12 Dental and Orthodontic Management of Cleft Lip and Palate
Dental and orthodontic management of the patient born with a cleft of the lip and/or palate requires care providers interested, motivated, and dedicated to a lengthy and sometimes complicated process. They should be willing to work in concert with a Cleft Palate Team and well versed in the principles of infant orthopedics (allows a proficient surgeon the best opportunity for primary repair of the cleft lip and nasal deformity) cleft dental anatomy, dental arch coordination, secondary alveolar bone grafting, facial esthetics, and comprehensive orthodontics and dentofacial orthopedics. Patients with clefts require an emphasis on the prevention of dental caries because their teeth are often more susceptible and their burden of care already great. Following the guidelines outlined in this chapter will result in successful treatment for the patient as well as an enjoyable and rewarding experience for the pediatric dentist, orthodontist, surgeon and other team members providing care.
Infants born with cleft lip and palate should be evaluated by the cleft team, including the pediatric dentist, within days of birth. Pediatric dentists are ideally trained to be a vital part of the cleft team. Their training programs include growth and development, behavioral guidance, guidance of the developing occlusion, preventive dentistry, an introduction to anesthesiology, and operating room protocols. The pediatric dentist has a responsibility to instruct parents in a preventive dental program, to prepare parents for the long dental road ahead, and to actively manage any program in presurgical orthopedic preparation that the cleft team chooses to utilize.
12.2 Dental Care Prior to Bone Graft
Parents of newborns or any young child are responsible for preventive dental care, especially in the case of a child born with cleft lip and palate. Before teeth erupt, the gum pads (alveolar ridges) should be wiped clean after feeding or nursing. By the sixth month of life, the first teeth usually erupt—mandibular teeth erupt before maxillary teeth. It is important to note that there is considerable variability in the timing and pattern and that precocious or delayed eruption should not be cause for great concern or the exposure of radiographs. In children with clefts, the teeth may erupt more slowly; they may be more delayed in the cleft quadrant(s) and slower in males than females. When teeth do erupt, the method of cleaning can be changed to cleaning with a moist gauze sponge or a clean moist washcloth. As the number of teeth increase and the child begins to walk, the method of tooth cleaning should be changed to brushing, first using nonfluoridated toothpaste and then moving on to fluoridated toothpaste at about 3 years of age, when the child can be instructed not to swallow the often-good-tasting toothpaste. Systemic fluoride should be available through the water supply or via supplementation. The child’s pediatrician or dentist should be familiar with the dosing and prescribe appropriately.
During the first year of life, a well-baby visit to the dentist is also recommended by the American Board of Pediatric Dentistry as well as by the American Board of Pediatrics. This initial visit establishes a dental home for the child. It also affords the parents the opportunity to ask questions and to the dentist to educate the parents in preventative methods as well as in dental issues that pertain particularly to children with clefts. It is important to note that even the most minimal instance of clefting may not be without its dental consequences, such as malformed teeth, missing teeth, extra teeth, dysplastic enamel, and even small boney defects.
The early years of childhood should be marked by efforts to preserve the existing teeth and their bony support. Supernumerary palatal teeth, teeth in the cleft, or dysplastic teeth should not be removed, and every effort should be made to keep them caries-free. These teeth are difficult for the child or the parents to brush, thus putting the child at an increased risk of developing dental decay; however, the literature is mixed with regard to the caries rate in children with clefts. In case of carious lesions on malpositioned or malformed teeth, restoration is recommended before the onset of infection. Referral to the pediatric dentist may be indicated, as his or her training in the management of young children will make any necessary treatment as atraumatic as possible.
The issue of the appropriateness of radiographs in the developing child is always a concern for the parents and the cleft team. Cavity-detecting radiographs, exposed no more frequently than every 18 months, are indicated in growing children when posterior teeth contact, when hygiene is less than ideal, and when the risk of caries is high enough to raise the issue of interproximal caries. A child should not be exposed to panoramic or periapical radiographs to determine dental development or to image teeth in the area of the cleft until the child has reached the early mixed-dentition stage (some permanent teeth erupted) or when timing for bone graft is being determined. Just prior to bone graft and to provide the cleft team with more complete imaging, cone beam computed tomography (CBCT) is the radiographic image of choice. With this three-dimensional (3D) reconstruction, proximity to the cleft and the position of teeth can be more accurately visualized. This type of image can also provide panoramic and cephalometric views, by reconstruction. Radiation exposure, given the need for information, is acceptable, and less than that from a medical CT.
12.2.1 Presurgical Infant Orthopedics—Complete Cleft of the Lip and Palate
If the team chooses to go directly to lip repair, it is assumed that the pressure created by the repaired lip will close the alveolar cleft and that pressure on the lip will not affect the esthetic outcome of the surgical scar. However, the authors feel that, in most cases, the repaired lip should not be the sole mediator of pressure on the alveolus. Unavoidable tension on the repaired lip will result in a more prominent surgical scar and the cleft segments will collapse, with the lesser segment falling behind the greater segment in unilateral clefts and both posterior segments remaining behind the premaxilla in bilateral clefts. These failures result in increased complexity of future orthodontic treatment, given later correction of this bony collapse is more difficult. Although the resulting dental crossbites may be corrected, the dentition will lie on a malpositioned bony base. Eventual relapse of the malocclusion is therefore more likely, and lip support, as a prime mediator of facial esthetics, may be compromised.
If the cleft team wishes to incorporate presurgical orthopedics in their treatment protocol, there are several alternatives, which are as follows:
Taping of the lip +/– the use of a hat or bonnet to provide retraction forces.
Nasoalveolar molding (NAM) (removable).
Fixed presurgical orthopedic treatment (FPOT).
Taping of the Lip
Taping of the lip provides another opportunity for pressure on the alveolar segments to retract the more anteriorly placed alveolar segment and close the alveolar cleft before surgical repair. However, placement and retention of the tape is difficult, and replacement of the tape, which must be done frequently, is even more difficult for the parents. This method of closure may be enhanced by the use of the Dynacleft taping system or a bonnet with Velcro attachments for an elastic strap, which will cross the upper lip for the anticipated and similar effect (Fig. 12‑1). This method is not only difficult for parents but also uncomfortable for the infant. Again, this method encourages collapse of the segments in a manner similar to the effect of no presurgical treatment described earlier.
Nasoalveolar molding is the most widely adopted of the treatment alternatives before lip surgery. In the early 1990s, Grayson et al described a presurgical removable device to move the palatal segments and mold the nasal cartilages. He and his group perceived that the major drawback of previous presurgical devices was their inability to shape the nose. Nasoalveolar molding, therefore, combines an intraoral removable molding appliance with extraoral taping and adds nasal prongs for the purpose of raising the nasal tip and shaping the alar cartilages. The intraoral appliance is adjusted to mold the alveolar segments in both unilateral and bilateral clefts via the addition of self-cure acrylic in the pressure areas and the alternate removal of acrylic on the side toward which movement is desired. When the segments have moved to reduce the alveolar cleft, nasal prongs are added to raise and shape the alar cartilages. Proponents of NAM state that the more difficult surgical goal is the elevation of the ala and the elongation of the columella and that this appliance supports these goals. Technical problems with NAM include hard-to-obtain/unpredictable posterior expansion and poorly directed retraction of the premaxilla in bilateral clefts as well as difficult-to-adjust nasal prongs, resulting in pressure on the ala that may be either inadequate or overzealous in both bilateral and unilateral clefts. Practical problems include the need for a dedicated in-house laboratory and a technician (to achieve the best results) as well as the need for frequent adjustment visits, placing a significant burden of treatment on the family (Fig. 12‑2).
Fixed Presurgical Orthopedic Treatment
The original sketches by Georgiaide and Latham emphasized on pressure to rotate and align the palatal shelves while closing the cleft alveolus in unilateral clefts. In bilateral clefts, it was noted that retraction of the premaxilla was not possible without expansion of the palatal shelves, so space had to be developed between the palatal shelves to accept the retracted and aligned premaxilla. The appliances were designed with hinges and activation screws. In case of bilateral clefts, symmetrical expansion was the goal. Latham later added an “auxiliary elastic” to the unilateral design to assist in rotation and closure of the wider clefts. In bilateral clefts, where retraction of the premaxilla was required, a transvomer pin was designed to pass through the bony portion of the anterior vomer just distal to the premaxilla. This pin was attached to the palatal appliance by parallel elastic chains. Both appliances were fixed in place to the palatal shelves with four transpalatal pins.
Our use and studies have supported the routine incorporation of the auxiliary elastic in all unilateral cases. The cleft can be closed by an average of 8.6 mm, thus reducing tension on the repair and enabling the choice of gingivoperiosteoplasty for the surgeon (Fig. 12‑3).
12.2.2 Fixed Presurgical Orthopedic Treatment Protocol of Boston Children’s Hospital
Unilateral Fixed Presurgical Orthopedic Treatment
Infants are examined and parents interviewed between 2 and 8 weeks of age with the goal of lip adhesion or repair at 3.5 months. Diagnostic records are taken, and an impression of the maxillary dental arch is made. All impressions are taken with the baby lying on the parent’s lap, with feet toward the parent and head on the operator’s knees (knee-to-knee position). Our material of choice is a high-quality alginate with color-changing characteristics. The alginate is placed in a “custom” acrylic tray (made from previous infant impressions and kept in a sterile pouch) (Fig. 12‑4).
Excess alginate is removed posteriorly, before insertion into the mouth. To limit the risk, the tray is not inserted in the mouth until the alginate progresses through several setting stages (purple to pink to white). In our experience, with the baby in this position, the airway has never been an issue, and a detailed impression may be obtained.
Infants with clefts who are to undergo fixed presurgical orthopedics are admitted to the hospital for short stays and brought directly to the operating room suite.
On the day of operation, the infant must have nothing by mouth for 6 hours in advance. An oral endotracheal tube is inserted; the patient is prepped and draped for a sterile procedure, and the oropharynx is packed. The appliance is tried in the mouth to ensure that it fits well; the pins are inserted in slots through the acrylic using a needle holder and set in place by using an orthodontic band seater and a surgical mallet (Fig. 12‑5 and Fig. 12‑6).
Each pin is approximately 15 mm in length, with a spring loop bend at the head, which will be compressed into the slot in the acrylic to ensure that the pin cannot be lost. When the pins are fully seated and the appliance is in position, the pin slots are covered with a small amount of restorative composite to ensure that the pin will not come out of the appliance, and the composite is set with a curing light. The appliance is activated by rotation of a screw within the cleft site, which extends on a diagonal from the anterior of the lesser segment posteriorly to a receiving cup at the posterior aspect of the greater segment. Initial activation requires 4 to 5 full (360-degree) turns, until the screw is firmly engaged in the cup. The elastic chain extending from the posterior aspect of the greater segment to the anterior aspect of the lesser segment and across to a hook on the greater segment is activated (Fig. 12‑7).
The throat pack may then be removed. The child is extubated in the operating room and awakened before being brought to the postoperative care unit. Infants are kept overnight to ensure that they begin to feed orally, that vital signs are stable, and that they are voiding appropriately. Although infants are restless, fussy, and have difficulty feeding immediately postoperatively, a recent study (Bronkhorst et al 2015) has assured us that the classic signs of pain are not present postinsertion.
The infants are then seen at 1 week, 3 weeks, and 5 weeks (more frequently if necessary) to ensure that the appliance is being properly activated at home (the screw is turned) and to permit reactivation of the elastic chain. The appliances are removed at the time of lip repair or lip adhesion.
Bilateral Fixed Presurgical Orthopedic Treatment
Infants with bilateral clefts are treated at a slightly older age than those with unilateral clefts (4–8 weeks of age). In the bilateral complete cleft, the anterior margins of the palatal shelves are frequently narrow and the premaxilla on the vomer stalk is markedly anterior and, in some cases, twisted in a lateral or superior/inferior direction. The goal of this treatment is to move the anterior aspect of the palatal shelves apart (transversely), while at the same time retracting the premaxilla to a position between the palatal shelves (Fig. 12‑8).
In the operating room, the junction of the premaxilla and vomer is visualized, and two points are marked along a horizontal line bisecting the cephalad–caudal width of the vomer, approximately 1 and 3 mm posterior to that junction (Fig. 12‑9). Using a handheld chuck and a twist drill (Peeso endodontic), two parallel channels are drilled through the vomer at these marks. A U-shaped 0.020 stainless steel wire (8–10 mm in length) is then prepared for insertion through these channels. Elastic chain is then attached to the more distal arm of the “U,” and it is passed through the vomer. Elastic chain is applied to the distal aspect, and the wire bent to prevent its loss (Fig. 12‑10 and Fig. 12‑11).
The elastic chains are then pulled through the appliance, as it is seated on the palate.
The appliance is secured with four pins in the same manner as the dental maintenance alternative (DMA). The elastic chains are then moved anteriorly and are separately attached with moderate force to the cleats at the anterior edge of each palatal shelf. The activation screw, which is in the posterior midline, is activated (Fig. 12‑12).
The expansion screw in the bilateral appliance (elastomeric chain premaxillary retraction [ECPR]) moves the palatal shelves in a “V” direction and provides enough width to accept the premaxilla. At the same time, the premaxilla is retracted by the elastic chain. The amount of expansion must be closely monitored to prevent a flattening of the nasal tip, excessive width at the alar base, and a prominence of the nasal eminences of the maxillary bone. The patient is monitored at 1 week, 3 weeks, and 5 weeks to ensure that the screw is activated appropriately and to allow the elastic chains to be reactivated. Feeding is again the main postoperative concern. In addition, mucus and milk curd accumulate between the palatal shelves and are cleaned with suction at each visit.
The impact of presurgical treatment on the family should not be minimized.
Parents of infants born with clefts of the lip and palate have already been significantly challenged in the postpartum stage. Although most parents now know through prenatal ultrasound that their child will be born with a cleft, the immediate mournful reaction after birth (when the reality is confronted) may be overwhelming. Relatives and friends who may not be fully prepared may become part of the problem. One of the advantages of presurgical care is the introduction and support of the cleft team and the knowledge that they are available to help at any time. From the initial impression on, this is a difficult period for parents. Our recent review of the postoperative course of infants who have had Latham-type appliances has shown that pain, as measured by vital signs and Face, Legs, Activity, Cry, and Consolability (FLACC) scores, is not a significant problem. However, it is not our intention to minimize the disruptions of these appliances, which include absence from work, loss of sleep, difficulties in feeding, the impact on other children in the family, and many more. These are significant disruptions and require that members of the cleft team, including the dentist and the feeding specialist, are available to the parents. However, the result of well-planned and executed presurgical infant orthopedics will leave the child with a dentition that is easily maintained, that has acceptable occlusion and appearance, and that is ready for the next phase of treatment in the mixed dentition.