186-188 Shaw, W.C.: Early orthopaedic treatment of unilateral cleft lip and palate. Brit. J. Orthodont. 5 (1978) 119-132
W. Hocbban, M.D., D.M.D. Dept. of Maxillo-Facial Surgery Georg-Voigt-Str. 3 D-3SSO Marburg West-Germany
J. Cranio-Max.-Fac. Surg. 17 (1989)
J. Cranio-Max.-Fac.Surg. 17 (1989) 2-4 © GeorgThiemeVertagStuttgart • New York
Presurgical Orthopaedic Treatment Using Hard Plates Walter Hochban, Karl-Heinz Austermann Dept. of Oral and Maxillo-FacialSurgery(Head:Prof. K.H. Austermann, M.D., D.M.D.),Philipps-University,Marburg,West Germany
Introduction It is well established that the deviation of maxillary clefts can be overcome to a high degree, by orthopaedic appliances in early infancy (Huddart, 1973; Huddart and Crabb, 1977; Sauer et al., 1977; Shaw, 1978; Hotz and Gnoinski, 1979; Huddart, 1986; Sarnds et al., 1986). Our own experiments with different types of appliance resulted in one simple form which we have been applying for four and a half years to all our children with clefts of lip, alveolus and palate.
W. Hochban, K.-H. Austermann Summary Our concept in the treatment of unilateral clefts of lip, alveolus and palate includes early maxillary orthopaedic treatment starting immediately after birth until the end of the first year of life and the surgical closure of the lip at three months and of the soft palate at twelve months. Hard palate and alveolus are closed after three years by secondary osteoplasty in the alveolar region. The appliance is made of hard acrylic resin and is adjusted monthly to allow for growth. It thus encourages passive orthopaedic guidance of maxillary growth. The local compatibility of the plate was excellent and the acceptance by the children created no problems until tooth eruption. Follow-up studies were conducted on twenty children treated in this way until three years of age. After the first year results show a good and harmonious arch alignment without any collapse of the alveolar segments. The cleft narrows and the steepness of the palatal slope flattens. This maxillary development is arrested after suspension of orthopaedic treatment, and a slight collapse of the alveolar segments is observed. Key words Cleft lip, alveolus and palate - Presurgical orthopaedic treatment
Methods of Treatment We have been using a thin acrylic appliance without active elements and without any soft acrylic parts. A model of the maxilla is taken with Kerr Permelastic® on a semi-individual impression tray. Thereafter an appliance of hard acrylic resin is molded on the plaster cast. Because of the appliance, the maxillary growth is influenced passively, as the power of lip, cheek and tongue will either be used or abandoned. In cases of unilateral clefts of lip, alveolus and palate, this means that the lesser segment is spared labiobuccally and the greater segment is influenced in the anterior part on the palatal side. Vertical differences and the rims of the palatal cleft are also spared. The treatment is likely to start immediately after birth. Every four weeks the appliance is renewed to adapt to the proceeding growth. After lip closure in the third month of life, the vestibular part of the appliance in the premaxillary region is removed in order to mold a rest protrusion of the premaxilla by the now actively restored lip. The treatment will be finished after closure of the soft palate at ten to twelve months. At age three, there will be the final closure of the alveolus and palate by secondary osteoplasty. Material and Method of Evaluation The basis of this investigation consists of the follow-up of twenty children treated in the manner described. The orthopaedic effectiveness of the appliance was judged by both acceptance and compatibility. Therefore, the maxillary casts of the twenty patients were evaluated in a horizontal and frontal coordinate system. Reference lines were the interconnection line between the two tuberosities and
the perpendicular line from the centre of it. Facebow recordings were not taken. The recorded points are shown in the two drawings (Fig. 1 and 2). Results The local compatibility of the appliance was excellent; sensitivity reactions or fungal infection did not occur. The appliance was tolerated well in all cases until about the eighth month of life, thereafter half the children did not tolerate the appliance well. The development of the maxilla during the treatment is shown by means of average values in Fig. 3 and 4. Around the canine points B and F (Fig. 3) there is an harmonious development within the first months of life both in the sagittal and transverse directions. Later a decrease in the transverse development with continuing sagittal growth occurs in association with a corresponding "collapse" of the two alveolar segments. At the alveolar cleft, the end of the lateral segment E develops only sagittally. The end of the medial alveolar segment D develops sagittally as well as transversely in the direction of the cleft. The incisal point C makes a similar movement whereby the sagittal development predominates over the transverse. The palatal cleft - cross-sectionally shown in Fig. 4 - narrows during the treatment by more than half. The steepness of the palatal slope flattens until the end of the first year of life, as can be seen by the diminution in the angles a and b. Afterwards the cleft narrows continuously, but the flattening of the palate does not increase.
PresurgicaIOrthopaedicTreatmentUsingHard Plates
Cranio-Max.-Fac.Surg. 17 (1989)
3
E
1
1F
Fig.1 Recordings of the maxilla sagittally and transversely A and G: Tuberosity points B and F: Canine points C: Incisal point D: End of the medial alveolar segment E: End of the lateral alveolar segment
~
/ ~ . 'r /
/!/] i!
Fig.2 Recordings of the maxilla cross-sectionally 2-3: Width of the palatal cleft a: Steepness of the palatal slope on the cleft side b: Steepness of the palatal slope on the non-cleft side
E
/
~
~
"-4,~, F
month" 3 6 .
,, ,,
",,
I ~,,-,\
\',\\
12 6 1 -
'
/i"i/\ -
/i'ii\
Fig.3 Maxillary development sagittally and transversely at 1.3, 6, 12 and 36 months of life (average values),
Discussion and Conclusions We tried to simplify the presurgical orthopaedic treatment of the infants as much as possible without at the same time risking compromising the orthopaedic effectiveness. These conditions are fulfilled by the appliance, but as soon as eruption of the teeth begins, the well-known problems of acceptance occur (Huddart, 1986). The orthopaedic effectiveness of the appliance must be judged positively, since harmonious growth in the desired direction until the end of the first year of life can be observed in all the patients. After cessation of the orthopaedic treatment, we saw a slight collapse of the segments in the anterior region of the palatal cleft and the flattening of the palate occurring during the orthopaedic treatment did cease as well. Although the continuation of the orthopaedic treatment would be desirable until the closure of
,,
]
Fig.4 Development of the palatal cleft and the steepness of the palatal slope cross-sectionally.
the alveolus and the hard palate, this often fails because of the progressing eruption of teeth and the diminishing acceptance of the treatment with increasing age. References
Hotz, M.M., W.M. Gnoinski:Effects of early maxillary orthopaedics in coordination with delayed surgery for cleft lip and palate. J. Max.-Fac. Surg. 7 (1979) 201-210 Huddart, A.G.:An evaluation of pre-snrgical treatment. Brit. J. Orthodont. 1 (1973) 21-25 Huddart, A.G.:Arch alignment and presurgical treatment - the West Midlands approach. In: Hotz,M. M. et al. (eds): Early treatment of cleft lip and palate, Huber, Bern 1986 Huddart, A.G.,J.J. Crabb:The effect of presurgical treatment on palatal tissue area in unilateral cleft lip and palate subjects. Brit. J. Orthodont. 4 (1977) 181-185
4
J. Cranio-Max.-Fac. Surg. 17 (1989)
W. Hochban, K.-H. Austermann: Presurgical Orthopaedic Treatment
Sarnds, K.-V., B. Rune, S. Jacobsson: Changes in maxillary alveolar arch morphology in complete unilateral cleft lip and palate from birth to 19 months of age. In: Hotz, M. M. et al. (eds): Early treatment of cleft lip and palate. Huber, Bern 1986 Sauer, H., H. Lithe, H. Scbiile: Untersuchungen iiber das Kieferwachstum bei priioperativer kieferorthop/idischer Behandlung yon Lippen-, Kiefer-, Gaumenspalten. Dtsch. Zahn~irztl. Z. 32 (1977) 186-188 Shaw, W.C.: Early orthopaedic treatment of unilateral cleft lip and palate. Brit. J. Orthodont. 5 (1978) 119-132
W. Hocbban, M.D., D.M.D. Dept. of Maxillo-Facial Surgery Georg-Voigt-Str. 3 D-3SSO Marburg West-Germany