Frequently Asked Questions
Which hospitals is NYCOMS affiliated with?
There are three NYCOMS offices: Manhattan, Lake Success, and Suffolk. We are involved with several hospitals, including New York Hospital, Weill Cornell Medical Center, Long Island Jewish, North Shore University Hospital, Cohen’s Children’s Hospital, and Stony Brook University Hospital. In addition, we all hold academic positions at the Northwell School of Medicine. We cover a geographic range of more than 100 miles, and each hospital provides us with the opportunity to safely perform tertiary oral maxillofacial surgery.
Why choose NYCOMS for a child that has a cleft issue?
Although cleft patients represent only a small portion of what we do, many parents and oral surgeons find that we are a valuable part of the treatment team. We serve an ancillary, supportive function to further the care provided by the child’s primary treatment providers.
Parents choose us for three main reasons:
1. Our tremendously experienced staff
2. Our cutting-edge technology
3. Our commitment to providing personalized private care for tertiary oral and maxillofacial problems
What is a cleft?
Cleft lip and cleft palate are used as catch-all terms for congenital defects in the fusion of the components that make up the face. Thinking of the face as a puzzle, the cranium, the orbits, the sinuses, the upper and lower jawbones, the cheekbones and their supporting structures, the jaw joints, the chin, and so forth are independent pieces that normally fuse during fetal development. They are covered by the ectoderm, or skin, and held together with the endoderm or mesoderm. Anything that disrupts the pieces from joining together can cause a defect known as a cleft, or a separation. Typically, the most common breaches are clefts of the lip, the upper jaw, the palate, or the soft palate. Other clefts involve the whole face. There are defects of the lip where the upper lip is not whole, but is instead divided into a left and a right component, and the cleft can run all the way through the alveolus bone that contains the teeth and into the palate. Most of the time these breaches create deformity and dysfunction, but are compatible with a normal healthy life. More rarely, they can be very serious and even affect the airway. These more serious clefts must be attended to in the immediate neonatal period, first by using special bottles and devices to provide adequate nutrition. Then a full treatment team needs to step in to correct the issue.
What is the age range of cleft patients NYCOMS works with?
Cleft patient care occurs throughout a continuum from the time the patient is born until he or she goes off to college. In infants, the immediate focus is on treating breathing and feeding issues. The lip is typically closed within the first few months of life, followed by the palate at one or two years of age. What happens in the years that follow depends on the individual patient’s needs and the timing of his or her growth and development. The team closely monitors the patient and chooses the optimum time for each step.
What is the typical relationship between a cleft patient, the family, and the NYCOMS team?
Many of the things we do are episodic. A patient presents with an accident or an injury or a tumor, we fix it, and everyone moves on. With a cleft patient and his or her family, though, we tend to become a part of their lives very early on, and deep bonds often form as we move through the various phases of treatment. In some ways, the bond resembles the one that we develop with kids who have jaw deformities. We get to know them very well over time.
What type of ongoing monitoring and care do cleft patients require at NYCOMS?
When we first get involved as primary surgeons, it is to focus on reconstruction of the alveolar clefts, which is a time of mixed dentition. This is when we work the most closely with the orthodontist and the plastic surgeon to plan how we will dynamically expand the face to keep up with the lower jaw. The oral surgeon will do a bone graft to close the defect, and at around 8 to 10 years of age, the plastic surgeon will likely touch up the lip and nose. The orthodontist then takes over to expand and configure the teeth, and together we plan for corrective jaw surgery at approximately 15 to 16 years old. If there are congenitally missing teeth, we will then place dental implants and work with a prosthodontist who specializes in birth defects to restore them. So, although we work with kids throughout their entire childhood, the high points typically occur at around ages 6, 12, 16, and 18.
Oral & Maxillofacial Surgery
What are tertiary oral and maxillofacial problems?
Primary care is routine, everyday oral surgery such as removing wisdom teeth. Secondary care is more difficult, such as placing dental implants. Tertiary care involves treating advanced problems that require extensive experience in managing those issues. NYCOMS is a group of six highly experienced specialists. We all do corrective jaw surgery, but each doctor also has a different area of expertise. For example, Dr. Ruggiero is an expert in bone necrosis and osteomyelitis, as well as in nerve repair. Dr. Schwartz and Dr. Rosenfeld do surgery for the temporomandibular joint, including total joint replacement. Cleft issues are primarily handled by Dr. Sachs, Dr. Ruggiero, Dr. Rosenfeld, and Dr. Neugarten. We focus on the secondary issues that these children face, such as bone grafts and growth catch-up surgeries.
What makes NYCOMS uniquely qualified to provide tertiary care?
NYCOMS began as an academic practice. Dr. Sachs was Chairman of Oral Surgery at Long Island Jewish, focusing on education. He chose to provide only tertiary oral surgery, particularly orthognathic surgery, at that time. When he left institutional practice in 1988, he already had a reputation in that area. Once Dr. Schwartz joined NYCOMS, the organization became a center for corrective jaw surgery. Each new addition furthered our skill set, and our younger doctors pushed hard to embrace the latest technology.
What tertiary care does NYCOMS provide for cleft issues?
Cleft lip and cleft palate are congenital conditions that emerge in one out of every 1,000 births. The cleft is typically in the mid-face and may involve a breach in the lip, bones, openings between the nose and mouth, or communications with the sinuses and the orbits. To provide the best care, kids with cleft issues should be managed as part of a team. The goal is to bring together a surgeon, a dentist, an orthodontist, a speech pathologist, a psychologist, a pediatrician, a geneticist, and possibly other professionals as well, into a single room with a singular focus. The goal is to get these kids through all the challenges that a cleft presents during their first 18 years of life, from impaired speech and hearing to difficulty feeding themselves. NYCOMS surgeons get involved at various stages. At the beginning, we may help the plastic surgeons by constructing a plastic palate to support the child’s natural tissues and make a large cleft a bit easier to close. When the child is between 6 and 10 years old, we can perform various types of bone grafts to repair the tunnel from the mouth into the sinus and the nose. We coordinate closely with the attending orthodontist and pediatric dentist, because the timing must be keyed to the eruption of specific teeth. When the child is 12 to 18 years old, depending on growth rates, the orthodontist and oral surgeon may need to expand the upper jaw. There are a variety of techniques, including something called “distraction osteosynthesis,” in which we cut the bones and insert a device to pull the jaw forward. Exactly when to perform this intervention is a decision made by the entire treatment team based on a variety of factors. In some cases, cleft patients are also born with extremely small lower jaws, which can cause sleep apnea. Our doctors are involved with pioneering work at Cornell that involves advancing the lower jaw until the sleep apnea is resolved. We work hand in hand with a group of ENT surgeons, neonatal specialists, and pulmonary specialists to treat these children. In every case, we pride ourselves on being highly involved in the overall treatment of the patient. Rather than simply taking referrals and performing the mechanical aspects of our practice, we serve in whatever capacity we are needed on the different treatment teams that are treating our patients.