Cleft Lip and Palate - part 3 potx

Chapter 6C Complete Bilateral Cleft Lip and Palate 135 Fig. 6C.28. (continued) By 8-3 the anterior overjet is markedly reduced by growth. 13-11 Conventional orthodontics were eventu- ally used to reduce the Class II occlusion and align the anterior teeth into an ideal overbite-overjet relationship 136 S. Berkowitz Fig. 6C.29. Case PM (KK-22). Computer-generated outlines of the serial casts were performed using an electromechanical dig- itizer.All casts are drawn to scale. The casts range from 12days to 17years, 4 months of age. This series demonstrates the spon- taneous closure of the anterior and posterior cleft spaces after “molding action” brought on by uniting the lip and then by gradual palatal growth at the border of the cleft space. The pre- maxilla was initially aligned forward of the lateral palatal seg- ments but was satisfactorily incorporated within the arch at a later age Table 6C.3. Surface Area of CBCLP.Case PM (KK-22).The palatal surface area increased by 4096 after 1 year,4 months and by 7696 at 2 years,1 month.By 8 years,2 months,the palatal surface area had increased two and a half times rohen the cleft space was closed. Skeletal Area Cleft Space Total Age Premax RLS LLS Tot Ant Post Tot SA + CS 0-0-12 145.5 335.5 282.7 763.7 127.4 417.0 544.4 1308.1 0-3 150.2 397.4 377.6 925.2 65.4 331.5 396.9 1322.1 1-4 154.0 469.5 464.3 1087.8 36.8 265.5 302.3 1390.1 1-10 211.8 502.6 506.2 1220.6 70.4 216.3 286.7 1507.3 2-1 217.6 589.0 549.5 1356.1 79.8 195.3 275.1 1631.2 2-10 220.7 603.9 551.3 1375.9 95.8 193.2 289.0 1664.9 3-10 271.6 660.4 616.5 1548.5 122.6 206.3 328.9 1877.4 5-8 273.3 673.0 675.9 1622.2 123.6 201.2 324.8 1947.0 6-7 273.6 811.0 820.5 1905.1 115.0 206.5 321.5 2226.6 7-4 277.3 813.0 839.5 1929.8 106.7 185.2 291.9 2221.7 8-2 306.5 844.6 890.8 2041.9 101.1 155.4 256.5 2298.4 12-3 346.8 1087.1 1116.1 2550.0 2550.0 14-0 348.7 1161.8 1226.4 2736.9 2736.9 14-5 351.1 1198.8 1237.0 2786.9 2786.9 17-4 353.5 1241.0 1246.3 2840.8 2840.8 Note: Premax = Premysxilla; RLS = Right Lateral Segment; LLS = Left Lateral Segment; Tot = Total Surface Area; Ant = Anterior Cleft Space; Post = Posterior Cleft Space; Tot = Ant + Post; SA + SC = Bony Surface Area + Cleft Space Area; #: Changing teeth. Chapter 6C Complete Bilateral Cleft Lip and Palate 137 Fig. 6C.30. Case PM (KK-22). Palatal outlines were superim- posed using the rugae for registration. This series shows that the premaxilla’s position within the maxillary complex at 17 years of age is similar to that seen at birth. Excellent growth occurs in all dimensions and is similar to the growth pattern seen in noncleft palates. Increased posterior palatal growth is necessary to accommodate the developing molars. Alveolar bone growth with tooth eruption increases midfacial height. Comments: The position of the anterior premaxilla relative to the anterior cranial base (Nasion) to the anterior position of pogonion of the mandibular symposium shows the same rela- tive position from birth to 17years of age. These 2 studies con- firm that midfacial growth is retarded Fig. 6C.31. Case DK (AI-31). Premaxillary ventroflexion with medial movement of the lateral palatal segments caused a great reduction in the anterior and posterior cleft spaces by 5months of age. Thereafter, for the next 19months, the anterior cleft space gradually reduced,while the posterior cleft space showed some increase due to the increase in palatal length. Both lateral palatal segments showed a similar,gradually increasing growth rate 138 S. Berkowitz Fig. 6C.32. Case DK (AI-31). After the initial change in cleft size brought on by medial movement of the lateral palatal seg- ments and ventroflexion of the premaxilla, the greatest acceler- ation of cleft space closure occurred between 2-10 and 3-5. The premaxilla reached its largest size by 3 years, which is associat- ed with eruption of the teeth. Palatal growth acceleration oc- curred between 1 to 3 months and 12 to 14months and then gradually tapered off. The palatal segments had increased 37% in size by 1year and 74% by 2years. Palatal growth at its medi- al borders still occurs; even though it narrows the cleft space, the total cleft space is increasing in size due to the increase in palatal length Chapter 6C Complete Bilateral Cleft Lip and Palate 139 Fig. 6C.33. Case PM (KK-22) Time sequence analysis of serial palatal growth shows that both palatal segments are growing at the same rate and to the same degree. The premaxilla is also in- creasing in size with tooth eruption but at a lesser rate. The greatest palatal growth acceleration occurs the first 2 years and then tapers off. The anterior cleft space is initially reduced as a result of premaxillary ventroflexion, but thereafter it remains the same dimensions until the palatal cleft is closed. The poste- rior cleft space initially is reduced with palatal medial move- ment.The resulting posterior cleft space remains approximate- ly the same size for the next 8years.It must be remembered that the cleft length is increasing while the cleft width is decreasing. The net cleft area is gradually reducing with growth.All fistulae are closed by 12–3 years of age 140 S. Berkowitz Fig. 6C.34. Serial midpalatal cross-sections showing vault height and palatal width changes using stereophotogrammetry. The left lateral palatal segment is attached to the vomer – while the right lateral palatal segment is displaced laterally.A lip mus- cle adhesion causes the displaced palatal segment to move me- dially, narrowing the cleft space. The appositional growth of the alveolar segments is continuous and becomes more obtuse. Closure of the palatal cleft space with a modified vomer flap maintains a normal vault height, and vault space flattening of the vault occurs in almost all cases in the absence of a vomer flap. Comments: A vomer flap with a von Langenbeck proce- dure seems to create a minimum scarring. Vomer flap alone performed early (6 months to 1year) created excessive scarring Chapter 6C Complete Bilateral Cleft Lip and Palate 141 Fig. 6C.35 a,b. Case PM (KK-22) a Cephalometric serial trac- ings of the skeletal and soft tissue profile show marked reduc- tion of the midfacial protrusion. b Superimposed serial tracings using Coben’s Basion Horizontal method show an excellent facial growth pattern which straightens the skeletal profile. There is very little forward midfacial growth between 11 and 20 years of age. During the same time period, growth at the anterior cranial base and the mandible contributed to flattening of the facial profile a b Fig. 6C.36. Case PM (KK-22). Cephaloradiographs taken at 5 years of age. Top : At rest with teeth together. Middle:Taken while vocalizing “Youu . . .” Bottom: Taken while vocalizing “Sss ”Comments:When vocalizing both sounds,the velum el- evates and makes contact with the adenoids. The pharyngeal depth is relatively small. The adenoids are of moderate size, the velum is of good length and shows good elevation. This is not a functional test to evaluate velopharyngeal closure but it does show the well-proportioned oral and nasal pharyngeal spaces which are conducive to good velopharyngeal closure. A gap space more than 5mm may indicate VPI exist with inadequate lateral pharyngeal wall movements 142 S. Berkowitz ab dc e Fig. 6C.37 a–e. Various palatal expansion appliances. a “W” appliance with finger springs designed to move the central in- cisors forward while correcting the posterior crossbite. b “W” appliance. c Arnold expander: a .040 wire is inserted into a .040 tube; the compressed open coil spring exerts a gentle lat- eral force moving the two segments apart. A larger diameter (.045) tube wire allows the cuspids to be moved laterally more than the molars. d A Hyrax expander, which needs a lever and parent involvement to activate the very strong expansion force. This appliance is rarely necessary with meager transpalatal scarring. e A three-part removable expansion plate used to simultaneously advance and expand the anterior and buccal segments in a BCLP. Appliances that attach to the teeth are more reliable and efficient than removable ones Chapter 6C Complete Bilateral Cleft Lip and Palate 143 Fig. 6C.38 a–s. Case ML (KK-56) demonstrates severe premax- illary protrusion at birth in IBCLP. “Whisker” forked flap was performed at 2months, definitive lip surgery at 6months, and palatal cleft closure at 18 months. Secondary alveolar cranial bone grafting was placed at 8years,3months.Maxillary surgery with chin augmentation was performed at 15 years, 7 months. a–g Facial and intraoral photographs show progressive facial and occlusal changes abc d fg e 144 S. Berkowitz Fig. 6C.38 a–s. (continued) h, i,and j Facial photographs at 8years of age. k After Lefort I advancement, the lateral incisor pontics were attached to the arch wire for aesthetics. l and m Occlusal photographs showing missing incisor spaces hi j k l mn [...]... the premaxilla forward 3- 5 After palatal cleft closure there is excellent buccal occlusion 4 -3 , 5-1 , 7 -3 , and 8-1 Good buccal and anterior occlusion is present for the next 4 years Fig 6C.54 (continued) 1 2-4 and 1 3- 3 This crossbite remains for the next 3 years and does not hinder dental function 1 6-1 0 and 1 8-1 After orthodontics Good Class I occlusion with good anterior overjet and overbite 169 170 S... Bilateral Cleft Lip and Palate p r tained with a removable Hawley retainer, which carries a lateral incisor replacement 167 168 S Berkowitz Fig 6C.54 Chapter 6C Complete Bilateral Cleft Lip and Palate ᮤ Fig 6C.54 Case ES (EE -3 4 ) Serial dental casts 0-0 -1 2 At birth 0-1 -0 After uniting the lip, the premaxilla has been positioned adjacent to the lateral palatal segments 2-7 The palatal cleft is still open... anterior open bite The upper lip was long and tight with the lateral elements brought together below the prolabium The palatal cleft was closed at 12 months of age At 1 3- 1 0, a removable plate replaced the right central incisor At 1 5-1 1, Complete Bilateral Cleft Lip and Palate orthodontic preparation for Lefort I posterior-impaction At 1 6-4 , after maxillary surgery At 1 9-9 , after anterior fixed bridge... Bilateral Cleft Lip and Palate a large anterior cleft space 1 1-2 -0 Waiting for the eruption of permanent bicuspids before initiating orthodontics 1 3- 0 -0 After the horizontally impacted cuspids and their supporting alveolar bone and the lateral incisors were brought within the arch, the premaxillary overjet was reduced Both of these factors were responsible for the closure of the anterior cleft space... the premaxilla prior to lip surgery The lip was united at 5 months of age using a Fork flap procedure The palatal cleft was closed at 43 months of age using a modified von Langenbeck procedure a and b Face and palate at birth c and d 3 months after lip surgery e–i 5 years of age with excellent buccal occlusion and good overbite-overjet relationship of the anterior teeth Upper lip is protrusive 165 166... to obtain good anterior overbite and overjet in the presence of strong mandibular growth 145 146 S Berkowitz Fig 6C .39 Case ML (KK-56) Serial casts from 0-0 -2 to 4 -3 : With the establishment of an intact lip musculature, the premaxilla and lateral palatal segments molded into a good arch form The premaxilla, although latero- and ventroflexed, still caused the upper lip to be pushed forward The left... upright and in an acceptable overbite-overjet relationship 1 2 -3 Maxillary expansion has been initiated The Complete Bilateral Cleft Lip and Palate maxillary central incisors are in tip-to-tip relationship 14 Continued orthodontic treatment to advance the premaxilla and position the incisor teeth in proper overjet-overbite relationship 155 156 S Berkowitz tioning with soft tissue closure of the anterior cleft. .. This shows the lack of palatal growth and reduction in cleft space over 2 years prior to surgical closure of the palatal cleft The anterior cleft space remains large up to 1 5-2 years 1 6-9 and 1 7-8 The premaxillary incisors were extracted Comment: This case clearly demonstrates the severe degree of osteogenic deficiency that can exist in bilateral clefts of the lip and palate The once protruding premaxilla... 6C.50 Case CT (AV-62) demonstrates a severe premaxillary overjet leading to a retruded midface and the successful use of protraction orthopedics This patient was adopted from Central American parents 4-6 It is important to note the wide cleft Complete Bilateral Cleft Lip and Palate space with an excellent Class I buccal occlusion prior to surgical cleft closure 5 -3 Two months after palatal cleft closure,... growth (time) and may eventually need to be brought forward Although palatal growth does occur, it may not be sufficient to appreciably reduce the posterior cleft space Fig 6C.44 (continued) 1 5-2 , 16, and 1 6-6 Premaxillary reposi- Chapter 6C Complete Bilateral Cleft Lip and Palate Fig 6C.46 Case CS (AF-48) The palatal segments show a very gradual growth acceleration curve, while the posterior cleft space . 150.2 39 7.4 37 7.6 925.2 65.4 33 1.5 39 6.9 132 2.1 1-4 154.0 469.5 464 .3 1087.8 36 .8 265.5 30 2 .3 139 0.1 1-1 0 211.8 502.6 506.2 1220.6 70.4 216 .3 286.7 1507 .3 2-1 217.6 589.0 549.5 135 6.1 79.8 195 .3. 275.1 1 631 .2 2-1 0 220.7 6 03. 9 551 .3 137 5.9 95.8 1 93. 2 289.0 1664.9 3- 1 0 271.6 660.4 616.5 1548.5 122.6 206 .3 328.9 1877.4 5-8 2 73. 3 6 73. 0 675.9 1622.2 1 23. 6 201.2 32 4.8 1947.0 6-7 2 73. 6 811.0. 206.5 32 1.5 2226.6 7-4 277 .3 8 13. 0 839 .5 1929.8 106.7 185.2 291.9 2221.7 8-2 30 6.5 844.6 890.8 2041.9 101.1 155.4 256.5 2298.4 1 2 -3 34 6.8 1087.1 1116.1 2550.0 2550.0 1 4-0 34 8.7 1161.8 1226.4 2 736 .9