Cleft / Craniofacial / Distraction
The Cleft Patient
At NYCOMS, we have the expertise and facilities and the ability to manage surgical care for patients ranging from youngest child to the adult population. This is particularly valuable and advantageous in cases that involve treatment over a period of many years. Cleft lip and cleft palate are examples of when a series of surgeries throughout a period of many years are necessary.
Cleft lip is an opening/split in the upper lip and cleft palate is an opening/split in the roof of the mouth (palate). Cleft lip and cleft palate result when these developing facial structures in an unborn baby do not close completely.
A series of surgeries can restore normal function and achieve a more normal appearance with minimal scarring.
A cleft lip is usually repaired between the ages of 3 to 6 months. Some children require a lip adhesion or a device such as a molding plate to bring the parts closer together before the full lip repair. A child with a cleft lip that is repaired will have a scar on the lip under the nose.
A cleft palate is usually repaired between 9 and 12 months of age. To repair the palate, the soft palate muscles from each side are connected to each other and the normal barrier between the mouth and nose is created.
Additional surgeries are needed to improve the appearance of the lip and nose, close the opening between the mouth and nose, help breathing, and stabilize and realign the jaw. Once the permanent teeth grow in, braces are often needed to straighten the teeth.
The following are services that the OMS performs:
- Palatal Prosthesis
- Bone Graft
- Dental Implant
- Orthognathic Surgery
Reconstruction of the nasal aperture provides support for the alar base and a solid foundation for future nasal reconstruction. The effect of anterior oral nasal communications on speech is not clear. However, there is no doubt that large palatally placed defects produce a hypernasal resonance that improves after surgical closure. Finally, patient and family perceive a great psychological lift when the left is finally completely eliminated.
When present, the alveolar cleft is a funnel-shaped defect that extends from the nasal aperture to the alveolar crest (Figure 3). Typically, it is lined with an epithelial tract that extends from the nasal cavity to the mouth. Often this soft tissue fistula extends into the labial vestibule and onto and through the hard palate. Invariably, the bony defect is considerably wider than the clinical examination suggests.
The goal at surgery is to partition the mouth and nose. Flaps are elevated, which permits direct closure of the nasal mucosa, and allows placement of the bone graft and complete closure with a “water tight” layer of oral-attached mucosa. While various homografts and alloplasts have been used for this purpose, the material of choice is autologous bone. This graft is harvested from the ileum, calvaria, mandible, tibia and rib. In our experience hip grafts are performed in over 90 perfect of cases.
The timing for alveolar cleft reconstruction is both critical and controversial. Some teams advocate early grafting (before age two). Typically that approach involves onlay grafts of rib. This technique often falls short in bone stock and is reported to have a negative effect on facial growth. The mainstream thinking today is that this graft should be performed between the ages of six and nine.
The decision regarding when to graft depends on the regional dental development. When a useful lateral incisor is present or a central incisor may be jeopardized if it erupts or is orthodontically guided into the cleft site, the procedure is done early (age six). When the lateral incisor is absent then the general rule is to allow the cuspid root to develop 50 percent of its root length and then graft. Prior to grafting, the field should receive a dental prophylaxis.
Late grafting is performed when the dentition has already erupted. This represents a failure in the system. As time passes, the interproximal bone on the cleft side is lost, creating significant periodontal bone loss and early tooth loss. In addition, the lining mucosa becomes hyperplastic and difficult to mobilize and suture. After grafting. The orthodontist develops proper arch form and monitors the eruption of teeth adjacent to the grafted cleft. Occasionally the cuspid requires surgical exposure and orthodontic traction, and from time to time, attached tissue grafting is indicted (X-ray series).
A final approach is to construct a fixed anterior dental bridge. This requires preparation of healthy teeth in young individuals and is the least preferred solution.
In the young patient, five to ten years old, the transverse and anterior posterior deficiency of the maxilla can be approached with a nonsurgical orthopedic widening and protraction of the midface. While still a subject of study, this approach seems to have some control over excessive mandibular growth, which would magnify the jaw-to-jaw discrepancy. In a cooperative patient this technique is exciting and dramatic.
Another opportunity to treat maxillary horizontal deficiency presents itself in the early adolescent phase. This approach involves surgically assisted osteodistraction. The final approach involves surgically assisted osteodistraction. The final approach involves formal orthognathic surgery. This is indicated in approximately 25 percent of CLPD patients. Formal osteotomy for advancement is routinely and safely performed. At the time of this surgery, residual fistulas and additional bone grafting can be performed. In a review of 300 CLPD patients operated on at our center, 15 percent required orthognathic surgery. More than half of the cases required both upper and lower jaw corrections. It appears that the number of double jaw cases is declining, which may be a consequence of aggressive growth enhancement by the orthodontists on our team with a secondary containment of compensatory mandibular excess.
Distraction osteogenesis is a jaw reconstruction process that allows bone to grow without the need for grafting by expanding the tissues and the affected area of the jaw. This procedure generates new bone by slowly stretching divided bone and is particularly useful when treating infants and children who might not be candidates for more traditional bone grafting.
While older patients may require longer treatment than younger patients, who typically experience new bone growth more quickly, distraction can be successful at all stages of development: