**2.1 Ante/post-natal stage**

Occasionally, an orthodontist is involved prior to the birth of a baby if a cleft lip and or palate is diagnosed on a 20 week scan. Ultrasonography is a noninvasive diagnostic tool which is widely used. The unexpected finding is a considerable psychological blow to parents and counseling is often necessary. In a district general hospital an orthodontist may be called to counsel the parents on the process and subsequently pass on the details to a hub cleft lip and palate Centre.

Postnatally the orthodontist may be required to continue to provide support and counseling to the parents. Additionally, the orthodontist may be involved in the identification of syndrome related conditions and congenital disorders. Cleft patients may also be born with mobile natal teeth which require assessment and possible extraction.

## **Figure 1.**

*Illustrative diagram of members involved in the multi-disciplinary management of cleft lip and palate patients.*

## **2.2 0–6 months**

Between 3 and 6 months lip repair is usually carried out by the cleft surgeon. Prior to lip repair an orthodontist may be involved in a phase of oral orthopedics to align the displaced cleft segments termed presurgical orthopedic treatment. Presurgical orthopedic treatment has been used since 1950. The earlier techniques focused on elastic retraction of the premaxilla using adhesive tape binding. In 1950, McNeil introduced the use of a series of plates to actively approximate the alveolar segments into the desired position which was developed by Burston who popularized the technique [3]. Thereafter, Georgiade and Latham introduced a pin retained active appliance to retract the premaxilla and simultaneously expand the posterior segments over several days [4]. Another example of an active appliance includes the DiBiase plate which uses an active coffin spring. Passive appliances aim to allow the segments to grow without the tongue being in the way. The use of passive orthopedic plates to align the cleft segments was described by Hotz in 1987 in response to controversy associated with active retraction of the premaxilla [5].

Fabrication of molding plates involves taking a heavy bodied silicone impression within the first week of birth. The impression is taken by inserting the impression tray whilst the infant is held upside down. This technique minimizes blockage of the airway by the tongue, impression material and oral fluids [6]. A dental stone model is then fabricated after which, the laboratory technician then obturates the cleft space and blocks out the undercuts with wax. Laboratory technicians may use a variety of methods to construct the molding plates. One technique involves approximating the segments on the model before an active plate is fabricated over this. In the case of a passive appliance the impression is taken and plastered out but the model is not cut prior to fabricating the passive plate over this. The molding plates usually have a minimum thickness of 2 mm, and should be relived in the region of the frenum, suitably adjusted distally and smooth around the edges. An emergency airway hole of approximately 6 mm in diameter is made on the palatal surface of the molding plate and positioned 8 mm from the posterior border to assure a patent airway in the instance of plate dislodgement. Retention buttons/arms are then added and positioned at the junction of the cleft segments and vertically at the junction of where the upper and lower lip rests. Appliances are secured extra orally to the cheeks and bilaterally by surgical tapes. Approximately 100 grams of force can be applied to an active plate through a combination of screws and or elastics that are extended from the retention arms/buttons and stretched approximately two times their resting diameter for an appropriate activation force. Active appliances should be reviewed weekly to modify the acrylic plate and gradually approximate the alveolar segments and reduce the size of the cleft. This is often achieved by removing acrylic resin in areas where alveolar segments are to move and application of soft liner in areas where alveolar bone is to be reduced. Following a few visits, parents are often instructed to place tapes to approximate cleft lip segments to the base of the nose extending from the non-cleft side to the cleft side [7]. It is important to note that lip strapping is seldom done in the UK and only considered for wide bilateral clefts. Objectives include elongation of the columella, expansion of the cleft nasal mucosa and improvement of nasal tip symmetry.

Occasionally, a nasal stent component is incorporated into the plate once the width of the alveolar gap is reduced to around 5 mm. The stent is made up of 0.36 inch round stainless steel wire and adopts the shape of a 'Swan neck'. The stent is attached to the labial flange of the molding plate. It extends forward and then curves backwards entering 3–4 mm past the nostril aperture where the stent is curved back on itself to create a small loop for retention. Hard acrylic is applied to the wire armature followed by soft acrylic to create a bi-lobed structure. In the case

**23**

cleft lip and palate.

*Orthodontic Management of Cleft Lip and Palate Patients*

• allows the segments to grow without tension;

• postures the tongue away from the palatal shelves;

• allows the lip and nose repair to heal without pressure;

of bilateral cleft lip and palate cases there will be two retention arms and two stents. Following the addition of nasal stents nonsurgical lengthening of the columella can be commenced by introducing a horizontal band of soft denture material which joins the left and right lower lobes of the stents and spans the base of the columella. Tape is then attached to the prolabium under the horizontal lip tape and stretches downward to engage the retention arms with elastics. The vertical pull works in the opposite direction to the upward force applied to the nasal tip by the stent and helps

The benefits of presurgical nasoalveolar molding (PNAM) have been debated but Scott's cartilaginous theory and Moss functional matrix theory suggests that by

creating a normal functioning environment for normal growth it in turn:

*DOI: http://dx.doi.org/10.5772/intechopen.90076*

to lengthen the columella [7].

• allows better feeding;

• facilitates better speech;

• interference with growth;

• occlusion of the airway;

• delaying surgery;

• risk of infection;

• reduces likelihood of choking; and

• yields psychological benefit for the parents.

Reported disadvantages/complications include:

• risk of ulceration/candida infection under a plate; and

The evidence for PNAM with plates is not conclusive due to limited long term results with some studies indicating that nasoalveolar molding is efficient at reducing cleft width and improving nasal shape and symmetry in uni- and bilateral clefts [8]. A randomized control trial (RCT) which looked at the effects of passive plates on feeding, archform, maternal satisfaction and cost effectiveness found no difference with any of the above [9]. A study by Maserai also found no difference in unilateral cleft lip palate cases [10]. Shaw et al., conducted a RCT and found no effect on feeding and the trial was stopped midway [11]. Most surgeons however, would agree that their chance of achieving a finer surgical scar, good nasal tip projection, and more symmetrical and precisely defined nasolabial complex would be better in an infant who presents with a smaller cleft deformity. Therefore, PNAM can be an adjunct to facilitate surgical repair in infants with

• development of skin sores from the tape.

*Orthodontic Management of Cleft Lip and Palate Patients DOI: http://dx.doi.org/10.5772/intechopen.90076*

of bilateral cleft lip and palate cases there will be two retention arms and two stents. Following the addition of nasal stents nonsurgical lengthening of the columella can be commenced by introducing a horizontal band of soft denture material which joins the left and right lower lobes of the stents and spans the base of the columella. Tape is then attached to the prolabium under the horizontal lip tape and stretches downward to engage the retention arms with elastics. The vertical pull works in the opposite direction to the upward force applied to the nasal tip by the stent and helps to lengthen the columella [7].

The benefits of presurgical nasoalveolar molding (PNAM) have been debated but Scott's cartilaginous theory and Moss functional matrix theory suggests that by creating a normal functioning environment for normal growth it in turn:

• allows better feeding;

*Current Treatment of Cleft Lip and Palate*

Between 3 and 6 months lip repair is usually carried out by the cleft surgeon. Prior to lip repair an orthodontist may be involved in a phase of oral orthopedics to align the displaced cleft segments termed presurgical orthopedic treatment. Presurgical orthopedic treatment has been used since 1950. The earlier techniques focused on elastic retraction of the premaxilla using adhesive tape binding. In 1950, McNeil introduced the use of a series of plates to actively approximate the alveolar segments into the desired position which was developed by Burston who popularized the technique [3]. Thereafter, Georgiade and Latham introduced a pin retained active appliance to retract the premaxilla and simultaneously expand the posterior segments over several days [4]. Another example of an active appliance includes the DiBiase plate which uses an active coffin spring. Passive appliances aim to allow the segments to grow without the tongue being in the way. The use of passive orthopedic plates to align the cleft segments was described by Hotz in 1987 in response to

Fabrication of molding plates involves taking a heavy bodied silicone impression within the first week of birth. The impression is taken by inserting the impression tray whilst the infant is held upside down. This technique minimizes blockage of the airway by the tongue, impression material and oral fluids [6]. A dental stone model is then fabricated after which, the laboratory technician then obturates the cleft space and blocks out the undercuts with wax. Laboratory technicians may use a variety of methods to construct the molding plates. One technique involves approximating the segments on the model before an active plate is fabricated over this. In the case of a passive appliance the impression is taken and plastered out but the model is not cut prior to fabricating the passive plate over this. The molding plates usually have a minimum thickness of 2 mm, and should be relived in the region of the frenum, suitably adjusted distally and smooth around the edges. An emergency airway hole of approximately 6 mm in diameter is made on the palatal surface of the molding plate and positioned 8 mm from the posterior border to assure a patent airway in the instance of plate dislodgement. Retention buttons/arms are then added and positioned at the junction of the cleft segments and vertically at the junction of where the upper and lower lip rests. Appliances are secured extra orally to the cheeks and bilaterally by surgical tapes. Approximately 100 grams of force can be applied to an active plate through a combination of screws and or elastics that are extended from the retention arms/buttons and stretched approximately two times their resting diameter for an appropriate activation force. Active appliances should be reviewed weekly to modify the acrylic plate and gradually approximate the alveolar segments and reduce the size of the cleft. This is often achieved by removing acrylic resin in areas where alveolar segments are to move and application of soft liner in areas where alveolar bone is to be reduced. Following a few visits, parents are often instructed to place tapes to approximate cleft lip segments to the base of the nose extending from the non-cleft side to the cleft side [7]. It is important to note that lip strapping is seldom done in the UK and only considered for wide bilateral clefts. Objectives include elongation of the columella, expansion of

controversy associated with active retraction of the premaxilla [5].

the cleft nasal mucosa and improvement of nasal tip symmetry.

Occasionally, a nasal stent component is incorporated into the plate once the width of the alveolar gap is reduced to around 5 mm. The stent is made up of 0.36 inch round stainless steel wire and adopts the shape of a 'Swan neck'. The stent is attached to the labial flange of the molding plate. It extends forward and then curves backwards entering 3–4 mm past the nostril aperture where the stent is curved back on itself to create a small loop for retention. Hard acrylic is applied to the wire armature followed by soft acrylic to create a bi-lobed structure. In the case

**2.2 0–6 months**

**22**


Reported disadvantages/complications include:


The evidence for PNAM with plates is not conclusive due to limited long term results with some studies indicating that nasoalveolar molding is efficient at reducing cleft width and improving nasal shape and symmetry in uni- and bilateral clefts [8]. A randomized control trial (RCT) which looked at the effects of passive plates on feeding, archform, maternal satisfaction and cost effectiveness found no difference with any of the above [9]. A study by Maserai also found no difference in unilateral cleft lip palate cases [10]. Shaw et al., conducted a RCT and found no effect on feeding and the trial was stopped midway [11]. Most surgeons however, would agree that their chance of achieving a finer surgical scar, good nasal tip projection, and more symmetrical and precisely defined nasolabial complex would be better in an infant who presents with a smaller cleft deformity. Therefore, PNAM can be an adjunct to facilitate surgical repair in infants with cleft lip and palate.
