New techniques for orthodontic and surgical treatment of infants and children with bilateral cleft lip and palate
-Preoperative nasal-alveolar bone contouring and early simultaneous labial-nasal-alveolar revision
[Abstract] OBJECTIVE: To explore the timing, methods, and characteristics of preoperative nasal-alveolar bone contouring and simultaneous labial-nasal-alveolar revision in infants with bilateral cleft lip and palate, and to make preliminary observations of the efficacy. METHODS: Preoperative nasoalveolar bone contouring and simultaneous labial-nasal-alveolar revision were performed on 21 infants with bilateral cleft lip and palate. The preoperative nasal-alveolar bone contouring mainly included anterior jaw recession, closure of the alveolar bone gap, lip retraction and nasal orthopedics; the simultaneous labial-nasal-alveolar revision included gingival-periodontal-alveolar bone contouring and the modified Changgeng-style bilateral cleft lip-nose revision. Results: 21 patients with preoperative nasal-alveolar osteoplasty had adequate anterior lip recession; the width of the cleft lip was narrowed, and the lip tissues on both sides of the cleft were moderately retracted; the nasal column lengthening and nasal collapse deformity were significantly improved; the alveolar cleft was narrowed to 1-2 mm. 19 postoperative patients were followed up for 1-5 years, and the results showed that: the upper lip height was consistent and coordinated bilaterally, the upper lip was tightened and loosened, the arch of the lip was natural and obvious. Conclusion: In order to obtain ideal lip-nose morphology and complete and stable alveolar bone in patients with bilateral cleft lip, preoperative orthodontic nasal-alveolar protrusion shaping and early simultaneous lip-nasal-alveolar revision is a practical, noninvasive, safe, feasible, economical, and worthwhile sequential treatment method. The application of nasal contouring devices is necessary to maintain the symmetry of the postoperative nasal shape, and the effect of this technique and method on the maxilla needs further study.
Preoperative nasal-alveolar bone contouring followed by simultaneous alveolar-nasal revision in infants with cleft lip and palate is the latest new method and technique for serial treatment of cleft lip and palate in western developed countries. The unilateral nasal-alveolar osteoplasty with simultaneous lip-nose-alveolar osteotomy has been reported in a separate article [1].
1 Clinical data and methods
1.1 General data: 21 newborns with complete bilateral cleft lip and palate, minimum age 10 days, maximum age 36 days, average 17 days; 16 males and 5 females. The mean age at the time of surgery was 198 days.
1.2 Preoperative nasal-alveolar bone contouring method for infants with bilateral complete cleft lip and palate
1.2.1 Taking an impression-plaster model: Under the condition that the oral and maxillofacial plastic surgeon is equipped with respiratory emergency measures, one person holds the child in an inverted position in a fully awake and non-anesthetized state, holding the child’s head with the left hand and pulling the legs with the right hand, and another person assists in pulling the legs to ensure the child’s safety. A suitable tray is selected and sharpened, and the oral maxillary impression is quickly made with a faster-setting and less liquid impression material.
1.2.2 The nasal-alveolar bone contouring device was made and put on; the intraoral maxillary contouring base was made of self-consolidating plastic (acrylic resin); two force-applying posts with a diameter of 4-5 mm and a length of about 2 cm were prepared at the anterior part of the corresponding cleft in the anterior-inferior direction, and a groove-like force-applying groove with a width of about 1.5 mm-2 mm was extended at its anterior end. To ensure the safety and comfort of the contouring device, the protruding sharp parts were adjusted and polished, and then entered the child’s mouth for trial use until the patient did not cry and other discomfort. The maxillary shaping base is inserted into the patient’s mouth, and a breathable tape is applied to the skin of the cheek on both sides of the cleft lip. For those with skin allergies, artificial skin is used for protection and topical medication to prevent eczema and inflammation of the skin.
1.2.3 Steps and modalities: Depending on the severity of tissue loss and displacement deformity in cleft lip and palate patients, there are some differences, generally in three stages, firstly, backing off the anterior jaw, secondly, reducing the width of the alveolar cleft, and again, nasal shaping, and implementing moderate lip tissue retraction throughout the above process.
1.2.3.1 Retraction of the anterior jaw and closure of the alveolar space: The intra-oral shaping plate is fixed to the maxilla and palate by means of extra-oral ventilation tape and rubber bands, and the palatal side of the shaping base is moderately and locally adjusted and reshaped at weekly follow-ups.
1.2.3.2 Labial retraction: The separated labial fissures are gradually reduced by the air permeable tape attached to the labial tissues on both sides of the upper labial fissures outside the mouth and the rubber band fixed to the force post of the shaping base.
1.2.3.3 Nasal orthopedics: When the closure of the anterior maxillary recession and alveolar bone gap is performed about one month later, the nasal shaping procedure can be carried out. The front part of the shaping plate and the two sides of the force post are used as the basis, and the nasal shaping post (ball) is installed by bending the Φ0.9mm elastic steel wire through the force post to the nose. The nasal shaping post is made of acrylic resin and has a “saddle-shaped” structure. the nasal column. To ensure that no tissue erosion or necrosis occurs when external forces are applied to the nose, the head of the orthopedic post made of acrylic is covered with a soft denture liner material.
1.2.3.4 Course of treatment: 3-5 months. Weekly follow-ups were performed to align the arch and reduce the alveolar fissure by selectively adding and abrading material in some areas of the shaping plate; the nasal orthopedic post was adjusted (gradually acrylic was added to the head of the post) to reposition the collapsed septal cartilage and nasal flange cartilage. Daily cleaning of the nasal-alveolar bone shaper and replacement of the extra-oral ventilation tape and rubber band.
1.3 Early concurrent lip-nose-alveolar reshaping
1.3.1 Gingival-periodontal-alveolar osteoplasty: After nasal-alveolar shaping treatment, 21 children underwent gingival-periodontal-alveolar osteoplasty when the fissure of the alveolar process was reduced to 1-2 mm to repair Alveolar fissure. The gingival, periodontal and mucoperiosteal membranes at the edge of the alveolar fissure were cut and turned up, sutured to the opposite side without tension, and the fissure was closed in a sleeve shape to form a periosteal tunnel, after which a bone bridge would be formed between the two broken ends to connect the two broken ends to the anterior jaw as one to receive teeth growing in.
1.3.2 Modified Changgeng method of bilateral cleft lip repair: We have performed modified Changgeng bilateral cleft lip repair in 21 patients with bilateral cleft lip since 2001, with the following surgical features [7 8]: (1) the width of the anterior lip flap is reduced by 4-6 mm, shaped like a trapezoid, similar to the normal “eight” human middle; (2) the anterior lip is used to (7) application of the “red line” concept to reconstruct the edge of the lip arch at the red lip defect on the affected side; (8) postoperative use of a silicone nasal plasticizer to maintain the shape of the nose.
2 Results
2.1 Preoperative nasal-alveolar bone contouring in infants and children with bilateral complete cleft lip and palate (Supplementary Figures 1, 2, 3)
In 21 patients, the anterior jaw recession was adequate and coordinated with the curvature of the alveolar bone on both sides, and the alveolar cleft on both sides was narrowed by 1-2 mm, but there was still a certain inclination of the alveolar bone on both sides of the cleft margin; the width of the cleft lip was significantly narrowed by the retraction of the lip tissue on both sides; the collapsed deformity of both noses was significantly improved and the average lengthening of the nasal minors was 3.67 mm.
2.2 Early concurrent lip-nose-alveolar revision (Figure 4, 5)
In 16 cases, the upper alveolar space was continuous and stable, but in most cases, the height and width of the alveolar space were not sufficient, and in 13 cases, molar teeth were grown in the original alveolar space.
3 Discussion
3.1 Significance of preoperative naso-alveolar bone contouring in infants with bilateral complete cleft lip and palate: In order to correct abnormal orofacial defects and displaced deformities in patients with cleft lip and palate before the first cleft lip repair, special orthodontic orthopedic devices are used to correct orofacial defects and displaced deformities in patients with cleft lip and palate to better tissue conditions. For bilateral complete cleft lip and palate, this is done by receding the protruding anterior jaw and bringing the separated alveolar bones on both sides together and in harmony with the anterior jaw alveoli with the help of naso-alveolar bone shapers; supporting the collapsed nasal cartilage and moderately lengthening the nasal column; lengthening the lip tissue on both sides of the cleft lip by traction to narrow the cleft lip on both sides, etc.
The principle of preoperative orthodontic treatment of cleft lip and palate patients, i.e., nasoalveolar osteomodelling, is that the earlier the better, the better, with the majority of patients starting two weeks after birth [2]. The basic procedure is the recession of the anterior jaw, followed by the narrowing of the alveolar fissure, followed by the shaping of the nose and the lengthening of the nasal minors, as well as the retraction of the lip tissue on both sides and the reduction of the lip fissure throughout. This adjustment is achieved by selectively grinding away and adding material to parts of the shaping plate to achieve anterior recession, alignment of the arch and reduction of the alveolar fissure. About one month after the recession of the anterior jaw and the closure of the alveolar space, a “saddle-shaped” nasal shaping post (ball) is added to the plastic plate to start the nasal shaping treatment, supporting the nasal cartilage from within the nostrils to correct bilateral collapse, lift the nasal tip and lengthen the nasal column. This is done by applying force to the nasal cartilage using the principle of plasticity [3]; the soft tissues on both sides of the labial cleft are gradually stretched under the action of elastic rubber bands and breathable tape attached to the force post of the intraoral substrate, resulting in a smaller cleft and growth of soft tissues. The whole process is non-invasive and easy for patients to accept and cooperate.
The non-surgical procedures include shaping and repositioning the deformed nasal cartilage, lengthening the short nasal column, narrowing the labial fissure to restore the normal labial-nasal structure; narrowing the wider alveolar fissure; receding the anterior jaw to form a normal maxillary dental arch; improving the surgical conditions; and early revision surgery, with the aim of achieving a good facial shape and maximizing the restoration of oral-nasal function after surgery. Our clinical practice over 5 years has shown that the preoperative non-surgical orthodontic approach significantly improved the facial morphology of the patients before surgery. The main manifestations are: narrowing of the labial and alveolar bone fissures; lengthening of the short nasal minors, elevation of the nasal tip height, and promotion of the symmetry of the nasal structure; and repositioning of the anterior jaws to form an ideal dental arch shape. The improvement of these defects and displaced deformities reduces the difficulty of surgery; it also significantly improves the feeding status of the child, allowing the patient to receive adequate nutrition and facilitating the early implementation of revision surgery; reduces the number of surgeries; reduces financial expenses; reduces postoperative scarring; and increases the aesthetics of facial morphology; however, the long-term maintenance of facial morphology has yet to be further investigated.
3.2 The necessity, timing and method of early surgical treatment after nasal-alveolar shaping: after nasal-lip-alveolar shaping, the collapsed lateral cartilage is reset, the short nasal column is lengthened, and a more normal nasal shape is obtained, but nasal shaping cannot remove the skin and fibrous connective tissue between the two nasal columns which have been widened. However, rhinoplasty cannot remove the skin and fibrous connective tissue between the widened glottis, which were deposited during embryonic development, and most of the nasal shape obtained by preoperative contouring disappears after a few weeks.
Although the preoperative alveolar shaping makes the gap between the broken segments of the alveolar process on both sides and the anterior maxillary alveolus significantly reduced, the broken segments of the alveolar bone on both sides are not connected into one, and the alveolar bone is still in an unstable position under the action of the muscle forces on both sides of the alveolar bone. Moreover, when the teeth erupt later, the teeth adjacent to the fissure will twist due to the lack of bone support, so it is necessary to perform gingival-periodontal-alveolar osteoplasty. After the completion of gingival-periodontal-alveolar osteoplasty, the foundation of the bony scaffold at the base of the nose is established. For nasal surgery after shaping treatment, early surgery removes part of the fibrous connective tissue between the two nasal cartilages and the nasal septum, and sutures the septal cartilage to the medial corner of the nasal cartilage on both sides at the tip of the nose to restore the normal position of the nasal The normal position of the lateral corner of the cartilage is restored to improve the height and symmetry of the nose and prevent recurrence of the deformity [3].
After nose-lip-alveolar contouring, a one-stage lip-nose repair was performed within 6-12 months after birth, and we used a modified Changgeng bilateral labial cleft repair along with gingival-periodontal-alveolar osteoplasty to close the alveolar fissure [6].
3.3 Characteristics of modified Changgeng method bilateral cleft lip repair: modified Changgeng method bilateral cleft lip repair was modified by Noordhoff [7] on the basis of Millard rotation-propulsion flap, and later improved by the Changgeng team represented by Chen Guoding of the Craniofacial Center of Changgeng Hospital in Taipei to form the Changgeng method bilateral cleft lip repair with Changgeng characteristics. Its main features are described as follows.
(1) The width of the anterior labial flap is reduced by 4-6 mm, shaped like a trapezoid, similar to the normal “eight” mid-lip.
(2) The anterior lip mucosal flap is turned over 1800 to cover the exposed anterior jaw bone to reconstruct and deepen the vestibular sulcus; the deepening of the labio-buccal sulcus of the anterior lip keeps the oral vestibular sulcus at the same level after surgery, avoiding the occurrence of limited activities and uncoordinated movements of the anterior lip after surgery.
For complete cleft lip, there is no muscle fiber attachment to the anterior lip.
(4) In complete bilateral cleft lip, the anterior lip tissue is thin, the lip margin is flat, the lip crest is not visible, and the red lip tissue is lacking, while the lateral lip has a distinct lip margin, prominent lip crest, and abundant red lip tissue, so we use the red lip muscle flap of the lateral lip margin to reconstruct the lip arch and lip bead, especially to reconstruct a three-dimensional graceful arch of the arch-back shape [9].
(5) Reconstruction of the nasal floor and closure of the oro-nasal fistula using the lateral labial mucosal flap with the inferior turbinate flap.
(6) In bilateral cleft lip patients with obvious displacement of the nasal wing, an incision was made on the dike of the bilateral nasal floor instead of a transverse nasal floor incision, and dissection was performed on the root of the nasal wing and around it, so that the lateral nasal wing foot was completely free, and the abnormally attached muscle fibers were cut, and the lateral nasal wing cartilage was subconsciously separated, so that the lateral nasal wing cartilage foot could also be easily rotated inward back to its normal position, reducing the scar at the base of the nasal wing and maintaining The natural shape of the lateral nasal foot is maintained, ensuring the symmetry and coordination of the postoperative nasal base dike augmentation. (b) Tajima’s incision was used in both nostrils to separate, reset and suspend the nasal cartilage to reconstruct a symmetrical nasal wing with a straight dorsal nasal tip, while appropriately lengthening the nasal column.
(7) Part of the lateral lip skin and lip muscles are preserved on the red lip flap of the lateral lip, and the lip bead reconstruction and three-dimensional realistic lip arch margin are completed in one stage surgery; the concept of “red line” is applied to reconstruct both sides of the red lip, the hanging lip bead and the beautiful lip arch margin. (8) Postoperative silicone nasal plasticizer was used to maintain the shape of the nose.
Nineteen cases of bilateral cleft lip repair by preoperative nasal-alveolar shaping combined with gingival-periodontal-alveolar osteoplasty and modified Changgeng method had good upper lip and nasal shape with lengthening of nasal small column. 13 cases had milk teeth growing out of the original alveolar cleft, which was important to maintain the continuity and stability of the alveoli. The defect is still to be repaired.
3.4 Advantages of nasal-alveolar shaping and early simultaneous labial-nasal-alveolar revision: nasal-alveolar shaping with early surgical simultaneous labial-nasal-alveolar revision has the following advantages (1) Preoperative nasal-alveolar sculpting
(1) Preoperative nasoalveolar contouring reduces the anterior jaw protrusion, decreases the width of the alveolar bone fissure, harmonizes the morphology of the maxillary arch, and facilitates the implementation of gingiva-periodontal membrane and osseous membrane contouring, and we found that the alveolar bone was connected at the alveolar bone fissure and the continuity and stability of the alveolar bone were enhanced in 16 patients after regular follow-up from 1 to 5 years. A study by Santiago et al [10] reported that more than 60% of the cases in which gingival osteoplasty was performed after preoperative nasoalveolar contouring greatly reduced the need for alveolar bone grafting during the period of tooth replacement. Accordingly, we tentatively speculate that a significant proportion of cases in which gingival-periosteal-alveolar osteoplasty was performed after naso-labial-alveolar contouring did not require second-stage alveolar implant treatment during the mixed dentition.
(2) Preoperative naso-alveolar shaping minimizes the scope and difficulty of surgery, creates surgical conditions for simultaneous correction of cleft dentition, cleft lip and nasal deformity, and ensures the stability of postoperative efficacy and long-term results of cleft lip and palate.
(3) For patients with bilateral cleft lip, non-surgical lengthening of the nasal columella avoids the scar produced by the second-stage surgery to lengthen the nasal columella and the surgery at the lip-nasal columella union; the symmetry of the nose is significantly improved after surgery. One of the most significant advantages of the bilateral cleft lip-palate nasoalveolarplasty is the non-surgical lengthening of the short nasal minors, usually by 4-7 mm, with an average lengthening of 3.67 mm reported in our group. Bilateral cleft lip and palate nasoalveolar bone contouring allows the patient to obtain a lengthened nasal minors, a symmetrical nostril shape and a maxillary dental arch in the anterior jaw in harmony with the alveoli on both sides.
(4) Nasal-alveolar bone contouring combined with early surgical simultaneous alveolar-labial-nasal revision can repair alveolar, labial and nasal complex deformities simultaneously, thus reducing the number and extent of surgical treatment required during the sequential treatment of cleft lip and palate patients and saving costs.
(5) Nasal-alveolar contouring can also promote the narrowing of the palatal cleft, which facilitates early cleft palate surgery for children with cleft lip and palate, prevents the formation and development of pathological speech, and guides the precise synchronization and harmonious movement of the brain, palate, pharynx, tongue and lip muscles during the correct pronunciation of the child; it also helps reduce infections in the nasopharynx, respiratory tract and middle ear, thus promoting the voice rehabilitation of the child.
(6) Early repair of cleft lip and palate can prevent children from developing low self-esteem and ensure their healthy physical and psychological development.