Presurgical management of unilateral cleft lip and palate in a neonate: A clinical report Rajendra Avhad, MDS,a Ranjukta Sar, MDS,b and Jyoti Tembhurne, MDSc Government Dental College and Hospital, Mumbai, Maharashtra, India A cleft lip and palate consists of fissures of the upper lip and/or palate, and is the most commonly seen orofacial anomaly that involves the middle third of the face. Early treatment of patients with a cleft lip and palate is important because of esthetic, functional, and psychological concerns. Nasoalveolar molding provides excellent results when started immediately after birth. This clinical report describes the presurgical management of an infant with a complete unilateral cleft of the soft palate, hard palate, alveolar ridge, and lip. (J Prosthet Dent 2014;-:---) A cleft lip and palate is a congenital defect of the middle third of the face, characterized by the presence of oronasal communication, malformation or agenesis of the teeth close to the cleft, and deficient sagittal and transverse growth of the maxilla.1 The etiology is complex and depends on genetic and environmental factors. Treatment is important not only because of esthetic and functional concerns but also because it has a positive psychological effect on the patient. Treatment planning for patients with a cleft lip and palate is related to factors, including the age, socioeconomic status of the patient, the type and severity of the defect, and the intraoral situation at the time that treatment is started. A multidisciplinary approach is necessary to evaluate, diagnose, and resolve functional and esthetic problems. Because there is no lip seal and because of the oronasal communication, the cleft results in problems of suckling and can lead to severe nutritional as well as respiratory problems if not corrected early. As the child grows, the effect on speech, occlusion, and appearance becomes more evident. Advances in reconstructive surgery have improved the quality of repair for clefts. However, surgery alone cannot a
correct all aspects of the cleft defects and yields a less than ideal esthetic result. Multiple additional surgeries are often required to improve the initial surgical repairs and to correct deficiencies that result from the surgery itself.2 Presurgical nasoalveolar molding (PNAM) provides the surgeon with an improved foundation to repair the defect. It reduces the size of the intraoral alveolar cleft through the molding of the bony segments, and the active molding and positioning of the surrounding soft tissues affected by the cleft, including the deformed soft tissue and cartilage in the cleft nose. PNAM depends on the inherent plasticity and moldability of the neonatal cartilaginous tissues. So, it provides excellent results when started early after birth.2
CLINICAL REPORT A 3-day-old neonate was reported to the Department of Prosthodontics unable to breast-feed and swallow because of lip and palatal defects. Before treatment, a detailed medical, dental, and social history was obtained from the patient’s parents, which was not signifi- 1 Intraoral view before nasoalveolar cant. There was no history of infection, molding, showing cleft involving lip, drug ingestion, vitamin deficiencies, alveolus, hard palate, and soft palate.
Assistant Professor, Department of Prosthetic Dentistry. Assistant Professor, Department of Prosthetic Dentistry. c Department Head, Department of Prosthetic Dentistry. b
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psychological, emotional, or traumatic stress during pregnancy. Other systemic abnormalities were absent. An intraoral examination revealed a complete unilateral cleft of the right side that involved the soft palate, hard palate, alveolus, and lip (Fig. 1). After an examination, the defect was diagnosed as a complete
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Volume unilateral cleft of unknown origin. The stepwise treatment was planned for PNAM, followed by surgery. After explaining the procedure and treatment goals to the parents, an impression was made. The procedure was done in the presence of a pediatric surgeon in the event of airway issues during the impression making. The infant was fully awake, without anesthesia, and was held face down to prevent aspiration of the impression material and regurgitation of stomach contents. The head was gently held in a slightly upright position during the impression procedure.2 Highvolume evacuation was available in case the child regurgitated stomach contents. The primary impression was made with a low fusing impression compound, which was carried on the ventral surface of the gloved thumb of the dentist. A custom tray was fabricated with self-polymerized acrylic resin (DPI-RR Cold cure acrylic repair material). The definitive impression was made with high-viscosity (putty) condensation silicone material (Speedex; Coltène/Whaledent). Care was taken to ensure that the material registered the border regions of the maxilla as well as the cleft region. When the material had fully polymerized, the impression was removed and inspected to ensure that all desired landmarks had been captured (Fig. 2). The impression then was poured into a Type IV dental stone (Kalrock; Kalabhai Karson Pvt Ltd). A second cast was poured. One cast was used as a working cast and the second cast was used as a record. In the working cast, undercuts were blocked with plaster pumice mix. The cleft region of the palate and alveolus were filled in with wax to approximate the contour and topography of an intact arch. A feeding plate was fabricated from selfpolymerized clear acrylic resin (DPI-RR Cold cure acrylic repair material). The appliance was finished and polished. An extraoral retentive button was then fabricated from self-polymerized clear acrylic resin and attached at the site of the cleft in the lip. The retentive button
was positioned facing downward on the labial flange at an approximately 45-degree angle to the occlusal plane to allow proper clearance of the upper and lower lips. Its length was adjusted for ease of breast-feeding. A groove 1to 1.5-mm deep was made at the center of the retentive button to incorporate elastics.3 At the delivery appointment, the appliance was fitted in the neonate’s oral cavity. It was fairly self-retentive. After inserting the appliance, the neonate was observed for a few minutes while the appliance was stabilized with a gloved index finger. The neonate was able to suckle without gagging or struggling. The tissue surface of the appliance was modified at the initial insertion appointment to begin the molding of the greater and lesser alveolar segments on either side of the cleft. To direct the greater segment inward, a 1- to 1.5-mm thickness of soft liner (GC Corp) was added to the inner labial aspect of the greater segment of the alveolus portion of the appliance and acrylic resin was removed from the palatal aspect. To direct the lesser segment outward from the cleft, acrylic resin was selectively removed from the inner labial aspect of the lesser segment of the alveolus (approximately 1-1.5 mm), and an equal amount of soft liner was added on the palatal aspect. The appliance was then inserted and retained extraorally.4 For retentive taping, broader base tape (0.5 1.5 inch) was first applied to the infant’s cheek
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2 Definitive impression. lateral and superior to the commissures. These base tapes served as anchors for thinner strips (0.25 4 inch) that held the appliance against the palate. Small red “orthodontic elastics (0.25-inch diameter), prime medical grade latex” were incorporated into loops of thinner strips. The elastic bands were placed over the retentive button, and the strips were pulled and secured to the base tapes on the cheeks. To obtain appropriate force, the elastics were stretched to twice their original length, and, to get proper force direction, the retentive tapes and elastics were directed posteriorly and superiorly (Fig. 3). The neonate was
3 Alveolar molding appliance retained extraorally.
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4 Incorporation of nasal stent in presurgical nasoalveolar molding appliance.
5 Infant with nasoalveolar molding appliance.
observed for sometime after inserting the appliance to check airway patency. Lip taping also was done at the initial insertion appointment. The parents were trained to insert, tape, remove, and clean the appliance. Instructions were given to keep the appliance in the oral cavity for 24 hours a day except during cleaning. The base tapes were kept for a longer time, but the thinner strips were changed daily. The patient was recalled on a weekly basis, and minor adjustments were made. When the cleft gap was reduced to approximately 6 mm or less, a nasal
stent was added, and active molding5 of the nasal cartilage was begun by adding a stainless wire loop bent in a swan neck fashion to the labial flange of the appliance above the retentive button (Figs. 4, 5). The loop on the end of the wire was covered with hard, clear, acrylic resin, which again was covered with a thin veneer of soft liner to prevent any injury to the nasal soft tissues. The PNAM plate with the nasal stent attached was inserted, and gentle pressure was applied to the depressed alar cartilage by activating the wire loop. An outward molding of the nasal
6 Infant after 11 weeks of presurgical nasoalveolar molding.
7 Postsurgical frontal view 2 weeks after surgery.
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cartilage was done, which gave a more symmetric nasal form. As the intraoral cleft closed, the nasal stent was modified to guide the tissue-expanding force in the desired direction. After 11 weeks, only a small cleft of 1 mm was observed between the alveolar segments (Fig. 6). The surgeon evaluated the lip, alveolus, and nasal position of the infant, and found the infant suitable for surgery. To identify a child as suitable for surgery, the rule of “three 10s,” coined by surgeons Wilhelmmesen and Musgrave in 1969, was followed (the child is at least 10 weeks of age, weighs at least 10
8 Postsurgical profile view 2 weeks after surgery.
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and providing a pseudopalate. The infant started suckling without any problem, and this correlated with an improvement in the child’s weight and overall nutritional status. However, for success, the cooperation of the parents was essential. By using PNAM, which acts as an adjunctive therapy, the deficient tissues could be expanded and malpositioned structures could be repositioned before surgical correction.
SUMMARY REFERENCES This clinical report describes a prosthodontic approach to the management of a cleft lip and palate deformity in an infant with a unilateral complete cleft. The molding appliance successfully rehabilitated the neonate by closing the oronasal communication
1. Shah CP, Wong D. Management of children with cleft lip and palate. Can Med Assoc J 1980;122:19-24. 2. Taylor TD. Clinical maxillofacial prosthetics. Chicago: Quintessence; 2000. p. 63-84. 3. Grayson B, Shetye P, Cutting C. Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Cleft J 2005;1:4-7.
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4. Yang S, Stelnicki EJ, Lee MN. Use of nasoalveolar molding appliance to direct growth in newborn patient with complete unilateral cleft lip and palate. Pediatr Dent 2003;25:53-6. 5. Grayson B, Santiago P, Brecht L, Cutting C. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofacial J 1999;36:486-98. 6. Lydiatt DD, Yonkers AJ, Schall DG. The management of the cleft lip and palate patient. Nebr Med J 1989;74:325-8. 7. Berkowitz S. Cleft lip and palate. 2nd ed.Berlin: Springer; 2006. p. 381-407.
Corresponding author: Dr Ranjukta Sar Government Dental College and Hospital St George Hospital Compound P. Dmello Road Mumbai - 400001, Maharashtra INDIA E-mail:
[email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
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