90
Journal of the Royal Society of Medicine Volume 83 February 1990
Early pre-surgical treatment of the cleft palate patient
P G Sullivan FDS DOrth Sheffield S10 2SZ
Department of Child Dental Health, School of Clinical Dentistry, Wellesley Road
Keywords: cleft palate; pre-surgical; orthodontic treatment
The pattern of treatment for cleft palate patients extends from birth until adult life. Treatment is required at many stages during this period, both to improve the quality of life and to treat the underlying disability. The necessary treatment is derived from a number of disciplines, and it is essential that the various therapeutic procedures are integrated and co-ordinated from the very beginning. The preferable arrangement is by the adoption of a joint cleft palate treatment planning clinic, on which the essential disciplines are represented. The patient attends the joint clinic at regular intervals from infancy until the definitive treatment to repair the cleft and re-establish an intact dental arch has been carried out. Thereafter, the patient may attend at longer intervals or cease regular attendance, requesting an appointment if necessary. Thus, from the neonatal period up to at least the early twenties, the patient will be a regular attender. The advantage ofthis approach is that the correct treatment may be arranged at the right time. As a minimum, the clinic should have a plastic surgeon, speech therapist, paediatrician, otolaryngologist and an orthodontist. At times, a procedure will
Figure 1. Bilateral cleft oflips and pakzt Profile view showing the discrepancy between the cleft surfaces of the upper lip
be required which will reflect contributions from other Paper read to medical and dental disciplines. This can best be Section of initiated by a referral from the joint planning clinic Odontology, at the most advantageous point in the child's 18 May 1987 development. The contributions made by the orthodontist to the immediate postnatal presurgical treatment are threefold. Firstly, to restore normal function by improving the infant's ability to suckle. Secondly to move the segments into as near their normal relations as possible to facilitate surgical repair. Thirdly, to prevent the tongue from entering the cleft area. The discontinuity caused by a complete cleft of the lips and palate is exaggerated by the displacement of the tissues on either side. In the case of unilateral clefts, the lesser and greater segments of the palate have been moved sideways opening the gap in the palate and exposing the nasal cavity on the side of the cleft. In bilateral clefts (Figure 1), the premaxillary segment is elevated upwards and forwards. The appearance ofthese infants is distorted, and furthermore the essential functions of the mouth and oral cavity are disrupted. Cleft palate babies find difficulty in suckling efficiently, because the infant finds difficulty in expressing milk from the feeding teat. Ingested milk tends to escape down the nose and feeding times are lengthened. Whereas the design of modified teats for feeding bottles has gone some way towards overcoming this problem, many cleft palate babies still show considerable difficulty in feeding properly. Furthermore, the displacement of the segments on either side of the cleft makes the task of the plastic surgeon more difficult in the repair of the lips. This procedure is usually carried out three to four months after birth. If continuity of the fibres ofthe Obicularis Oris muscle is to be achieved, it must be possible to dissect out the muscle ends with sufficient spare tissue to permit them to be sutured together. This is rendered more difficult if the surfaces of the lips to be joined together are strained apart by the 10-12 mm, for instance shown in Figure 1. Presurgical orthodontic treatment is provided by the use of a removable acrylic appliance which is fitted as soon as possible after birth. This appliance provides an artificial palate against which the child can suckle and can also be designed to provide a moulding effect to the gum pads in order to close the gap between the segments.
Appliance design During the first 24 h after birth, an impression is taken of the baby's palate. This is used to make a working model for the construction of the appliance, which is modified according to whether the cleft is incomplete or complete, that is whether the cleft
0141-0768/90/
020090-04/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 February 1990
Figure 4. Adjustable appliance for treatment of bilateral cleft patient Figure 2. Incomplete cleft ofhard and soft palate Palatal view showing the intact gum pad arch and a wide cleft of the hard palate. The white structure running vertically to the right of the cleft area is a naso-enteric feeding tube passing through the nasal cavity
Figure 3. Appliance showing attachment for dental floss
extends anteriorly to involve the gum pads and lips as well as the hard and soft palate. Incomplete clefts In the case of patients with clefts limited only to the hard and soft palates (Figure 2) the appliance is designed to assist in efficient feeding by acting as an artificial palate. A simple baseplate (Figure 3) is formed over the working model and worn by the patient fitted over the maxillary gum pads. The appliance roofs over the cleft in the hard and soft palate, and in the case of the patient shown in Figure 2 resulted in a marked reduction in feeding time. Fish' also suggested that an appliance which excluded the tongue from the cleft area would facilitate maximum growth of the palatal shelves, thus reducing the width of the cleft. Complete clefts The use of acrylic plates to modify the shape of the arches in cleft palate patients prior to lip repair was originally described by McNeil2 and was later refined by Burston3, Huddart4, Robertson5 and Shaw6. The method described employed a procedure whereby the gum pad segments were repositioned by sectioning and reforming the working model before the appliance was constructed7. The drawback to the use of this design lay in the need to take a new impression and make another appliance at each of the progressive stages in moving the segments together.
A more recent development described by Di Biase and Hunter8 employs an adjustable appliance constructed in two parts which fit over the gum pad segments (Figure 4). The two components are connected by a 'U' shaped spring, which is adjusted to provide the thrust to mould the segments into their new positions. In addition to the insertion of the spring, the two parts ofthe plate are finished in such a way as to overlap. When fitted, although in two parts, the plate provides an intact surface against which the infant can suckle. This appliance confers the ability to make adjustments to the moulding force by chairside adjustment of the 'U' shaped spring. At each visit the effect of the spring may be modified without the necessity to take another impression and make a new appliance. The cut between the two parts of the appliance is orientated to facilitate the required movement of the segments. In unilateral cases the cut is made obliquely to allow differential movement between the two segments. In bilateral cases the cut is made in an anterior-posterior direction.
Use of appliance and facial strapping A further effect in approximately the cleft borders of the lips is obtained by the use of facial strapping. A strip of rolled adhesive tape is fixed across the infant's face so as to provide a moulding force which tends to swing the displaced segments in towards each other. Prior to fitting the tape, two squares of micropore adhesive tape are stuck to the patient's cheeks and left in place over several days. The effect of the strapping may be enhanced by the addition of polyurethane foam to form a short thickened length of the adhesive tape. The site of the thickened area is chosen to provide the most effective moulding action to restore the symmetry of the arch shape with the maxillary labial fraenum in the mid line. The method used to cut out and form the strapping is demonstrated to the child's parents who then are able to replace it, when necessary, between visits to the treatment clinic. The use of facial strapping is particularly effective in rotating the forward displaced premaxillary segment backwards and downwards in the case of patients with bilateral clefts of the lips and palate
(Figure 5). Unilateral clefts The moulding effect of the appliance is employed to reform the smooth contour of the maxillary arch in
91
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Journal of the Royal Society of Medicine Volume 83 February 1990
Figure 5. Facial strapping
the treatment of patients with unilateral clefts. This requires that the lesser gum pad segment is moved anteriorly and mesially and that the larger segment is rotated anteriorly in a direction to close the cleft discrepancy. This is achieved by adjusting the 'U' shaped spring joining the two components ofthe appliance. Prior to insertion, the spring is closed by approximately 3 mm, such that the appliance no longer fits passively onto the working model. When fitted in the mouth, tongue pressure particularly during suckling, seats the appliance over the maxillary segments. During this seating pressure the 'U' shaped spring is opened and provides a moulding thrust which tends to move the segments together. The moulding effect can be modified to act differentially by activation of the 'U' shaped spring.
If the adjustment of the spring is limited to a simple closing action, the lesser segment will move mesially into contact with the greater segment, resulting in asymmetry in the arch. To prevent this, the spring is adjusted to tend to move the lesser segment anteriorly, as well as mesially, to regain the contour ofthe gum pads which would have resulted if no cleft had occurred. This affect is further enhanced if the division between the two parts of the appliance is arranged in an oblique plane. It is unnecessary to fit projecting bows or spurs as the appliance is well-tolerated without extra oral fixation. A small lug constructed in stainless steel wire is let into one segment to provide attachment for a length of dental floss which is pinned to the infant's clothing (Figure 3). Although it is almost impossible for the infant to swallow the appliance, the dental floss acts as a safety measure should it be necessary to remove the appliance urgently. The progressive stages in the treatment of a patient with a unilateral cleft of the lip and palate is demonstrated in Figure 6. The first model represents the beginning of treatment. The second model shows the effect of the adjustment of the spring and the use of facial strapping after a three week interval. The third model illustrates the relationship of the segments after a further 3 week period of treatment. Treatment was continued until the patient's amision for lip repair at the age of 11 weeks. The appliance was replaced from one week to 10 days following suture removal.
Bilateral clefts In the case of treatment for patients with bilateral clefts of the lip and palate, it is frequently necessary to expand the distance between the two segments to permit the retraction of the premaxillary segment into position. In this case the 'U' shaped spring is opened by 2-3 mm and provides a moulding force which tends to increase the separation between the segments. The treatment for the patient shown in Figure 1 consisted of expansion of the gum pad segments using the appliance shown in Figure 6, and the use of facial strapping (Figure 5) to retract the displaced premaxillary segment. Lip repair is carried out in two stages, the repair of one side being performed 2 to 3 weeks before the repair to the other side.
Figure 6. Effect of facial strapping and appliance wear - stages in treatment of a patient with a unilateral clef First model taken 24 h after birth, second and third after intervals of three weeks. Closure of the cleft discrepancy is achieved by moulding the segments into a smooth arch, and not by closing the smaller segment directly into the larger segment.
Journal of the Royal Society of Medicine Volume 83 February 1990
The appliance is replaced as soon as practicable after the repair to the first side and the strapping regimen recommenced after suture removal. Frequently the arrangement of the facial strapping will require adjustment to compensate for the lateral pull on the premaxillary segment from the recently repaired side during the fortnight before repair to the second side.
Period between lip and palate repair The interval between surgery to the lips and repair of the palate varies between 6 and 9 months according to the practice of the plastic surgeon. The plate is retained to act as a feeding appliance until the palate is repaired in order to prevent the passage offood via the cleft into the nasal cavity and to preserve the position of the segments. No activation of the spring is necessary during this period. If required, a new impression may be taken using the appliance as a special tray in order to construct a simple baseplate which may be worn instead of the appliance.
Some recent books Medicine Advances and Controversies in Thalassemia Therapy. (Progress in Clinical and Biological Research, Vol 309). C Dean Buckner et al. eds, (pp 416, $88) ISBN 0-8451-5159-3, New York: Alan R Liss 1989 Better Health and the Reverse Effect. Walter A Heiby. (pp 104) ISBN 0-938869-03-5, Illinois: Mediscience publishers 1988 Biochemistry of the Acute Allergic Reactions. (Progress in Clinical and Biological Research, Vol 297). Alfred I Tauber et al. (pp 350, $96) ISBN 0471-51514-0, New York: Alan R Liss 1989 Competing for the Disabled. (IEA Health Unit Paper, No. 7) Charles S B Galasko & Caroline Lipkin. (pp 63, £5) ISBN 0-255-36256-0, London: IEA Health Unit 1989 Concepts in Hypertension. Sir Stanley Peart. (pp 119) ISBN 3-7985-0749-X, New York: Springer Verlag 1989Gastrointestinal Secretion. J S Davison. (pp 254) ISBN 0-7236-1043-6, London: Wright 1989 Growth Regulation ofThyroid Glad and Thyroid Tumours. P E Goretzki and H D Roher. (pp 162, £68.80) ISBN 3-80554984-9, Basel: Karger 1989 Hypersensitivity Pneumonitis: A Clinical Approach. 0 P Sharma. (pp 186, £72.50) ISBN 3-80554974-1, Basel: Karger 1989 Lung Cancer. The Evolution ofConcepts. John G Gruhn and Steven T Rosen. (pp 249, £48.50), New York: Field & Wood 1989 Opportunities Fungal Infections Focus on Fluconazole. R G Richardson. (pp 70, £7.50) ISBN 1-85315-109-2, London: Royal Society of Medicine 1989 Psoriasis & Eczema. (Clinical Handbook Series). Lionel Fry, ed. (pp 202, £15) ISBN 1-85457-002-1, Lancaster: Gazelle 1989
References 1 Fish J. Growth of the palatal shelves ofpost-alveolar cleft palate infants. Br Dent J 1972;132:492-501 2 McNeil CK. Congenital oral deformities. Br Dent J 1956;101:191-8 3 Burston WR. The early orthodontic treatment of cleft palate conditions. Dent Pract Dent Rec 1958;9:41-52 4 Huddart AG. Pre-surgical dental orthopaedics. Dent Pract Dent Rec 1962;12:339-50 5 Robertson NRE. Recent trends in the early treatment of cleft lip and palate. Dent Pract Dent Rec 1971;21: 326-39 6 Shaw WC. Early orthopaedic treatment of unilateral cleft lip and palate. Br J Orthod 1978;6:119-32 7 Robertson NRE. Oral orthopaedics and orthodontics for cleft lip and palate. London: Pitman Books, 1983: 102-12 8 Di Biase DD, Hunter SB. A method of pre-surgical oral orthopaedics. Br J Orthod 1983;10:25-31 (Accepted 26 June 1989)
Responsibility for Nutrition Diagnosis. Michael Gracey et al. (pp 64, £10) ISBN 1-85463-014-8, London: Smith Gordon 1989 Rheumatology. Philip Helliwell et al. (pp 178, £11.50) ISBN 3-540-19554-8, London: Springer Verlag 1988 The Return of Blood to the Heart. A M N Gardner and R H Fox. (pp 184, £25) ISBN 0-86196-074-2, London: John'Libbey 1989 The Use of Isradipine and other Calcium Antagonists in Cardiovascular Diseases. P A Van Zwieten, ed. (pp 88, £10) ISBN 1-85315-108-4, London: Royal Society of Medicine 1989
Wills' Biochemical Basis of Medicine. (2nd Edition). J Hywel Thomas and Brian Gillham, eds. (pp 590, £19.95) ISBN 0-7236-0914-4, Kent: Butterworths 1989
Surgery and anaesthesia Aids to Undergraduate Surgery (3rd edn). Peter M Mowschenson, (pp 190, £6.95) ISBN 0443-04037-0, Edinburgh: Churchill Livingstone 1989 A Very Short Textbook ofSurgery. Peter Ryan. (pp 85, A$15) ISBN 07316-35221, Canberra: Dennis and Ryan 1988 Biomedical Engineering. (An International Symposium). Wen-Jei Yang and Chun-Jean Lee. (pp 360, £42) ISBN 0-89116-827-3, New York: Hemisphere Publishing 1989 Fundamental Anatomy for Operative General Surgery. S J Snooks, R F M Wood. (pp 91, £11.95) ISBN 3-540-19535-1, London: Springer Verlag 1989 General Anaesthesia. (5th edn). J F Nunn et al. (pp 1434) ISBN 0407-00696-6, Kent: Butterworths 1989 Second Vienna Shock Forum. (Progress in Clinical and Biological Research, Vol 308) Gunther Schlag and Heinz Redl, eds (pp 1142) ISBN 0-8451-51584, New York: Alan R Liss 1989 The History of Anaesthesia. (International Congress and Symposium Series 134). Richard S Atkinson and Thomas B Boulton. (pp 649) ISBN 0-905958-69-1, London: Royal Society of Medicine 1989
93
Journal of the Royal Society of Medicine Volume 83 February 1990
Early pre-surgical treatment of the cleft palate patient
P G Sullivan FDS DOrth Sheffield S10 2SZ
Department of Child Dental Health, School of Clinical Dentistry, Wellesley Road
Keywords: cleft palate; pre-surgical; orthodontic treatment
The pattern of treatment for cleft palate patients extends from birth until adult life. Treatment is required at many stages during this period, both to improve the quality of life and to treat the underlying disability. The necessary treatment is derived from a number of disciplines, and it is essential that the various therapeutic procedures are integrated and co-ordinated from the very beginning. The preferable arrangement is by the adoption of a joint cleft palate treatment planning clinic, on which the essential disciplines are represented. The patient attends the joint clinic at regular intervals from infancy until the definitive treatment to repair the cleft and re-establish an intact dental arch has been carried out. Thereafter, the patient may attend at longer intervals or cease regular attendance, requesting an appointment if necessary. Thus, from the neonatal period up to at least the early twenties, the patient will be a regular attender. The advantage ofthis approach is that the correct treatment may be arranged at the right time. As a minimum, the clinic should have a plastic surgeon, speech therapist, paediatrician, otolaryngologist and an orthodontist. At times, a procedure will
Figure 1. Bilateral cleft oflips and pakzt Profile view showing the discrepancy between the cleft surfaces of the upper lip
be required which will reflect contributions from other Paper read to medical and dental disciplines. This can best be Section of initiated by a referral from the joint planning clinic Odontology, at the most advantageous point in the child's 18 May 1987 development. The contributions made by the orthodontist to the immediate postnatal presurgical treatment are threefold. Firstly, to restore normal function by improving the infant's ability to suckle. Secondly to move the segments into as near their normal relations as possible to facilitate surgical repair. Thirdly, to prevent the tongue from entering the cleft area. The discontinuity caused by a complete cleft of the lips and palate is exaggerated by the displacement of the tissues on either side. In the case of unilateral clefts, the lesser and greater segments of the palate have been moved sideways opening the gap in the palate and exposing the nasal cavity on the side of the cleft. In bilateral clefts (Figure 1), the premaxillary segment is elevated upwards and forwards. The appearance ofthese infants is distorted, and furthermore the essential functions of the mouth and oral cavity are disrupted. Cleft palate babies find difficulty in suckling efficiently, because the infant finds difficulty in expressing milk from the feeding teat. Ingested milk tends to escape down the nose and feeding times are lengthened. Whereas the design of modified teats for feeding bottles has gone some way towards overcoming this problem, many cleft palate babies still show considerable difficulty in feeding properly. Furthermore, the displacement of the segments on either side of the cleft makes the task of the plastic surgeon more difficult in the repair of the lips. This procedure is usually carried out three to four months after birth. If continuity of the fibres ofthe Obicularis Oris muscle is to be achieved, it must be possible to dissect out the muscle ends with sufficient spare tissue to permit them to be sutured together. This is rendered more difficult if the surfaces of the lips to be joined together are strained apart by the 10-12 mm, for instance shown in Figure 1. Presurgical orthodontic treatment is provided by the use of a removable acrylic appliance which is fitted as soon as possible after birth. This appliance provides an artificial palate against which the child can suckle and can also be designed to provide a moulding effect to the gum pads in order to close the gap between the segments.
Appliance design During the first 24 h after birth, an impression is taken of the baby's palate. This is used to make a working model for the construction of the appliance, which is modified according to whether the cleft is incomplete or complete, that is whether the cleft
0141-0768/90/
020090-04/$02.00/0 © 1990 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 February 1990
Figure 4. Adjustable appliance for treatment of bilateral cleft patient Figure 2. Incomplete cleft ofhard and soft palate Palatal view showing the intact gum pad arch and a wide cleft of the hard palate. The white structure running vertically to the right of the cleft area is a naso-enteric feeding tube passing through the nasal cavity
Figure 3. Appliance showing attachment for dental floss
extends anteriorly to involve the gum pads and lips as well as the hard and soft palate. Incomplete clefts In the case of patients with clefts limited only to the hard and soft palates (Figure 2) the appliance is designed to assist in efficient feeding by acting as an artificial palate. A simple baseplate (Figure 3) is formed over the working model and worn by the patient fitted over the maxillary gum pads. The appliance roofs over the cleft in the hard and soft palate, and in the case of the patient shown in Figure 2 resulted in a marked reduction in feeding time. Fish' also suggested that an appliance which excluded the tongue from the cleft area would facilitate maximum growth of the palatal shelves, thus reducing the width of the cleft. Complete clefts The use of acrylic plates to modify the shape of the arches in cleft palate patients prior to lip repair was originally described by McNeil2 and was later refined by Burston3, Huddart4, Robertson5 and Shaw6. The method described employed a procedure whereby the gum pad segments were repositioned by sectioning and reforming the working model before the appliance was constructed7. The drawback to the use of this design lay in the need to take a new impression and make another appliance at each of the progressive stages in moving the segments together.
A more recent development described by Di Biase and Hunter8 employs an adjustable appliance constructed in two parts which fit over the gum pad segments (Figure 4). The two components are connected by a 'U' shaped spring, which is adjusted to provide the thrust to mould the segments into their new positions. In addition to the insertion of the spring, the two parts ofthe plate are finished in such a way as to overlap. When fitted, although in two parts, the plate provides an intact surface against which the infant can suckle. This appliance confers the ability to make adjustments to the moulding force by chairside adjustment of the 'U' shaped spring. At each visit the effect of the spring may be modified without the necessity to take another impression and make a new appliance. The cut between the two parts of the appliance is orientated to facilitate the required movement of the segments. In unilateral cases the cut is made obliquely to allow differential movement between the two segments. In bilateral cases the cut is made in an anterior-posterior direction.
Use of appliance and facial strapping A further effect in approximately the cleft borders of the lips is obtained by the use of facial strapping. A strip of rolled adhesive tape is fixed across the infant's face so as to provide a moulding force which tends to swing the displaced segments in towards each other. Prior to fitting the tape, two squares of micropore adhesive tape are stuck to the patient's cheeks and left in place over several days. The effect of the strapping may be enhanced by the addition of polyurethane foam to form a short thickened length of the adhesive tape. The site of the thickened area is chosen to provide the most effective moulding action to restore the symmetry of the arch shape with the maxillary labial fraenum in the mid line. The method used to cut out and form the strapping is demonstrated to the child's parents who then are able to replace it, when necessary, between visits to the treatment clinic. The use of facial strapping is particularly effective in rotating the forward displaced premaxillary segment backwards and downwards in the case of patients with bilateral clefts of the lips and palate
(Figure 5). Unilateral clefts The moulding effect of the appliance is employed to reform the smooth contour of the maxillary arch in
91
92
Journal of the Royal Society of Medicine Volume 83 February 1990
Figure 5. Facial strapping
the treatment of patients with unilateral clefts. This requires that the lesser gum pad segment is moved anteriorly and mesially and that the larger segment is rotated anteriorly in a direction to close the cleft discrepancy. This is achieved by adjusting the 'U' shaped spring joining the two components ofthe appliance. Prior to insertion, the spring is closed by approximately 3 mm, such that the appliance no longer fits passively onto the working model. When fitted in the mouth, tongue pressure particularly during suckling, seats the appliance over the maxillary segments. During this seating pressure the 'U' shaped spring is opened and provides a moulding thrust which tends to move the segments together. The moulding effect can be modified to act differentially by activation of the 'U' shaped spring.
If the adjustment of the spring is limited to a simple closing action, the lesser segment will move mesially into contact with the greater segment, resulting in asymmetry in the arch. To prevent this, the spring is adjusted to tend to move the lesser segment anteriorly, as well as mesially, to regain the contour ofthe gum pads which would have resulted if no cleft had occurred. This affect is further enhanced if the division between the two parts of the appliance is arranged in an oblique plane. It is unnecessary to fit projecting bows or spurs as the appliance is well-tolerated without extra oral fixation. A small lug constructed in stainless steel wire is let into one segment to provide attachment for a length of dental floss which is pinned to the infant's clothing (Figure 3). Although it is almost impossible for the infant to swallow the appliance, the dental floss acts as a safety measure should it be necessary to remove the appliance urgently. The progressive stages in the treatment of a patient with a unilateral cleft of the lip and palate is demonstrated in Figure 6. The first model represents the beginning of treatment. The second model shows the effect of the adjustment of the spring and the use of facial strapping after a three week interval. The third model illustrates the relationship of the segments after a further 3 week period of treatment. Treatment was continued until the patient's amision for lip repair at the age of 11 weeks. The appliance was replaced from one week to 10 days following suture removal.
Bilateral clefts In the case of treatment for patients with bilateral clefts of the lip and palate, it is frequently necessary to expand the distance between the two segments to permit the retraction of the premaxillary segment into position. In this case the 'U' shaped spring is opened by 2-3 mm and provides a moulding force which tends to increase the separation between the segments. The treatment for the patient shown in Figure 1 consisted of expansion of the gum pad segments using the appliance shown in Figure 6, and the use of facial strapping (Figure 5) to retract the displaced premaxillary segment. Lip repair is carried out in two stages, the repair of one side being performed 2 to 3 weeks before the repair to the other side.
Figure 6. Effect of facial strapping and appliance wear - stages in treatment of a patient with a unilateral clef First model taken 24 h after birth, second and third after intervals of three weeks. Closure of the cleft discrepancy is achieved by moulding the segments into a smooth arch, and not by closing the smaller segment directly into the larger segment.
Journal of the Royal Society of Medicine Volume 83 February 1990
The appliance is replaced as soon as practicable after the repair to the first side and the strapping regimen recommenced after suture removal. Frequently the arrangement of the facial strapping will require adjustment to compensate for the lateral pull on the premaxillary segment from the recently repaired side during the fortnight before repair to the second side.
Period between lip and palate repair The interval between surgery to the lips and repair of the palate varies between 6 and 9 months according to the practice of the plastic surgeon. The plate is retained to act as a feeding appliance until the palate is repaired in order to prevent the passage offood via the cleft into the nasal cavity and to preserve the position of the segments. No activation of the spring is necessary during this period. If required, a new impression may be taken using the appliance as a special tray in order to construct a simple baseplate which may be worn instead of the appliance.
Some recent books Medicine Advances and Controversies in Thalassemia Therapy. (Progress in Clinical and Biological Research, Vol 309). C Dean Buckner et al. eds, (pp 416, $88) ISBN 0-8451-5159-3, New York: Alan R Liss 1989 Better Health and the Reverse Effect. Walter A Heiby. (pp 104) ISBN 0-938869-03-5, Illinois: Mediscience publishers 1988 Biochemistry of the Acute Allergic Reactions. (Progress in Clinical and Biological Research, Vol 297). Alfred I Tauber et al. (pp 350, $96) ISBN 0471-51514-0, New York: Alan R Liss 1989 Competing for the Disabled. (IEA Health Unit Paper, No. 7) Charles S B Galasko & Caroline Lipkin. (pp 63, £5) ISBN 0-255-36256-0, London: IEA Health Unit 1989 Concepts in Hypertension. Sir Stanley Peart. (pp 119) ISBN 3-7985-0749-X, New York: Springer Verlag 1989Gastrointestinal Secretion. J S Davison. (pp 254) ISBN 0-7236-1043-6, London: Wright 1989 Growth Regulation ofThyroid Glad and Thyroid Tumours. P E Goretzki and H D Roher. (pp 162, £68.80) ISBN 3-80554984-9, Basel: Karger 1989 Hypersensitivity Pneumonitis: A Clinical Approach. 0 P Sharma. (pp 186, £72.50) ISBN 3-80554974-1, Basel: Karger 1989 Lung Cancer. The Evolution ofConcepts. John G Gruhn and Steven T Rosen. (pp 249, £48.50), New York: Field & Wood 1989 Opportunities Fungal Infections Focus on Fluconazole. R G Richardson. (pp 70, £7.50) ISBN 1-85315-109-2, London: Royal Society of Medicine 1989 Psoriasis & Eczema. (Clinical Handbook Series). Lionel Fry, ed. (pp 202, £15) ISBN 1-85457-002-1, Lancaster: Gazelle 1989
References 1 Fish J. Growth of the palatal shelves ofpost-alveolar cleft palate infants. Br Dent J 1972;132:492-501 2 McNeil CK. Congenital oral deformities. Br Dent J 1956;101:191-8 3 Burston WR. The early orthodontic treatment of cleft palate conditions. Dent Pract Dent Rec 1958;9:41-52 4 Huddart AG. Pre-surgical dental orthopaedics. Dent Pract Dent Rec 1962;12:339-50 5 Robertson NRE. Recent trends in the early treatment of cleft lip and palate. Dent Pract Dent Rec 1971;21: 326-39 6 Shaw WC. Early orthopaedic treatment of unilateral cleft lip and palate. Br J Orthod 1978;6:119-32 7 Robertson NRE. Oral orthopaedics and orthodontics for cleft lip and palate. London: Pitman Books, 1983: 102-12 8 Di Biase DD, Hunter SB. A method of pre-surgical oral orthopaedics. Br J Orthod 1983;10:25-31 (Accepted 26 June 1989)
Responsibility for Nutrition Diagnosis. Michael Gracey et al. (pp 64, £10) ISBN 1-85463-014-8, London: Smith Gordon 1989 Rheumatology. Philip Helliwell et al. (pp 178, £11.50) ISBN 3-540-19554-8, London: Springer Verlag 1988 The Return of Blood to the Heart. A M N Gardner and R H Fox. (pp 184, £25) ISBN 0-86196-074-2, London: John'Libbey 1989 The Use of Isradipine and other Calcium Antagonists in Cardiovascular Diseases. P A Van Zwieten, ed. (pp 88, £10) ISBN 1-85315-108-4, London: Royal Society of Medicine 1989
Wills' Biochemical Basis of Medicine. (2nd Edition). J Hywel Thomas and Brian Gillham, eds. (pp 590, £19.95) ISBN 0-7236-0914-4, Kent: Butterworths 1989
Surgery and anaesthesia Aids to Undergraduate Surgery (3rd edn). Peter M Mowschenson, (pp 190, £6.95) ISBN 0443-04037-0, Edinburgh: Churchill Livingstone 1989 A Very Short Textbook ofSurgery. Peter Ryan. (pp 85, A$15) ISBN 07316-35221, Canberra: Dennis and Ryan 1988 Biomedical Engineering. (An International Symposium). Wen-Jei Yang and Chun-Jean Lee. (pp 360, £42) ISBN 0-89116-827-3, New York: Hemisphere Publishing 1989 Fundamental Anatomy for Operative General Surgery. S J Snooks, R F M Wood. (pp 91, £11.95) ISBN 3-540-19535-1, London: Springer Verlag 1989 General Anaesthesia. (5th edn). J F Nunn et al. (pp 1434) ISBN 0407-00696-6, Kent: Butterworths 1989 Second Vienna Shock Forum. (Progress in Clinical and Biological Research, Vol 308) Gunther Schlag and Heinz Redl, eds (pp 1142) ISBN 0-8451-51584, New York: Alan R Liss 1989 The History of Anaesthesia. (International Congress and Symposium Series 134). Richard S Atkinson and Thomas B Boulton. (pp 649) ISBN 0-905958-69-1, London: Royal Society of Medicine 1989
93
