Lupine Publishers | Complete Unilateral Cleft Lip and Palate Repair: A Modification of the Millard Surgical Technique

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Cleft lip is one of the most commonly encountered craniofacial deformities. The comprehensive treatment of cleft lip and palate deformities requires thoughtful consideration of the anatomic complexities of the deformity and the delicate balance between intervention and growth. As evidenced by the multiple techniques that have been developed for its repair, a functionally and aesthetically pleasing result is challenging to attain. In this study, we describe a modification of the surgical technique for the repair of complete unilateral cleft lip and palate, through the design of flag-shaped flaps without removing any tissue, as a modification to the rotation and advancement flaps or Millard technique.

Keywords: Cleft lip; cleft palate; rotation; advancement flap

Introduction

Since 390 B.C.E., the treatment of upper lip clefts has represented a challenge for surgeons [1]. The modern reconstruction of clefts requires an anatomical, functional, and tridimensional understanding of the cleft (and noncleft) lip, nose, and alveolar bone. Multiple repair techniques and modifications reflect the wide variety and constant evolution of the surgical principles for the repair of clefts [2]. Lip development occurs from the fourth to the seventh week of gestation [3,4]. Unilateral cleft lip occurs when the complete merging of the two maxillary processes and the medial nasal process on one side fails. Several anomalies can happen during the lip and palate development, finding the cleft lip and palate as the most frequent anomaly (and the cleft lip alone being less frequent) [5]. Cleft lip (with or without a cleft palate) is most frequently found in boys with a 6:3:1 ratio of left/ right/bilateral involvement, respectively [6]. This anomaly occurs in approximately 2 out of 1000 Asians, 1 out of 1000 Caucasians and 0.5 out of 1000 Afro-Americans. Cleft lip is usually isolated and associated with few syndromes like van der Woude, DiGeorge, Conotruncal anomaly, Velocardiofacial syndrome and Stickler [5]. The aim of this study is to describe a modification of the surgical technique for the nasal and complete unilateral cleft lip repair, with excellent aesthetical and functional results, without the need of removing any tissue

Technical Note

Preoperative consideration

The ideal timing of lip repair is between 3 and 6 months of age and it is recommended that the patient weigh at least 10 pounds and have a hemoglobin of at least 10 g/dL. Prior to surgery, patients wear presurgical orthopedics. These techniques are ideally initiated in the first week of life and are continued until the time of repair. The technique proposed by Dr. Tulio Chacín, has been used exclusively to repair defects in a complete unilateral cleft lip and palate (CLP). This technique consists of rotation and advancement flaps with the modification of a flag-shaped flap design for the reconstruction of the posterior side of the lip and vestibule, tractioning the displaced alveolar process and repositioning the displaced nasal structures, without removing any tissue. The goal of cleft lip repair is to recreate a continuous oral sphincter, attain adequate vertical lip height with symmetry of cupid’s bow, and generate symmetry of the nostrils and nasal sill with a minimally visible scar. This study was approved by the Hospital Coromoto de Maracaibo IRB and all participants signed an informed consent agreement.

Surgical technique

Surgical repair is performed under general anesthesia with an oral tube placed at the midline lower lip so that it does not distort the upper lip. The neck is slightly ex- tended with a small shoulder roll and the OR table is tilted slightly in reverse Trendelenburg position. An alcohol pad is used to dry the vermillion boarder and enhance its identification. Key landmarks (as described below) are marked with methylene blue using a 30-gauge needle. This is performed prior to injection of the local anesthetic.

Landmarks

a) Point 1: Lateral peak of the lip (noncleft side).
b) Point 2: Center of the philtrum (located on the mucocutaneous line).
c) Point 3: Lateral peak of the lip (cleft side) (equal to the distance between 1-2).
d) Point 4: Lateral wall of the columellar base (noncleft side).
e) Point 5: Lateral wall of the columellar base (cleft side).
f) Point 6: Medial wall of the nasal ala (noncleft side).
g) Point 7: Medial wall of the nasal ala (cleft side). It’s drawn from point 9 with a medial direction, equal to the distance between 3-4.
h) Point 8: It is placed where the horizontal mucocutaneous line becomes vertical and the mucous border starts to get thin (the distance between 7-8 must be the same as the distance between 3-5).
i) Point 9: Lateral wall of the nasal ala (cleft side).
j) Flap A: Lip mucosa of the noncleft side: used to reconstruct the posterior wall of the lip, and it is fixated on the displaced alveolar zone.
k) Flap B: Lip mucosa of the cleft side: used to reconstruct the posterior wall of the lip, and it is fixated on the non-affected alveolar ridge.
l) Point C: Used to release a portion of the incorrectly positioned alar cartilage.
A – B = Flag-shaped flaps.
C = Nasal structural reposition (Figure 1).

Figure 1: Anatomic landmarks and flag-shaped flaps design.

Taking into consideration these reference points and the principles of the rotation and advancement technique, the flagshaped flaps proposed by Dr. Tulio Chacín are designed. These flaps consist of an A flap on the lip vermillion of the noncleft side, having a triangular design with a distal end and a proximal base. A B flap on the contralateral vermillion, with an M form on its distal end and having a proximal base. Furthermore, a marginal incision is performed on the nasal vestibule of the cleft side in order to release the alar cartilage and improve the rotation of the nasal component. Once the design of the technique has been made, the nasal-labial reconstruction is conducted. Starting with the cephalic transposition of the flag shaped flaps, which are fixated on the nasal floor and the alveolar bone respectively, intertwining them (flap A with flap B), in order to create the posterior part of the lip and the oral vestibule as well as giving support to the nasal component (Figure 2). After that, the muscular and cutaneous component are settled (Figure 3). Additionally, on the remaining mucous plane, the coincidence of the triangular design on the lip vermillion is detailed, in order to break the wound and avoid its retraction, which could create a whistler deformity (Figure 4).

Figure 2: Release of the flag-shaped flaps and cephalic reposition of the flag-shaped flaps.

Figure 3: Muscle component reconstruction.

Figure 4: Skin component and vermilion border reconstruction.

Discussion

The first record about unilateral cleft lip repair was written in 390 A.D. in the Tang dynasty in China. The edges of the cleft lip were cut and sutured, and the child could not speak for a period of 100 days [7]. Ambroise Pare repaired unilateral cleft lips by merging/ joining both sides of the cleft, with a large needle and thread [8]. Rose and Thompson reported a modification, consisting of straightline closures, for the unilateral cleft lip repair. All of these “straight line” techniques closed the cleft. However, vertical retractions and notches in the lip were frequently found after [9,10]. Several efforts have been made in order to improve the aesthetic and functional results obtained by the “straight line closure” technique. Within these, several types of geometrical repairs with full-thickness lip flaps are included. These techniques were designed with the purpose of breaking the scars on the lip and to prevent vertical retractions and notches [11]. LeMesurier reported a quadrangular full thickness (with a lateral base) flap on the cleft side, which intercepts the scar in the mucocutaneous union [12]. Tennison, Marcks et al, introduced a triangular flap, where a Z-plasty was designed on the inferior section of the lip [13,14]. Later, Randall uses the same design as Tennison, but reducing the size of the triangular flap [15]. Millard, in 1957, reports the rotation and advancement flaps technique for the repair of the unilateral cleft lip. This technique consists of 2 full-thickness flaps and its design is made in order to place the scar on the philtral ridge, and it is the most used technique to repair unilateral cleft lips nowadays [16].
The primary objective of the treatment of unilateral upper lip clefts is to restore the anatomy and function of the lip. Other objectives are to close the nasal floor, correct the asymmetry of the nasal tip and to approximate the alveolar cleft. The rotation and advancement technique involves two full-thickness flaps, which are approached in order to repair the cleft and avoid the notching of the lip. This design allows the rearrangement of the orbicularis oris muscles. The geometrical flaps techniques require a more accurate design, which allows creating flaps that are more precise in shape and extent. This is ideal for less experienced surgeons. However, with this technique the surgeon will have less flexibility during the surgical procedure. The main advantage of the rotation and advancement flaps is the flexibility of the technique, allowing continuous modifications during its design, incisions and the repair. Another advantage is that the incision is designed in order to place the scar on the new philtral ridge. Most of the geometrical flaps violate the philtral sub-unity. Within other advantages of the rotation and advancement technique we can find: the minimum waste of tissue and the maximum repair of the muscular component. One disadvantage of this technique is that less experienced surgeons could have difficulties with the flap design. Also, this technique requires an extensive dissection, having the tendency to create a small nostril on the cleft side. Because of this, the surgeon must try to make the cleft side nostril slightly wider than the one from the noncleft side, given the fact that it is easier to repair a wide nostril than a narrow one [17].
In conclusion, the technique proposed by Dr. Tulio Chacín for the nasal and complete unilateral cleft lip repair represents a valuable tool for plastic/maxillofacial surgeons when repairing this severe anomaly. Modifications in this technique include: the reconstruction of the posterior wall of the lip, not removing any tissue, the traction of the displaced alveolar process, the reposition of the displaced nasal structures (giving them support), and the breaking of the wound on the lip vermillion in order to avoid retractions. The aesthetical and functional sequels of the techniques used previously (such as: short and depressed lips, the retraction of scars, an inadequate reposition of the affected nasal ala and the collapse of the cleft alveolar process) create the need for modifications, and some of them are obsolete and not even used nowadays. We consider that the nasal and complete unilateral cleft lip repair, using Dr. Tulio Chacín’s technique, may be one procedure to choice during the correction of this complex anomaly.

Funding

No funding was received for this study

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgment

Special thanks to Michelle De Bacco for making the illustrations of the surgical technique.

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Lupine Publishers | Presurgical Infant Orthopaedics - Journey So Far

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

The successful management of patients with cleft lip and palate deformity requires a multidisciplinary approach. Historically, cleft lip and palate care starts with treatment modality of presurgical infant orthopaedics (PSIO). However, the necessity of presurgical orthopaedics in managing the resulting orofacial deformity is the discussion to ponder upon due to the variety of methodologies available and results produced by these devices. The objectives of this paper were to review the journey of PSIO appliances so far, basic principles of PSIO treatment, the various types of techniques and the protocol followed, and to critically appraise the advantages and disadvantages of these techniques. In conclusion, we believe that PSO treatment, with its objective to approximate the segments of the cleft maxilla may reduce the intersegment space in readiness for the surgical closure of cleft sites.

Keywords: Cleft lip and palate; presurgical infant orthopaedics; PSIO

Abbreviations: PSIO: Presurgical Infant Orthopaedics; CLP: Cleft Lip and Palate; NAM: Nasoalveolar Molding; DMA: Dentomaxillary Advancement Appliance; UCLP: Unilateral Cleft Lip and Cleft Palate

Introduction

Cleft lip and palate (CLP) are the most common congenital malformation caused due to variation in development of facial structure during gestation [1]. The incidence of patients with CLP is about 1.7 in 1000 live births globally [2]. The incidence is highest in Afghan population as 4.9 and lowest in Negroid population as 0.4 per 1000 live births [3,4]. The presence of cleft involving lip, palate and alveolus results in disfigurement and distorted growth and development. There is wide presentation of facial features among patients depending upon the severity of the cleft. A wide nostril base, separation in the upper lip of the cleft side is the characteristic feature of unilateral cleft defect. There is lateral and inferior displacement of affected lower lateral nasal cartilage which results distortions in the anatomic form of nose, tripod tilt in skeletal structure, a depressed dome, increased alar rim and deformities in apex of nostril. Shift in the base of the nose, deviation of septum to non-cleft side is also seen in patients with CLP. The separated premaxilla may overhang from the maxilla with variation in size [5,6]. Supervision and management of patients with CLP is a process that begins in infancy and continues in adulthood. Early treatment in the form of Presurgical Infant Orthopaedics (PSIO) is required to reduce the cleft width and to help maxillary arch development, thereby improving occlusion, feeding, speech, hearing, and language development and aesthetics [6,7]. PSIO has been defined as “use of forces to reposition tissues secondarily displaced due to a cleft deformity” [8]. Active and passive orthopaedic appliances have been developed for correction of CLP defect by using compressive & tensional forces or passively guiding growth. The aim of PSIO is to decrease the width of the cleft gap, to achieve a favorable alignment in the cleft segments within the initial few months of infancy prior to cheiloplasty, and to allow surgical repair with minimal tension [9]. In addition, there is improvement and ease in feeding, increased fluid intake, subsequently weight gain, improvement in functioning of tongue, reduced risk of aspiration and reduction in severity of dental & skeletal deviations.

Various methods and treatment protocol have been developed over ages and suggest PSIO prior to the primary surgery in patients with CLP for better surgical aesthetic results and prevent the social stigma. The aim of this review is to sum up the history, evolution, efficacy, advantages, disadvantages, complications, recent advances of different PSIO appliances, and critically analyze the evidence as well as the current status of PSIO.

Historical Perspective

PSIO has been a part of treatment strategy used in the management of patients with CLP for centuries. As early as in 1556, detailed explanation of the indications, surgical technique, and post-operative care of the cleft lip has been documented. A technique involving lip repair with cleft lip pins has been described by Amboise Pare in 1575. However, it was in the year 1689, Hoffmann demonstrated the use of facial binding to narrow the cleft and thereby prevent postsurgical dehiscence. The technique of retraction of the maxilla before surgical repair in patients with bilateral CLP was introduced in 1790 by Desault [10,11]. Adhesive tape binding usage in presurgical preparation was popularized by Hullihen [12]. Brophy in 1927 clinically demonstrated that silver wire passing cleft alveolus can be gradually tightened to approximate the alveolus before lip repair [13]. The modern school of presurgical orthopaedic to mould the alveolar segments using a series of plate system with active forces was introduced by 1950 McNeil [14] later popularized by Burston. Cupid’s bow and the philtrum symmetrical correction as Millard’s rotation advancement closure technique was introduced by Millard in1960 [15]. A pinretained active appliance which could simultaneously help in retraction of premaxilla and expansion of the posterior segments was introduced by Georgiade and Latham in 1975 [16]. The use of a passive orthopaedic plate for slow alignment of the cleft segments was described by Hotz in 1987 [17]. Matsuo’s (1988-91) series of research on molding of neonatal nasal cartilage and nostril with the help of silicone tubes was the gateway to invent newer modern methods [18-20]. The paradigm shift in the PSIO treatment was with the introduction of Nasoalveolar molding (NAM) by Grayson and Cutting in 1993, a novel technique in which presurgical molding of the alveolus, lip and nose is carried out in infants born with CLP [21].

Objectives of PSIO

Literature has highlighted the objectives of PSIO: to stimulate growth of patalal shelves, upper arch development, improvement in the projection of nasal tip leading to overall growth of the face. It also facilitates improvement in occlusion, feeding, speech, hearing, and language development. Eventually, PSIO aim at achieving a more uniform osseous base. The achievements of these objectives facilitate surgical closure and improve the final aesthetic result [22- 25].

Classification of PSIO appliances

PSIO appliances can be classified into active and passive appliances based of force application (Table 1). Active appliances act by active forces being applied on the separated alveolar processes for growing them into desired anatomic position. The various appliances used for PSIO are discussed below and the technique of PSIO in different cleft types is summarized in Table 2.

Table 1: Classification of PSIO appliances.

Table 2:PSIO techniques in different cleft types.

Lip taping

Approximation of the alveolar segments within 5 mm of each other can be managed by using Lip taping. In this technique medical adhesive tape such as Steri-strips® is placed across the upper lip in the first week of life following which skin adherent dressing such as Tegaderm ®, are placed over the area of the cleft lip. Elastic forces will exert a retracting, backward pressure against the protruding premaxilla, improve their positions and allow definitive lip skin repairing. The clinical effectiveness of Lip taping is documented, however with only limited studies [26].

McNeil method

The pioneer work for alignment of the alveolar parts presurgical for patients with CLP was done by McNeil, who believed that a normal position of maxilla, alveolar & palatal cleft segment can be achieved by molding and approximating segments into correct preplanned position using a series of appliances. This method not only stimulated soft tissues to grow in cleft region but also modify the postnatal development of the maxilla. This method was further popularized by Burstone, an orthodontist. The advantage of this method is that a smaller number of appointment are required, hence encourage patients who may have to travel long distances for treatment [14,27].

Latham appliance

The Latham appliance also known as the Dentomaxillary Advancement Appliance (DMA) was developed to align the alveolar arch through rapid orthopedic correction and alignment of cleft segments was introduced by Dr Lantham and Georgiade [16,28]. Latham based his treatment concept on the facial growth hypothesis of Scott [29,30] with aim of the procedure ‘to carry the interrupted embryonic process to normal completion’ by maxillary alignment, stabilization of the alignment along with tunneling of the alveolar cleft with periosteum, and reconstruction of the nasal floor to support the alar base. This appliance is an active pin-retained appliance fixed surgically to the bone for patients with age around 2 to 5 months. The appliance works by simultaneously applying pressure to the cleft segments over a 4 to 6-week period to move the alveolar segments into proper position, which is followed by alveolo periosteoplasty and lip adhesion. According to Drs. Latham and Millard, these alignments allow the performance of gingiva periosteoplasty (GPP), providing stabilization of the maxillary segments and reconstruction of the nasal floor [31]. Greater values for cephalometric measurements in maxillary length, maxillary prominence and ANB angle has been found for patients treated with this appliance [32]. However, other authors have concluded that this appliance did not affect dental arch relationships in preadolescent children [33]. The problem associated with procedure is that, besides neonatal maxillary orthopedics, infant periosteoplasty is always performed, although it is more limited with less undermining of periosteum on the maxilla.

Hotz appliance

In Europe, the treatment principles of McNeil for neonatal maxillary orthopaedics were greatly modified by grinding away the acrylic in specific areas to bring out necessary alignment, known as Hotz appliance (Zurich approach). According to Hotz and Gnoinski, the primary aim of presurgical orthopedics is not to facilitate surgery or to stimulate growth, as postulated by McNeil, but to take advantage of intrinsic developmental potentials. In Zurich approach lip operation is performed at the age of 6 months while palate repair is postponed until 5 years of age [34,35]. The appliance is made of hard acrylic or a combination of hard and soft acrylic: it passively covers the alveolar segments and extends slightly into the area of the cleft and the buccal sulci. This appliance assists with both bottle-feeding and to allow some breast-feeding in infants with CLP. Harmonization in the vertical and transverse positions of the cleft segments has been found with Hotz plate therapy [36]. Long-term effects of the Hotz plate and early lip adhesion have been studied by several researchers and it has confirmed that arch width and length of the anterior part of the maxilla improves better than other treatment options [37]. Similarly, the two-stage palatoplasty in combination with application of the Hotz’ plate has good effects on the maxillary growth than one stage palatoplasty without Hotz plate [38].

Nasoalveolar molding

Earlier PSIO appliances were designed to correct the alveolar cleft only, despite the fact that the nasal deformity among these patients remains the greatest esthetic challenge. Grayson [21,39] described a new technique to presurgical mould the lip, alveolus and nose in infants born with CLP. The concept of naso alveolar molding (NAM) works on Matsuo’s principle; [18-20] that the nasal cartilage could be molded due to increased plasticity concurrent to increased levels of maternal estrogen if treatment is initiated within 6 weeks of life. The NAM appliance consists of an intraoral molding plate with nasal stents to mould the alveolar ridge and nasal cartilage concurrently. Beside other advantages of traditional plates, the main objectives of NAM appliances are improving nasal symmetry and lip aesthetics while elongating the columella and correcting nasal cartilage deformity. Hence, a less extensive surgery is required for the lip and nasal repair, and there is less tension on the reconstruction, greater nasal symmetry is be obtained after cleft lip repair using NAM therapy as well as better lip form, reduced oronasal fistulas and labial deformities, and a namely a 60% reduction in the need for secondary bone grafting [24].

Objectives of NAM in unilateral cleft lip and cleft palate (UCLP)

The main objective of NAM for UCLP is to reduce the severity of the original cleft deformity by reducing the width of the alveolar cleft segments and alignment of the base of the nose and lip segments [21]. Taping the lips together helps in correction of the inclined columella upright along the mid-sagittal plane. As the lower mid-face skeletal elements (alveolar ridge and lower maxilla) improve in relation to each other, the overlying soft tissue improves concurrently. The alar rim, which was initially stretched over a wide alveolar cleft deformity, shows some laxity that enables it to be elevated into a symmetrical and convex form. The nasal tip on the cleft side is overcorrected in its forward projection; this is achieved through the use of a nasal stent, an intra-oral acrylic plate, and surgical tapes [39-44].

Objectives of NAM in bilateral cleft lip and cleft palate cases

The main objective being the non-surgical elongation of the columella and also to center the pre-maxilla, along the mid-sagittal plane, retraction of the pre-maxilla in a slow and gentle process to achieve continuity with the posterior alveolar cleft segments. Reduction in the width of the nasal tip, improved nasal tip projection and increase in the nasal alar base width [21,39,43].

Benefits of NAM

Proper alignment of lip, nose and alveolus is achieved, thereby enabling surgeons for better surgical repair of the cleft deformity and hence reduce post-surgical breakdown [42,43]. Approximation of alveolar process before surgery also enables surgeons to perform gingivo-periosteoplasty successfully. NAM provides stable change in nasal shape with less scar tissue and better lip and nasal form. It also reduces the number of surgical revisions for excessive scar tissue, oro-nasal fistulas, nasal and labial deformities, due to proper columellar elongation and lengthening. With the alveolar segments in a better position and increased bony bridges across the clefts, the permanent teeth have a better chance of eruption in a good position with adequate periodontal support [39,40].

Complications of NAM

a) Locked-out segments: It may occurs due to the poor and un-volunteered molding process, wherein the greater segment moves more rapidly, without the change in position of the lesser segment, as a result, the lesser segment gets locked out behind the greater segment.
b) Nostril overexpansion (Mega-nostrils): This occurs when the nasal stent application is started before the size of the cleft gap is adequately reduced. The premature nasal stenting exerts excessive force against the nasal tissue leading to excessive alar expansion and resulting in mega-nostrils.
c) Tissue ulceration: It occurs due to application of pressure by the intra-oral acrylic appliance, which may be due to ill-fitting appliance. At times the area under the horizontal prolabium band may also get ulcerated, if the band is too tight.
d) Skin ulceration: It may result due to frequent application and removing of tape, resulting in irritated and ulcerated skin over the cheek region.
e) Dislodgement of the acrylic plate: It is the complication which may result in obstruction of the airway. This can only occur, if the arms of the appliance are taped too horizontally or with inadequate activation [39-44].

Prevention of the complications associated with NAM Therapy

a) NAM therapy must be closely monitored and volunteered at timely basis with adequate application of mechanics and robust principles of the therapy must be followed.
b) Tissue expanding direction and associated mechanics should be monitored vigorously and nasal stenting should commence only after the cleft gap is reduced by minimum 6 mm and softer denture liner must be covered over the nasal stent tip, so as to apply gentle forces. c) Tissue ulcerations can be prevented by coating of tissue lubricant over the appliance before insertion into the oral cavity.
d) Skin ulcerations over the cheek region can be prevented by using Duo-derm or Tega-derm, underneath the tape strapped.
e) Parents must be thoroughly educated to continue the use of NAM appliance for their child until the therapy lasts. Feeding instructions must also be given accordingly.
f) Motivating the parents to visit the dentist on scheduled appointments and in timely manner is of utmost importance for a successful NAM therapy [39-44].

Modifications

Recently NAM appliance has been modified by different authors in many ways. It includes modified muscle-activated maxillary orthopaedic appliance [45], incorporation of expansion screw [46], dynamic presurgical nasal remodeling intraoral appliance design [47], extra-oral nasal molding appliance [48], self-retentive appliance with orthodontic wire [49,50], use of TMA wire instead of SS wire for making nasal stent [51] and the latest technique of OrthoAligner “NAM” [52] & NAM custom aligners [53].

DynaCleft ® and Nasal Elevators

DynaCleft® is a premade nasal and alveolar molding device which can be used to successfully mold the upper lip, alveolus and nose prior to cleft lip repair. Traditional surgical adhesive tape (e.g. Silk tape, Steri-strips®) have been used in the past, unlike tape, DynaCleft® offers the benefit of being able to provide a constant approximation force with an elastic centre that allows it to conform to a baby’s mouth better because of its ability to expand and contract. Additionally, the controlled force provided to the prolabium and premaxilla could improve surgical results and decrease the necessity of early lip adhesion surgery. As the DynaCleft® device is pre-made; there is no need to create custom-made devices for the molding process. Studies have shown that with the use of DynaCleft® with a nasal elevator has produced results similar to that of NAM therapy. However, unlike the NAM appliance, it does not require adjustments with growth of the infant. Nasal elevators have been found to improve the shape of the nose and alae, thereby reduce the need for primary surgery to the nose in patients with UCLP. Due to its elastomeric core and stretch property, DynaCleft® allows the infant to feed and cry without limitation.

Conclusion

Many orthodontists working on patients with CLP have shown great enthusiasm for PSIO to improve surgical outcomes with minimal intervention. Although different forms of PSIO appliances are available, it seems that NAM therapy has been especially popular in all over the world. Undoubtedly, every orthodontist or surgeon aims to use the best treatment modality for their patients. Nevertheless, PSIO effects can be confounded by surgical type and timing of the primary repair, as is discussed in many studies. In such cases, one should be cautious when evaluating the particular outcomes for patients with CLP since it is difficult to differentiate the sole effect of an individual surgical or orthodontic intervention.

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Lupine Publishers | It’s Never Too Early to Cleanse the Oral Cavity of Our Babies

 Lupine Publishers | Journal of Pediatric Dentistry

Editorial

Dental caries continues to be the single most common chronic disease of infancy and one most widespread pathologies in the world. In Italy recent studies showed that 22% of 4-year old and 44% of 14-year-old suffer from dental caries. In industrialized nations this trend appears to be decreasing in 6-19-year old. Dental caries is increasing by 15.2%, according to recent epidemiological studies (2007), in children aged 2-5 years, in Milan, in the north-east of Italy, regrettably in the news, as the main site of the Covid-19 outbreak, last March 2020. Why are deciduous teeth more prone to caries? In part because although the enamel of deciduous teeth takes more time to develop, it demineralizes faster. Parent responsibility is also an important factor. Many parents don’t begin cleaning their children’s teeth until they reach 2-3 years of age and often it’s not performed properly. A diet rich in sugar, snacks, candy and chocolate also plays a key role. Another cariogenic feature is the prolonged use of the baby bottle filled with sugary or acidic liquids given to the child in the evening or during the night, when there’s a reduction in saliva flow.

For caries to form three factors must be present:

a) A tooth that easily demineralizes
b) Sugar in the diet
c) Specific bacteria

The first factor cannot be modified, while the other two are adjustable. Intervening on either one of these two aspects can prevent caries from forming. The easiest to correct, aimed at reducing the number of harmful bacteria, is oral hygiene. Bacteria begin developing in the infant’s oral cavity following birth. At birth the oral cavity is sterile. In the children’s saliva mainly bacterial strains of the respective mothers are found. The main source of infection is, therefore, maternal saliva. Primary prevention for the 2-5 age group can and must be initiated by the mother, followed by the father, the grandparents or other care givers. It’s never too early to begin cleaning the child’s or even the newborns oral mucosa. How? By using a clean or sterile gauze. It’s is a very simple but efficient means of removing bacteria from the oral mucosa. Place the index finger in the center of an open gauze then wrap it around the index finger of your dominant hand. To soften the gauze dampen it with a normal saline solution or plain tap water. The mouth is gently opened and the oral mucosa along with the gums are delicately rubbed. This simple procedure is effective in reducing the number of bacteria, while at the same time being non traumatic to the infant or small child.

Everyone agrees that prevention is more important than treatment, but only few reward acts of prevention.

An article entitled “Oral Diseases Affect Some 3.9 Billion People”, published in 2015 in the evidence-based literature search site (Pub Med) revealed how widespread oral disease is on a global level. Today our understanding of the ferocity and aggressiveness of bacteria and viruses that inhabit or transit via the oral cavity is greater than ever before. The need to implement procedures for their mechanical reduction is crucial and it must begin at infancy. In Italy, during the period of forced lock-down due to the Covid-19 pandemic, parents became teachers, playmates, and hairdressers for their children. They invented new forms of creative entertainment even in their children’s home care. “Digital brushing” might have been cleverly introduced. Children would mimic their parent’s gestures by rubbing their oral tissues and teeth with a gauze wrapped around their finger soaked in normal saline solution or plain water. For the child this was a game, but from an oral health standpoint this is extremely important not only in preventing disease, but in forming good, lifelong habits. A scrubbing action is indispensable to detach the adhesive biofilm from oral structures. Rinsing will not remove it. Rinsing only removes loose, floating debris and does not reach bacteria and viruses enclosed in the inter-microbial plaque matrix. Gentle scrubbing will produce adequate cleansing, even in areas of recession or dentinal sensitivity. It can also be used in situations where the bristles of the toothbrush could become irritating creating an “avoiding” reaction.
The forced lockdown of the Covid-19 pandemic brought on other important lessons in hygiene. Parents taught their children to wash their hands often and instructed them not to touch their eyes, nose and mouth with unwashed hands, simple but powerful weapons in helping to prevent disease. As clinicians the treatment of patients is our core mission, but prevention and education are just as important, following a patient for a lifetime. Quoting Elisabeth Stone: “Making the decision to have a child - it is momentous. It is to decide forever to have your heart go walking around outside your body”.

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Lupine Publishers | Effect of Thickness on the Fracture Resistance of Ceramic Partial Restorations: A Review

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

This publication describes the effect of thickness and type of material on the resistance fracture of ultra-thin ceramic restoration. The restorative phase of the treatment should not cause additional damage of the residual tooth structure. Ultrathin restorations (veneers, onlays , inlays) are considered as an alternative to traditional onlays and complete crowns. the technical aspects required for the success and the good prognosis of those new restorative design based on the control of tooth preparation with diagnostic wax-up, provisionalization, and the use of CAD-CAM technology.

Keywords: Ultrathin; restoration; ceramics; thickness; fracture

Introduction

The dental enamel is designed to withstand a lifetime. Her progressive reduction is biological consequence of advancing age. The loss of tissue may be due to the action of acidic foods, gastroesophageal reflux disease medications, and the reduction of salivary flow [1]. There are now many new protocols for a new concepts of ultrathin and non-preceramic restorations. Ceramic veneers and inlays, onlays and overlays are frequently presented as the major class of clinical conservative modalities [2]. CAD/CAM technology became popular during the last decade for the conception and fabrication of restorations. Different materials are supplied in the form of blocks that are milled to obtain the restorations [3]. Among ceramic CAD/CAM materials, lithium disilicate have recently expanded their indications to include ultra-thin restorations, with promising results. Recently, hybrid ceramic (vita Enamic) has been developed to allow faster milling of the ceramic block as ultrathin restorations with good mechanical behavior and good prognosis. Due to the importance of dental tissue preservation, it’s important to evaluate the fracture resistance of reduced thickness materials made with different restorative materials [4,5].

Effect of Thickness

It’s very notable how well patients presenting with tooth fracture, moderate to severe loss of tooth structure when ultrathin restorations are proposed to them, both economic and biological costs are significantly lower compared to traditional and more invasive approaches. Minimal thickness can be used were in the Table 1 [1,2,6-8]. The possibility of making ultrathin (0, 3mm-0,6mm) ceramic restoration allows for a more conservative preparation with minimal wear to the tooth structure. It’s believed that these positive and promising results are due in part to the adhesive luting technique, dental substrate, and restorative material [13]. According to the study of Nordahi et al. comparing five thickness (0,3-0,5-0,7-1-1,5) for high-translucent(HTZ) and low –translucent (LTZ) zirconia restorations and glass ceramic (LDS) crowns. The lowest recorded load at fracture within & mm groups was 634 N, and 550N for the Y-TZP groups at thickness of 0,5mm.Compared to the forces measured during mastication (approximately 5 to 364N); the results suggest the possibility to reduce restorations thickness with good prognosis especially for Monolithic ceramic YTZP material [9]. On the other hand, the study of JP Andrade Showed that the fracture resistance was significantly higher at a thickness of 1,5 mm compared to a thickness of 0,6 mm for veneers made of lava ultimate and vita Enamic. Manufactures of lava Ultimate, vita 3namic and IPS e.max CAD, affirmed that restorations with a minimum thickness of 1, 5 mm on the occlusal surface of posterior teeth will support masticatory loads. Nevertheless, other studies showed that it is possible to treat severe erosive lesions or loss of wear on posterior teeth with ultrathin (0,5-1mm) ceramic and composite resin materials [1,5]. The study of JP Andrade evaluated 0,6 mm of thickness (veneers), which are considered ultrathin restorations. On the other hand, the study of Egbert et all, shows a fracture resistance of occlusal veneers with a 0,3 mm using Paradigm MZ 100, Vita Enamic and lava Ultimate; and found promising fracture resistances. Hence, it seems that the use of use of thickness smaller than 0,6 mm could be used with good prognosis [3].

Table 1.

The Luting Material and Protocol

Ceramic indirect restoration looted by the adhesive luting technique provided better fracture resistance than conventional luting technique. Hence, the use of adhesive restorations has been recommended for reinforcing the remaining dental structure because It allows intimate contact between the dental substrate, luting agent, and ceramic material, therefore occlusal forces are dissipated through the root of tooth, periodontal ligament, and alveolar bone [3,8]. According to many studies, associating hydrofluoric acid with silane was the most effective surface treatment with which to potentiate the bond between the ceramic and the adhesive material [2,5,7]. The silane enhances the chemical bond between the silicon-containing materials and the resinous material used for luting.

The Type of Material [5,7,10]

The study of Katrin Heck et all showed that IPS e max CAD and lava ultimate should be preferred to IPS Empress CAD for the treatment of occlusal tooth loss with ultrathin restoration, whether this result is due to the viscoelastic proprieties of the composite material [11]. In another study , Johansson et al, compared fracture resistance of monolithic zirconia and monolithic lithium disilicate after cyclic loading and thermos-cycling. they reported higher strength for zirconia restorations with the same occlusal thickness (0,5mm and 1mm). According to Niklas Nordhal, Ceramic materials, such as glass ceramics and zirconia show a greater scatter in fracture strength compared to other material such as metal. This result calls for special factor approach when indicating reduced ceramic restoration [12].

Conclusions

Ultrathin restorations (inlay, onlays, veneers.) appear to be a promising restorative procedure in posterior and anterior teeth. The feasibility of their application depends on their fabrication options and fracture properties. Recent advances in technology and materials are offering new options for good treatment.

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