Review Article

Maxillary orthopedics in the presurgical managementof infants with cleft lip and palateFrank J. Sierra, DMD Clara Turner, DMD

T he use of maxillary orthopedic appliances totreat infants with cleft lip and palate has been asubject of debate for many years. Much contro-

versy lies in the type and timing of orthopedic inter-vention and in the timing of surgery. Infants with wideunilateral cleft lip and palate (UCLP) or bilateral cleftlip and palate (BCLP) with a protrusive premaxilla areparticularly problematic for the surgeon due to the dis-tance the tissue must be mobilized to close the defect.Surgical closure of a wide defect causes excessive ten-sion on the suture line, which may lead to failure. It iscommon to use a two-stage cheiloplasty in many ofthese circumstances. The objective of the first stage, lip-adhesion surgery, is to attach the orbicularis orismuscle and allow muscle forces to mold the maxillarysegments, thus facilitating the definitive lip repair. 1 Inmost patients with cleft lip and palate (CLP), arch align-ment without the use of active and/or passive appli-ances is often unfavorable. Coordination between theplastic surgeon and the dentist has made it possible tobetter position the maxillary segments in order to fa-cilitate a one-time surgical repair of the lip.

Proper repair of the CLP can produce favorablechanges in the initial distortion seen in infants with acleft. 2 Crossbite of the dentition in the child with CLPis a common clinical finding. 3 Undoubtedly, a predis-position to dental crossbite is established early in in-fancy, either as a result of the birth defect or as an un-favorable response of the alveolar segments to theinfluence of lip and palate repair. This has led someauthors to recommend the use of presurgical orthope-dics in an attempt to control arch form in the early yearssurrounding most major surgical repairs. ~ With a bal-anced, stabilized maxillary platform, a definitivecheiloplasty and/or rhinoplasty may be more ideallycompleted. Presurgical infant orthopedics achievealignment of the maxillary segments, presenting a moresymmetrical platform and width reduction of the alveo-lar ridge cleft. This enables elevation of the alar baseon the cleft side and lip closure without tension or withminimal tension.8

Passive acrylic appliances may be utilized for mold-ing and/or retention. If the lateral segments are held

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in position by a maxillary appliance, the premaxillarysegment responds to the muscle forces of the lip--re-sulting in lingual movement, probably through reshap-ing of the vomer and nasal septum. Hochban andAustermann9 treated 20 infants with UCLP with pas-sive appliances until the hard palate and alveolus wererepaired at approximately age 3 years. Collapse of thealveolar segments was evident after appliance therapywas discontinued. In cases of BCLP with adequatetransverse width, a removable palatal appliance tomaintain the position of the lateral segments--with anacrylic bulb fitted over the premaxilla for retraction--may be used. Anchorage for the premaxillary retrac-tion may be achieved by extraoral straps attached to abonnet worn by the infant. 1° In a study of 40 childrenwith BCLP, each subject was assigned to a group,which 1) received orthopedic therapy with intraoralappliances and a bonnet with extraoral straps or 2) re-ceived same treatment without orthopedic forces."Records were taken during primary and mixed denti-tion stages. Significantly greater incidences of incisorcrossbite were reported in the untreated cases in bothprimary and mixed dentitions. In terms of maxillaryanteroposterior displacement, the effect of passive ap-pliances in treating infants with CLP must be regardedas unpredictable.~2

The aims of this article are to review presurgicalmaxillary orthopedic techniques and the advantagesand disadvantages of appliance therapy, and to illus-trate fixed appliance therapy in infants with unilateraland bilateral cleft lip and palate.

Purpose of appliance therapyThe objectives of early active maxillary orthopedics

are two-fold. First, in cases of wide unilateral clefts (Fig1) or protrusive premaxilla in bilateral clefts (Fig 2), initial cheiloplasty is difficult due to the distance thetissue must be mobilized to close the defect. This causesexcessive tension on the surgical site, which may leadto wound dehiscence. Presurgical maxillary orthope-dics allow earlier, more ideal lip closure with minimumtissue tension since the soft tissues will overlie a morenormal bony anatomy. If definitive closure of the de-

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Fig 1. UCLP, occlusal view

Fig 2. BCLP, occlusal view

feet will cause excessive tension on the surgical site, thesurgeon also may elect to perform the lip repair in twostages. By using orthopedic therapy, the requirementof lip adhesion surgery prior to a definitive repair maybe eliminated. Early maxillary orthopedics can movethe maxillary segments to a more anatomically correctposition and the soft tissues will be carried with thesegments, leading to a decrease in the width of the de-fect, which will reduce surgeon time, hospital time, andthe risks of additional general anesthesia. Eliminatinglip adhesion surgery also eliminates the need to per-form additional surgery in the presence of scar tissuefrom an earlier operation. Additionally, if lip closureis accomplished in one operation, the patient has amore normal appearance earlier in life, and the risk andcost of an additional surgical procedure are eliminated.

Second, left untreated, the lateral alveolarsegment(s) usually "collapse", leading to malalignmentas depicted in Fig 3. With early orthopedic intervention,a more normal arch form may be achieved, resultingin better alignment of the segment(s) as in Fig 4. Themore normal or near normal alveolar alignment leadsto better soft tissue approximation. It is unknownwhether this arch alignment will lead to more idealocclusal relationships with future growth. Long term,well-controlled studies are necessary to determine theeffect of early orthopedic therapy on final growth.

Fig 3. UCLP-collapsed alveolar segments (left). BCLP-collapsed lateral segments with a protrusive premaxilla(right)

Fig 4. UCLP-ideal alignment (left). BCLP-ideal alignment(right)

Unilateral cleft lip and palate

Appliance design and mechanicsThe fabrication of any intraoral appliance depends

on an accurate impression. Tempered red compoundimpression material is recommended because it is lesslikely to flow deep into undercuts of the cleft. Break-age of impression material in the cleft may result indifficult retrieval and/or airway obstruction. Duringthe impression procedure it is recommended that theinfant be placed prone, which displaces the tonguedownward and forward, promoting a patent airwayand avoiding aspiration if vomiting occurs. The stonemodel produced from the impression is used to fabri-cate the orthopedic appliances.

The appliances used in the orthopedic treatment ofinfants with UCLP can be divided into two major cat-egories: removable and fixed. Both appliances gener-ally consist of acrylic pads adapted to the alveolar seg-ments and an adjustment screw, which inducesmovement of the segments. The lack of retention of theremovable appliance limits its use as an activepresurgical appliance. The fixed appliance, which isattached to the palatal bone by stainless steel pins, pro-vides good retention and a constant, controllable ortho-pedic force. An example of this type appliance is thedentomaxillary advancement (DMA) appliance de-scribed by Latham13 (Fig 5). It has been advocated thatan ideal approach to treatment of infants with UCLPwould be to move the entire maxilla forward using trac-tion to stimulate an adjustment response of the maxil-lary sutures.13 Such an advancement would improvealignment of the dental arch. If this were accomplishedprior to surgery, the cheiloplasty might result in morenormal anatomic relationships with minimal mobiliza-tion of facial tissues. The DMA appliance was devel-oped for such an orthopedic correction.

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The DMA appliance has two acrylic pads joined bya posterior stainless steel hinged strut. The end of theadjustment screw, which is attached to the lesser seg-ment, fits into a slot on the greater segment. The appli-ance is attached to the palatal bone using stainless steelpins placed 30-40" to the vertical. This pin placementfacilitates good retention and avoids the developingteeth. Rotation of the screw applies a force that ad-vances the lesser segment anteriorly (Fig 6). The greatersegment acts as anchorage, but does receive slight pos-terior rotation of the premaxillary position.

Appliance placement, activation, and removal

Once constructed, the appliance is evaluated to as-certain proper fit, correct advancement of the threadedscrew, tongue clearance, and freedom from possibleareas of tissue irritation. The infant is sedated withproper monitoring and local anesthesia is infiltratedinto the palate in the areas of pin placement. The ap-pliance is placed on the palate and the retaining pinsare inserted at the proper orientation and seated. Cold-cure acrylic may be placed over the pins. Parents aregiven postoperative instructions and the correctmethod of daily appliance activation. The patient isfollowed weekly, and surgery is scheduled for lip clo-sure when the segments are approximated. Dependingon the width of the cleft, 2 to 3 weeks of daily activa-tion is required. The appliance is removed in the oper-

Fig 5. DMA appliance

ating room at the time of the cheiloplasty. With appro-priate alignment of the alveolar segments, elevation ofthe alar base and definitive lip repair with excellentesthetics (Fig 7) can be achieved.

Bilateral cleft lip and palate

Appliance design and mechanicsThe orthopedic appliances used to treat infants with

BCLP may be divided into removable, fixed, and com-bination appliances. Many patients with BCLP benefitfrom premaxilla retraction. If the lateral segments arenot collapsed medially, they can be maintained by us-ing a lateral segment stabilization appliance (fixed orremovable) while the premaxilla is retracted withextraoral strapping.14 In cases where the lateral seg-ments block the premaxilla retraction, an expansionappliance is necessary. The expansion appliance alsomay be removable or fixed. One must use caution inplacing the retraction component of the appliance. Ifnot precisely positioned, a downward rotation of thepremaxilla may result, rather than retraction. Lack ofretention with removable appliances may prohibit op-timal results, while a pinned expansion appliance withan extraoral retraction strap is a treatment alternative.15

Georgiade and Latham16 described an intraoral fixedappliance with a palatal expansion component and apin placed into the premaxilla for premaxillary retrac-tion. This totally intraoral, fixed appliance utilizes elas-tic chain premaxillary retraction (ECPR). The applianceconsists of acrylic pads over the lateral segments con-nected posteriorly by an expansion mechanism (Fig 8).The premaxilla is retracted by elastic chains attachedto a pin placed through the premaxilla just anterior tothe premaxillovomeral suture.

Appliance placement, activation, and removalInserting the ECPR appliance requires more preci-

sion than the appliances used for orthopedic movementin UCLP, and it is best placed using general anesthe-sia. The location of the premaxilla pin is marked usingradiographs (Fig 9) and anatomical landmarks. The pinis placed anterior to the premaxillovomeral suture byfirst preparing two parallel holes into the vomer. With

Fig 6. DMA appliance mechanics

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Fig 7. Following cheiloplasty

American Academy of Pediatric Dentistry 421

one elastic chain attached to the closed end of the pin,the pin is inserted through the vomer via the preparedholes. The second elastic chain is attached to the openend of the pin on the opposite side of the vomer. Theopen end of the pin is bent closed to secure the elasticchains. The acrylic pads are placed on the lateral seg-ments and the palatal pins placed. The elastic chainsare passed via a roller on the posterior of the palatalportion of the appliance and adjusted to approximately3 oz of tension prior to attachment to the anterior of thepalatal portion of the appliance.

Parents are given instructions for postoperative careand daily appliance activation. The patient is followedweekly and surgery is scheduled for lip closure whenthe premaxilla is retracted (Fig 10). Depending on thewidth of the cleft, 2 to 3 weeks of daily activation isrequired. The appliance is removed in the operatingroom at the time of the cheiloplasty. Retraction of thepremaxilla facilitates definite lip repair with excellentresults (Fig 11).

Facial morphology considerationsThe reasons for abnormal facial morphology in chil-

dren with a cleft involves three factors: intrinsic devel-opmental deficiencies, functional distortions affecting

the position and growth of both normal and abnormalparts, and iatrogenic factors introduced by treatment.17

It has been stated that the primary objective of earlyorthopedics is not to facilitate surgery, but to take ad-vantage of intrinsic developmental potentialities.4 Stud-ies have concluded that the long-term outcome ondentofacial morphology of the specific surgical man-agement of the UCLP patient cannot be predicted.18 Itwas determined that up to 50% of all patients may de-velop normal arch form with little or no additional in-tervention other than surgery itself. An equal numberwill suffer immediate postsurgical arch collapse thatdoes not improve.

Changes caused by iatrogenic factors are of greatconcern. For example, it has been demonstrated thatpalatal tissue growth is retarded after orthopedic ap-pliance therapy.19 Despite this effect, presurgical ortho-pedic treatment should be considered since it facilitateslip and palate repair and has beneficial social aspects.The social perception of the cleft impairment is a com-plex process that includes the severity of the facial de-formity and overall facial attractiveness.20 These find-ings suggest that a surgical intervention thatsignificantly reduces severity and improves estheticsshould improve social desirability.

Fig 8. ECPR appliance. Fig 10. Post-ECPR therapy.

Fig 9. Lateral radiograph demonstrating premaxillovomer- Fig 11. Following cheiloplasty.al suture (arrow) and placement of premaxillary pin (*)

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Family involvementIn studies of families of children with craniofacial

anomalies, 91% of respondents of a survey indicatedtheir desire to participate in treatment decisions; 36%wished for more participation. ~ Active orthopedicsinvolves the family in the daily home care and appli-ance adjustment. Such participation gives parents sat-isfaction since they are actively involved in the treat-ment necessary to correct their infant’s birth defect.

Success/retention debateBeyond the orthopedic therapy questions, there is

considerable debate on what type of surgery should beperformed to maintain the orthopedic correction. Earlyautogenous bone grafting often is used to stabilize bothpassive and active orthopedic corrections. 22 A group of35 children with BCLP, UCLP, or UCL and alveoluswere followed from age 5 to 17 years.~3 Periosteoplastywas performed between age 4 and 7 years and resultedin bone formation in 80% of the cases, with new boneformation continuing for several years. Whenpared to controls with neither bone graft norperiosteoplasty, the delayed periostoplasty was sug-gested to be superior because there is no negative ef-fect on the dental occlusion or craniofacial growth.

The period of puberty is important in the develop-ment of the face and in effecting the results of orthodon-tic therapy. Smahel and Mullerova2. examined cranio-facial growth and development in males with UCLPbetween the ages of 10 and 15 years who had primaryosteoplasty at the time of lip repair. The data were com-pared to males with similar treatment, with the excep-tion of periostoplasty at the time of lip repair ratherthan bone graft. Persistent anterior crossbite was morecommon in the individuals who had primaryosteop}asty at the time of lip repair. It is very clear thatthe use of preoperative maxillofacial orthopedics andthe timing and type of surgery requires an individualapproach to each case.

Dr. Sierra is in private practice in Tampa, Florida. Dr. Turner isassociate professor, department of pediatric dentistry, Universityof Florida, Gainesville.

The authors coordinated treatment of the cases presented with Dr.M. Brent Seagle, eraniofacial surgeon, University of Florida andthank him for his input, The authors also thank Dr. Barry Marcumfor his participation in patient care and Dr. Ralph Latham for de-sign and fabrication of the appliances.

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