Latham's appliance for presurgical repositioning of the protruded
premaxilla in bilateral cleft lip and palate Klaus Bitter
Department of Maxillo-facial Plastic Surgery (Head: Professor K. Bitter, MD, DMD), University Hospital, Frankfurt, Germany.
SUMMARY. Dislocation of the maxillary segments in cleft lip and palate still is a challenge to the surgeon and the orthodontist. The premaxillary protrusion in bilateral cleft lip and palate, complicates the treatment severely. Latham's appliance, inserted on average at 2-months-of-age, relocates the segments over 3-4 weeks. Removal of the appliance is immediately followed by functional surgery. The first operation comprises: (1) intravelar veloplasty; (2) closure of the alveolar cleft with the help of a gingivo-periosteal-plasty; (3) lip adhesion and (4) insertion of ear tubes. This operating schedule establishes the functional matrix as early as possible. Midfacial growth as well as language and speech development are provided with the necessary preconditions as far as we understand this complex situation. Five cases, being representative of 41 cases, are outlined in detail. The longest follow up period is 3 years; no growth disturbance of the maxilla has been detected to date. Definitive lip and columeila surgery is facilitated. KEY W O R D S : Bilateral cleft lip and palate - Presurgical repositioning of the maxillary segments - Functional surgery Premaxilla
hypothetically, to stimulate the growth at the cleft edges. Continuous removal of acrylic from the undersurface of the appliance guides the segments by active growth into the correct position. Burston showed cases of perfect realignment of the maxillary arch. He was, however, forced to keep the babies on an inpatient basis for an intensive and close follow-up. My personal experience with Hotz's modification is that it takes too much time to obtain proper alignment for readily and anatomically performed surgery. Especially, the premaxilla cannot be moved backwards into the correct position. Rosenstein et al. (1982) modified the use of the removable plate. They only covered the secondary palate and left the primary palate open. Early closure of the lip turned the alveolar prOcesses by natural forces into a butt joint, whereas the dorsal width of the palate was preserved by the plate. As soon as the butt joint was achieved the mucosa of the alveolar cleft edge was prepared in terms of a gingivo-periosteal plasty and rib bone was inserted into the gap. Recently, Rosenstein et al. (1991) published a 10 year follow-up of their cases with convincing results. This procedure shows dearly, what 'minimal' surgery in the bony region can produce. Nevertheless, Rosenstein mentioned in a subordinate clause, that his report referred only to those children in whom the lip surgery succeeded in bringing the alveolar processes in touch. He does not report on how many cases failed and had to be treated in some alternative way. Despite the fact that the acrylic palatal plate keeps
INTRODUCTION The protruding premaxilla and the concomitant dislocation of the lateral maxillary segments in bilateral cleft lip and palate has long been a challenging problem for surgeons and orthodontist. The treatment history has produced different concepts of treatment, three of which are today in widespread use: 1. Closure of soft tissue (lip and velum) is expected to work against the dislocation and mould the maxillary arch. Lip surgery is done as adhesion or definitively, i n one stage or in two stages, depending on the width of the cleft. Regarding the lip, the results are usually disappointing as severe tissue traction stretches the scars, if muscle closure is possible at all. The majority of patients therefore has need of extensive secondary surgery. Regarding the maxillary arch, perfect alignment is seldom achieved. The premaxilla remains protruded and in many cases the lateral segments collapse and block out the premaxilla. Nothing can be done to ameliorate this during the first years of life. Childhood and youth is overburdened with the problems of a face of poor appearance. Trying to comfort the child and the parents with the promise of good final result in adulthood is a form of cruelty in view of the sensitive phases of the childs mental growth. 2. Another widespread method consists of inserting a passively-working acrylic plate to cover the cleft maxilla as soon as possible after birth (Burston, 1958; Hotz and Gnoinski, 1976). The plate is expected, 99
100 Journalof Cranio-Maxillo-FacialSurgery the tongue out of the cleft, the restored orbicularis oris muscle often does not achieve closure of the alveolar cleft by retropositioning of the premaxilla. Another critical point is lip surgery producing tension across an open alveolar cleft. No doubt, the result will be worse the wider the cleft. Ideally lip closure should be definitive after one operation. Reentering the lip at a later stage causes more severe scar problems than in young babies. 3. Therefore, surgeons have been searching for centuries for an actively-working appliance, capable of moving the premaxilla backwards into a properlyshaped gap between the lateral maxillary segments (Millard, 1977a). In recent times, McNeil (1950), popularized a combination of an intraoral appliance and an extraoral rubber strip, fixed to a head cap and gently pressing on the prolabium. No doubt this procedure is successful if carefully handled. ' I f ' means a high degree of parental compliance, and this seems to be the crucial explanation for a high failure rate. Georgiade, et al. (1968) shifted the appliance intraorally. The plate was pinned to the palatal shelves and rubber strips pulled the premaxilla backwards. Georgiade and Latham (1975) refined the technique of the appliance and developed an apparatus named Mark III. Initially, this little 'machine' was restricted to insertion only in babies with a disastrous bilateral cleft with total collapse of the lateral palatal segments and a severely protruding premaxilla. The very good results the authors obtained stimulated Latham to further refinement in view of its routine use in every cleft child. In 1980 he introduced an appliance reduced in size to what is normal in orthodontics. Since then, Latham and Millard have been working together, with Berkowitz on follow-up documentation and to provide a very critical assessment. A preliminary 10-year analysis (Millard et al. 1988) revealed encouraging results. Potential risks .or disadvantages are discussed later in this paper.
MATERIAL
AND METHODS
T e c h n i c a l description o f Latham's appliance 1
The appliance consists of a straight metal bar that crosses the maxilla from tuberosity to tuberosity (Fig. 1). In the middle of the bar a screw moves a lever arm which continues through a pivot to another lever arm, which is placed on the alveolar process of the lateral maxillary segments. Turning the screw expands the gap between the anterior borders of the lateral segments if necessary. The appliance is available commercially and individually adapted to a plaster cast with the help of an acrylic plate. Just behind the premaxilla a double clip is inserted through the prevomerine stalk. On both ends of the clip, elastic strips are fixed that run backward to a pulley on the underside of the crossbar. After passing around the pulley the strips run forward to a button, where 1Leibinger Ltd., 7202 Mtihlheim-Stretten,Germany.
Fig. I - Latham's appliance in situ. The mechanicaldeviceis commerciallyavailable1. Acrylicplates are individually fabricated. NASAL SEPTUM
ACRYLIC APPLIANCE
GUMPAO
Fig. 2 - Cross section of the maxilla with Latham's appliance in
place.
traction can be adjusted. Mechanically these elastic strips pull the premaxilla backward and the lateral maxillary segments forward. In both acrylic plates two slots are positioned within the palatal planes. Pins are inserted through these slots into the palatal shelves (Fig. 2). T i m e schedule and surgical m e t h o d
The basic philosophy of the treatment plan tries to respect the array of priorities (Millard, 1986a). First of all a baby with a cleft lip and palate suffers from lack of function and secondarily presents aesthetic problems. Lack of function means: (l) Open, non-functioning soft palate (2) Impaired hearing capability due to Eustachian tube malfunction (3) Adverse effect of the cleft lip and nose musculature leading to centrifugal dislocation of the cleft
Latharn's appliance for presurgical repositioningof the protruded premaxillain bilateral cleft lip and palate 101 segments and absence of growth stimulus to the bony midfacial structures (4) From (1) and (3) follows an unopposed, relative hyperactivity of the tongue, which widens the cleft by pushing the segments further apart. The treatment starts therefore with the insertion of an acrylic plate soon after birth as recommended by Hotz and Gnoinski (1976). This plate prevents the tongue from pressing into the cleft space. During the following weeks a narrowing of the cleft can usually be recognized. A healthy baby, of average birth weight, is scheduled to be operated on at 3 months of age. To have the maxillary segments in proper alignment (butt joint of the alveolar processes) the Latham appliance is inserted 4 weeks before the operation. The insertion can easily be done under slight sedation e.g. Dominal. The elastic strips are adjusted to 80 g tension on either side, i.e. 160 g traction forces on the premaxilla and the lateral segments respectively. The elastic strips have to be readjusted once a week. Usually the alignment can be achieved during the first 213 weeks. The appliance, however, is left in place as a retainer and is removed the day before the operation. The slightly irritated, mucosa underneath the acrylic plate looks completely normal 1 day after removal of the appliance. The first operation includes four functional aspects: (l) intravelar veloplasty; (2) ear tubes; (3) gingivoperiosteal closure of the alveolar cleft and (4) lip adhesion. (1) The intravelar veloplasty was introduced by Braithwaite (1964) and later popularized by Kriens (1969, 1970). Among different technical modifications the author prefers the following procedure: The mucosa of the velum is incised from the dorsal nasal spine to the tip of the uvula along the cleft equator. The nasal and oral mucosa is dissected carefully from the anterior muscle bundles. These are cut off the nasal spine and retropositioned so far as possible to be joined to each other in the midline. The nasal mucosa is sutured from dorsal to anterior so far as the lateral traction allows. The muscles are sutured together and finally covered with the oral mucosa. The anterior part of the velum remains open and the slots, where the muscles were, simply closed by suturing the oral mucosa to the nasal mucosa. (2) Through a paracentral incision, the serous fluid or 'glue' is sucked out of the tympanic cavity and Goode tubes are inserted. (3) Closure of the alveolar cleft is not a direct functional restoration but the newly created premaxillary-maxillary suture is an object for functional influences. An open cleft is a 'dead space'. Only a bone suture can be stimulated to grow (Latham 1980). To close the cleft, the Millard-Latham-modification of a periosteoplasty is used (Millard 1980). Figure 3 outlines the incisions: The tissue is elevated subperiosteally along the natural junction between nasal and oral mucosa to close the nasal floor above the alveolar process and in the anterior part of the secondary palate. This nasal closure follows Veau's
Incision-linesfor closure of the nasal floor according to Veau and for gingivo-periostealflap raising. See also Figure 4.
Fig. 3 -
Closure of the nasal floor on the left side. Closure of the oral layer on the right side.
Fig. 4 -
Fig.
5 Definitiveclosure from the oral aspect.
procedure exactly. On the oral side, 3 interdigitating gingival flaps are raised from the cleft borders (Fig. 4) and sutured together to bridge the alveolar and anterior palatal cleft (Fig. 5). A tunnel is created between the nasal and oral layer bordered by two bony surfaces. Initially filled with a blood clot, bone is expected to grow across the tunnel and close the cleft. (4) The gingivo-periosteoplasty incisions are continued into the lip and lip closure in terms of an adhesion achieved. The technique of lip adhesion is modified several times but principally to restore a closed orbicularis muscle ring. Two months after the first operation the patient comes back to the operating room for definitive lip
102 Journal of Cranio-Maxillo-Facial Surgery correction. The technique consists of shaping a normal philtrum island by shifting the lateral excess prolabial skin into the 'whisker' position and closure of the muscle ring behind the philtrum island. Technical details are extensively outlined by Millard (1977b, 1986a). Restoring muscular function anterior and posterior to the maxilla stimulates bone growth. F r o m this follows spontaneous narrowing of the still open hard palate Cleft. On average a year later, it can be closed by suturing the nasal floor in its natural borders and by moving two narrow bridge flaps from the palatal shelves to the midline. The columella is lengthened by cutting the prolabial flaps out of the 'whisker' position and advancing them to a proportional columella shape. Cephalometry was done with calipers to avoid Xrays. This measurement system has been developed recently (Bitter, unpublished data, in preparation).
metrical position of the lateral maxillary segments 15.06.90-Lip adhesion (Fig. 7C) transformed into definitive lip repair (Fig. 7D); Fig. 7 E shows the palatal situation at this time: on the right side enhanced eruption of a supernumerary deciduous tooth, vomer less but still slightly curved; Fig. 7E shows the child at 14 months of age; closure of the hard palate and columella lengthening is scheduled for October 1991. Figure 7F shows the lateral cephalogram. The Latham appliance achieved a perfect relationship between the premaxilla and the maxillary segments. Nevertheless the angle Tragus-Nasion-Maxilla is still of too high degree compared to the normal average of 74° (Bitter, unpublished data). This means, the Latham appliance moves the premaxilla in part backwards and the maxillary segments in part forwards. Overall, the maxillary complex remains in an anterior position and is further integrated into normal midfacial relations by time. The follow-up of this child will reveal, whether there is a potential hazard to forward growth capacity or not.
RESULTS
Case 3
Since June 1988, to date 41 patients with complete bilateral clefts of lip and palate have been treated according to the procedure described. A statistical analysis still remains incomplete because of the relatively low number of cases and the short observation time. Instead, 5 representative cases will be shown here. Case 1 Patient D.S. male, born 1.4.88, birth weight 3600 g, uneventful pregnancy, family history: one cleft palate case known. 02.04.88 - H o t z appliance inserted 11.06.88- Latham appliance inserted (Fig. 6A) 08.07.88- Appliance removed (Fig. 6B); the impression was taken immediately after removal, so that the irritation of the mucosa is still visible intravelar veloplasty, gingivo-periosteoplasty and lip adhesion, insertion of ear tubes 10.09.88 -Transformation of lip adhesion into definitive lip reconstruction (Fig. 6 C and D) 07.09.90 -Closure of the hard palate (Fig. 6E) Note in Fig. 6E the notching of the alveolar process on the left side, reflecting, that the gingivo-periosteal flaps have been retracted inward. Spontaneous bone formation might be hampered (?). Figure 6F shows a lateral directly measured cephalogram (Bitter, unpublished data); length of the measurements and the angles are within the normal range. So far, the maxilla has not shown any lack of forward and downward growth. In September 1991 columeUa lengthening is scheduled. Case 2 Patient M.K. born 21.12.89, male, birth weight 4000g, family history without clefts, uneventful pregnancy. 22.12.89 - Hotz plate inserted 27.02.90- Latham appliance inserted (Fig. 7A) - 29.03.90- Latham appliance removed (Fig. 7B) intravelar veloplasty, gingivo-periosteoplasty; lip adhesion; insertion of ear tubes; note the slightly curved vomer, depending on the asym-
Patient Y.t)., born 3.9.89, male, birth weight 1700 g, 10 weeks before E.T., uneventful pregnancy, family history unremarkable, in addition to the cleft: club foot and slight signs of midline malformation. 10.09.89 - Hotz plate inserted 17.01.90 - Latham appliance inserted without prevomerine clip, because of total maxillary collapse the site was inaccessible (Fig. 8A) 19.02.90- Prevomerine clip inserted 13.03.90- Latham appliance removed (Fig. 8B); perfect alveolar alignment but still collapse in the posterior palatal region dependant on the appliance mechanism; intravelar veloplasty, gingivo-periosteo-plasty, lip adhesion, ear tubes inserted 15.05.90 - Lip adhesion (Figs 8 C and E) transformed into definitive lip repair, still has notching of the alveolar process 13.03.91 -Closure of the hard palate. Fig. 8D shows the lip at that time and Figure 8 F the intraoral aspect of the maxilla. Figure 8 G shows the lateral cephalograms : growth up to 18 months of age uneventful. Case 4 Patient M.W. born 12.7.89, male, birth weight 4000g, uneventful pregnancy, family history unremarkable. 15.07.89 - Hotz plate inserted 01.11.89- Latham appliance inserted (Fig. 9A), the cast shows complete afiterior maxillary collapse 07.12.89-Scheduled operation had to be cancelled because of a severe virus infection; the appliance remained in place inactively as a retainer 18.01.90-Latham appliance removed; mucosa more irritated because of the time interval (Fig. 9 B), intravelar vdoplasty, gingivo-periosteo-plasty and lip adhesion; ear tubes 10.05.90 - Lip adhesion into definitive lip repair (Figs 9 C and D). The alveolar process is closed, but the premaxilla seems to be pinched forwards 08.03.91- (Figs 9E and F) closure of the hard palate and columella lengthening; since May 1990 the arch has been moulded perfectly by normal
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
28 mths Nose
//
103
12 mths Tragus
Maxilla Mandible
Fig. 6 A - F - Case 1. Average case with symmetrical moderate protrusion of the premaxilla and slight collapse of the lateral segments. (A) maxilla before appliance; (B) 4 weeks after appliance; (C) situation of lip adhesion; (D) definitive lip reconstruction with prolabial excess in 'whisker' position; (E) hard palate after 28 months; (F) lateral cephalometry within normal range.
104 Journal of Cranio-Maxillo-Facial Surgery
14 mths
S i
,- 16 mths . " f 2 mths / Tragus
Nose,
Maxilla
F
Mandible
Fig. 7 A - F - Case 2. Moderate protrusion of the premaxilla and asymmetrical collapse of the lateral segments, (A) before appliance; (B) after appliance, 4 weeks later. Note the thickening of the vomer; the curvature depends not on buckling but on the asymmetrical position of the lateral segments; (C) lip adhesion; (D) definitive lip, prolabium flaps in the 'whisker' position; 0g) hard palate after 6 months; (17) lateral cephalogram within the normal range.
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
Fig. 8A-F - (for legend see page 106).
105
106 -Journal of Cranio-Maxillo-Facial Surgery
18 mths // 8mths f 6 mths Nose r ~
Tragus
Maxilla
G
Mandible
Fig. 8A-G- Case 3: Severeprotrusion of the premaxilla and total collapse of the lateral segments. (A) before appliance: total collapse of the lateral maxillary segments; (B) after appliance, 8 weeks later; (C) lip adhesion; (D) definitivelip repair; (E) maxilla after 8 months; (F) maxilla at 18 months of age; (G) lateral cephalogram.
muscle function. On the left side a second incisor, in palatal malposition, had to be removed because of tongue injury. Lateral cephalogram normal (not shown). Case 5 Patient P.S., born 25.11.88; birth weight 3750g, family history unremarkabte, placental bleeding since fourteenth week of pregnancy. 28.11.88 - Hotz plate inserted 02.02.89-Latham appliance inserted; Fig. 10A shows severe asymmetry depending on a tiny mucosal bridge of the nasal floor above the alveolar process 29.02.89 - Latham appliance removed (Fig. 10B), intravelar veloplasty, gingivo-periosteo-plasty, insertion of ear tubes. Gingivo-periosteoplasty on the left side was difficult because of a mucosal'supernumerary tooth 15.06.89- Definitive lip repair (Fig. 10D) 26.10.90-Closure of the hard palate and gingivoperiosteo-plasty on the left side repeated. Figure 10D shows the lip and the columella lengthening flaps still in the 'whisker' position. Figure 10E shows good alveolar alignment and the deep notching of the left alveolar cleft. Lateral cephalogram (Fig. 10F) reveals normal forward growth of the maxilla.
D I S C U S S I O N AND C O N C L U S I O N S It is well accepted, for several reasons, that a cleft lip and palate has to be closed stepwise. Regarding the array of surgical steps, innumerable schedules have been developed to date. To rationalize this apparent confusion, one has to define the problems, a newborn baby with an open cleft, which one of these deserves priority? First of all lack of different functions are determinative and secondly aesthetic considerations are of importa~ace.
Lack of function means: 1." Dys- or non-functioning velum 2. Dysfunction of the Eustachian tube 3. Mal- or dysfunction of the labial muscle system 4. Overwhelming tongue forces especially in the dorsocranial direction, i.e. into the cleft space. Closely related to muscle function is growth of the supporting bones (Functional Matrix, Moss, 1969). Besides the intrinsic growth capacity the skeleton needs muscular stimulation for normal development. The sutural growth mechanism is not cleaHy, understood; but in close analogy with skull growth one can suggest, hypothetically, that bone is formed in a suture under appropriate traction. If there is an open cleft instead of the suture, the traction forces only will displace the adjacent bones. Aesthetic problems, i.e. visible lip cleft and nose deformity are less important due to the baby's unawareness of it's own disfigurement. Extensive i n f o r m a t i o n - given to the p a r e n t s - calms the whole family and enables the surgeon to follow a rational treatment plan. These reflections clearly demand an early reconstruction Of the whole malformed muscle system. The dislocation of the maxillary segments, however, usually hinders the surgery unless the segments are presurgically relocated in their normal position or at least are brought as close together as to achieve an anatomically correct muscle system. The 'feeding plate', even when inserted early, does nothing more than impede the tongue pressing into the cleft. Narrowing of the cleft margins is observed in greater or lesser degree, but not sufficient for early surgery. Thereforel Latham's appliance seems to facilitate the most rational approach so far. Even when repositioning of the maxillary segments is achieved rapidly some questions of potential disadvantage arise. First, does the pinning to the palatal shelves and premaxillary neck and the forced
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
107
1
Fig. 9 A - F " Case 4: Moderate protrusion of the premaxilla and total anterior collapse of the lateral segments. (A) before appliance; (B) after appliance, 9 weeks later; (C) lip adhesion; (I)) maxilla with lip adhesion: the premaxilla seems to be pinched forwards; (E) lip at 20 months of age; (F) maxilla at 20 months : alveolar arch perfectly moulded by tongue and lip, note the left lateral incisor in palatal malposition.
108
Journal of Cranio-Maxillo-Facial Surgery
23 mths /6.5 mths mths,
////3
Tragus
Nose
M
F
a
x
l
l
l
a
~
Mandible
Fig. I O A - F - Case 5: Severe asymmetrical protrusion of the premaxilla depending on aSimmonart's band on the right side, no lateral collapse; (A) before appliance; (B) after appliance, 3~ weeks later; (C) lip adhesion; (D) definitive lip repair; (E) maxilla at 23 months of age; (F) lateral cephalogram.
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
backward traction of the premaxilla do any harm to the forward growth of the maxillary complex? The pinning is a microtrauma, much less then surgery, necessary for closure of wide clefts. Careful comparison of the vomer shape before and after L a t h a m ' s appliance shows, that the vomer does not buckle but thickens, depending on tissue inflow. The early cephalometric measurements reveal an unimpaired forward growth of the maxilla after a short interval of stand still. An interesting observation is that the premaxilla remains protruded after the presurgical repositioning, though the relationship to the lateral segments is perfect. This can only be explained by a forward movement of the lateral segments. This anterior shift does not cause any intramaxillary elongation of P-S or P1-S1 but induces postmaxillary bone apposition, i.e. the normal growth mechanism ( R o s s , 1990). G e o r g i a d e and coworkers (1989) published results of patients treated with the M a r k appliance more than 15 years ago. So far, no growth inhibition has been observed. Nevertheless, no report was given with regard to the concomitant orthodontic therapy. M i l l a r d and L a t h a m (1991) follow their patients for about 12 years without having recognized any forward and downward growth inhibition. B e r k o w i t z (1991) points out that closing the alveolar cleft after repositioning potentially creates an anterior cross bite in those cases with missing lateral incisors. The radius of the anterior alveolar process is too small to fit the mandibular alveolar arch. This type of crossbite does not reflect a malposition of the maxillary base. But, if the tongue will not expand the dental arch, early insertion of an orthodontic appliance is necessary. Another crucial question is, is there spontaneous bone formation after the gingivo-periosteal closure of the alveolar cleft? S k o o g (1965) developed the principle of shifting periostium from the cleft vicinity to the cleft itself. He succeeded in producing bone, but subsequent authors could not reproduce the same success rate. M a s s e i (1986) modified the technique by preparing a periosteal flap that remained attached to the overlying cheek tissue and obtained a sufficient amount of new bone in about 50 % of the patients. 2.5% of the clefts did not develop bone at all; 3 % were ' i n a d e q u a t e ' and the rest, 45 %, showed some bone, which required further bone grafting. M i l l a r c f s and L a t h a m ' s gingivo-periosteal-plasty differs completely from S k o o g ' s and M a s s e i ' s proCedure. Regarding the fact, that the alveolar segments are in a butt joint, only the cleft gingiva and mucoperiostium are necessary for the closure. This means minimal trauma but the surgical preparation is difficult in view of the tooth buds. M i l l a r d and L a t h a m (1990) clearly demonstrated bone formation in the alveolar tunnel. To date, they have not-needed for secondary bone grafting. The number of cases, however, is too small, to judge definitely. Regarding my own cases, I have the feeling that the width of the alveolar cleft at the time of the gingivo-periosteal-plasty is ~of prime importance. T h e r e is some degree of competition between spontaneous bone formation' and collagen
109
filaments. I f the gap between the bone surfaces is too wide, there is a definite collagen build up that cannot be penetrated by bone. The alveolar notching reflects this situation. On the other hand, in every case some degree of notching is visible but it disappears by bony fusion and merging. It seems reasonable to relocate the alveolar cleft margins as close together as possible. The narrower the bony gap, the greater the chance of bony bridging. An appreciable side-effect of the presurgical repositioning is facilitation of the lip surgery. A rational anatomical reconstruction is possible and columella lengthening can be advanced to an earlier date, as the skeletal platform is correct. References Berkowitz, S. : Pers. comm. (1991) Braithwaite, F.." Cleft palate repair. In: Gibson, T. (Ed.):
Modern trends in plastic surgery. Butterworth, Washington 1964, 35-43 Burston, W. R. : The early orthodontic treatment of cleft palate
conditions. Dent. Pract. 9 (1958) 41-53 Georgiade, N. G., R. A. Mladnik, F. L. Thorne : Positioning of the
premaxilla in bilateral cleft lip by oral pinning and traction. Plast. Reconstr. Surg. 41 (1968) 240249 Georgiade, N. G., R. A. Latham : Maxillary arch alignment in bilateral cleft lip and palate infant, using the pinned coaxial screw appliance. Plast. Reconstr. Surg. 56 (1975) 52-59 Georgiade, N. G., R. Mason, R. Riefkohl, G. Georgiade, W. Barwich: Preoperative positioning of the protruding premaxilla
in the bilateral cleft lip patient. Plast. Reconstr. Surg. 83 (1989) 32-43 Hotz, M., W. Gnoinski: Comprehensivecare of cleft lip and palate children at Ziirich University: A preliminary report: Am. J. Orthod. 70 (1976) 481-489 Kriens, O.: An anatomical approach to veloplasty. Plast. Reconstr. Surg. 43 (1969) 29-37 Kriens, O.: Fundamental anatomic findings for an intravelar veloplasty. Cleft Palate J. 7 (1970) 27-36 [~atham, R. A. : In: Millard, D. R. : Cleft Craft Vol. III. Little / Brown, Boston 1980, 284-298 JLatham, R. A. : Orthopedic advancement of the Cleftmaxillary segment: A preliminary report. Cleft Palate J. 17 (1980) 227-233 Massei, A. : Reconstruction of cleft maxilla with periosteoplasty. Scand J. Plast. Reconstr. Surg. 20 (1986) 41-53 McNeil, C. K. : Orthodontic procedures in the treatment of congenital cleft palate. Dent. Res. 79 (1950) 126-133 Millard, D. R. : What 'to do or not to do' about the projecting premaxilla. In: Millard D. R. (ed): Cleft Craft Vol. II. Little Brown, Boston 1977a, 40-80 Millard, D. R. : Details of closing a complete bilateral cleft and banking the fork. In: Millard D. R. (ed): Cleft Craft Vol. II. Little Brown, Boston 1977b, 359-374 Millard, D. R. : Gingivo-peri0steoplasty.In: Millard D. R. (ed): Cleft Craft Vol. III. Little Brown, Boston 1980, 289-298 Millard, D. R. : Principlization of plastic surgery. Little Brown, Boston, 1986a, 361-363 Millard, D. R. : Principlization of plastic surgery. Little Brown, Boston, 1986b, 1-18 Millard, D. R., S. Berkowitz, R. A. Latham, S. A. Wolfe:
Discussion of presurgical orthodontics in patients with clefts. Cleft palate J. 25 (1988) 403-412 Millard, D. R., R. A. Latham: Improved primary surgical and dental treatment of clefts. Plast. Reconstr. Surg. 86 (1990) 856-871 Millard, D. R., R. A. Latham : Personal Communication i1991) Moss, M. L: The primary role of functional matrices in facial growth. Am. J. Orthod. 55 (1969) 565-571 Rosenstein, S. W., C. W. Monroe, D. A. Kernahan, B. N. Jacobson, B. J. Griffiths, B. S. Bauer." The case for early bone
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Journal of Cranio-Maxillo-Facial Surgery
grafting in cleft lip and cleft palate. Plast. Reconstr. Surg. 70 (1982) 297-307 Rosenstein, S. W., D. V. Dado, D. Kernahan, B. H. Griffith, M. Graseshi: The case for early bone grafting in cleft lip and
palate: A second report. Plast. Reconstr. Surg. 87 (1991) 644-654 Ross, R. B. : Facial growth in cleft lip and palate. In: McCarthy, J. : Plastic surgery, Philadelphia, Saunders, Vol. 4, 1990, 2553-2580 Skoog, T.: The use of periosteal flaps in the repair of cleft of the primary palate. Cleft Palate J. 2 (1965) 332-347
Prof. Dr. Dr. K. Bitter
Johann-Wolfgang-Goethe-Universit/it Abt. MnndKiefer und Gesichtschirurgie Theodor-Stern-Kai 7 W-6000 Frankfurt/Main 70 Germany Paper received 4 September 1991 Accepted 15 November 1991
premaxilla in bilateral cleft lip and palate Klaus Bitter
Department of Maxillo-facial Plastic Surgery (Head: Professor K. Bitter, MD, DMD), University Hospital, Frankfurt, Germany.
SUMMARY. Dislocation of the maxillary segments in cleft lip and palate still is a challenge to the surgeon and the orthodontist. The premaxillary protrusion in bilateral cleft lip and palate, complicates the treatment severely. Latham's appliance, inserted on average at 2-months-of-age, relocates the segments over 3-4 weeks. Removal of the appliance is immediately followed by functional surgery. The first operation comprises: (1) intravelar veloplasty; (2) closure of the alveolar cleft with the help of a gingivo-periosteal-plasty; (3) lip adhesion and (4) insertion of ear tubes. This operating schedule establishes the functional matrix as early as possible. Midfacial growth as well as language and speech development are provided with the necessary preconditions as far as we understand this complex situation. Five cases, being representative of 41 cases, are outlined in detail. The longest follow up period is 3 years; no growth disturbance of the maxilla has been detected to date. Definitive lip and columeila surgery is facilitated. KEY W O R D S : Bilateral cleft lip and palate - Presurgical repositioning of the maxillary segments - Functional surgery Premaxilla
hypothetically, to stimulate the growth at the cleft edges. Continuous removal of acrylic from the undersurface of the appliance guides the segments by active growth into the correct position. Burston showed cases of perfect realignment of the maxillary arch. He was, however, forced to keep the babies on an inpatient basis for an intensive and close follow-up. My personal experience with Hotz's modification is that it takes too much time to obtain proper alignment for readily and anatomically performed surgery. Especially, the premaxilla cannot be moved backwards into the correct position. Rosenstein et al. (1982) modified the use of the removable plate. They only covered the secondary palate and left the primary palate open. Early closure of the lip turned the alveolar prOcesses by natural forces into a butt joint, whereas the dorsal width of the palate was preserved by the plate. As soon as the butt joint was achieved the mucosa of the alveolar cleft edge was prepared in terms of a gingivo-periosteal plasty and rib bone was inserted into the gap. Recently, Rosenstein et al. (1991) published a 10 year follow-up of their cases with convincing results. This procedure shows dearly, what 'minimal' surgery in the bony region can produce. Nevertheless, Rosenstein mentioned in a subordinate clause, that his report referred only to those children in whom the lip surgery succeeded in bringing the alveolar processes in touch. He does not report on how many cases failed and had to be treated in some alternative way. Despite the fact that the acrylic palatal plate keeps
INTRODUCTION The protruding premaxilla and the concomitant dislocation of the lateral maxillary segments in bilateral cleft lip and palate has long been a challenging problem for surgeons and orthodontist. The treatment history has produced different concepts of treatment, three of which are today in widespread use: 1. Closure of soft tissue (lip and velum) is expected to work against the dislocation and mould the maxillary arch. Lip surgery is done as adhesion or definitively, i n one stage or in two stages, depending on the width of the cleft. Regarding the lip, the results are usually disappointing as severe tissue traction stretches the scars, if muscle closure is possible at all. The majority of patients therefore has need of extensive secondary surgery. Regarding the maxillary arch, perfect alignment is seldom achieved. The premaxilla remains protruded and in many cases the lateral segments collapse and block out the premaxilla. Nothing can be done to ameliorate this during the first years of life. Childhood and youth is overburdened with the problems of a face of poor appearance. Trying to comfort the child and the parents with the promise of good final result in adulthood is a form of cruelty in view of the sensitive phases of the childs mental growth. 2. Another widespread method consists of inserting a passively-working acrylic plate to cover the cleft maxilla as soon as possible after birth (Burston, 1958; Hotz and Gnoinski, 1976). The plate is expected, 99
100 Journalof Cranio-Maxillo-FacialSurgery the tongue out of the cleft, the restored orbicularis oris muscle often does not achieve closure of the alveolar cleft by retropositioning of the premaxilla. Another critical point is lip surgery producing tension across an open alveolar cleft. No doubt, the result will be worse the wider the cleft. Ideally lip closure should be definitive after one operation. Reentering the lip at a later stage causes more severe scar problems than in young babies. 3. Therefore, surgeons have been searching for centuries for an actively-working appliance, capable of moving the premaxilla backwards into a properlyshaped gap between the lateral maxillary segments (Millard, 1977a). In recent times, McNeil (1950), popularized a combination of an intraoral appliance and an extraoral rubber strip, fixed to a head cap and gently pressing on the prolabium. No doubt this procedure is successful if carefully handled. ' I f ' means a high degree of parental compliance, and this seems to be the crucial explanation for a high failure rate. Georgiade, et al. (1968) shifted the appliance intraorally. The plate was pinned to the palatal shelves and rubber strips pulled the premaxilla backwards. Georgiade and Latham (1975) refined the technique of the appliance and developed an apparatus named Mark III. Initially, this little 'machine' was restricted to insertion only in babies with a disastrous bilateral cleft with total collapse of the lateral palatal segments and a severely protruding premaxilla. The very good results the authors obtained stimulated Latham to further refinement in view of its routine use in every cleft child. In 1980 he introduced an appliance reduced in size to what is normal in orthodontics. Since then, Latham and Millard have been working together, with Berkowitz on follow-up documentation and to provide a very critical assessment. A preliminary 10-year analysis (Millard et al. 1988) revealed encouraging results. Potential risks .or disadvantages are discussed later in this paper.
MATERIAL
AND METHODS
T e c h n i c a l description o f Latham's appliance 1
The appliance consists of a straight metal bar that crosses the maxilla from tuberosity to tuberosity (Fig. 1). In the middle of the bar a screw moves a lever arm which continues through a pivot to another lever arm, which is placed on the alveolar process of the lateral maxillary segments. Turning the screw expands the gap between the anterior borders of the lateral segments if necessary. The appliance is available commercially and individually adapted to a plaster cast with the help of an acrylic plate. Just behind the premaxilla a double clip is inserted through the prevomerine stalk. On both ends of the clip, elastic strips are fixed that run backward to a pulley on the underside of the crossbar. After passing around the pulley the strips run forward to a button, where 1Leibinger Ltd., 7202 Mtihlheim-Stretten,Germany.
Fig. I - Latham's appliance in situ. The mechanicaldeviceis commerciallyavailable1. Acrylicplates are individually fabricated. NASAL SEPTUM
ACRYLIC APPLIANCE
GUMPAO
Fig. 2 - Cross section of the maxilla with Latham's appliance in
place.
traction can be adjusted. Mechanically these elastic strips pull the premaxilla backward and the lateral maxillary segments forward. In both acrylic plates two slots are positioned within the palatal planes. Pins are inserted through these slots into the palatal shelves (Fig. 2). T i m e schedule and surgical m e t h o d
The basic philosophy of the treatment plan tries to respect the array of priorities (Millard, 1986a). First of all a baby with a cleft lip and palate suffers from lack of function and secondarily presents aesthetic problems. Lack of function means: (l) Open, non-functioning soft palate (2) Impaired hearing capability due to Eustachian tube malfunction (3) Adverse effect of the cleft lip and nose musculature leading to centrifugal dislocation of the cleft
Latharn's appliance for presurgical repositioningof the protruded premaxillain bilateral cleft lip and palate 101 segments and absence of growth stimulus to the bony midfacial structures (4) From (1) and (3) follows an unopposed, relative hyperactivity of the tongue, which widens the cleft by pushing the segments further apart. The treatment starts therefore with the insertion of an acrylic plate soon after birth as recommended by Hotz and Gnoinski (1976). This plate prevents the tongue from pressing into the cleft space. During the following weeks a narrowing of the cleft can usually be recognized. A healthy baby, of average birth weight, is scheduled to be operated on at 3 months of age. To have the maxillary segments in proper alignment (butt joint of the alveolar processes) the Latham appliance is inserted 4 weeks before the operation. The insertion can easily be done under slight sedation e.g. Dominal. The elastic strips are adjusted to 80 g tension on either side, i.e. 160 g traction forces on the premaxilla and the lateral segments respectively. The elastic strips have to be readjusted once a week. Usually the alignment can be achieved during the first 213 weeks. The appliance, however, is left in place as a retainer and is removed the day before the operation. The slightly irritated, mucosa underneath the acrylic plate looks completely normal 1 day after removal of the appliance. The first operation includes four functional aspects: (l) intravelar veloplasty; (2) ear tubes; (3) gingivoperiosteal closure of the alveolar cleft and (4) lip adhesion. (1) The intravelar veloplasty was introduced by Braithwaite (1964) and later popularized by Kriens (1969, 1970). Among different technical modifications the author prefers the following procedure: The mucosa of the velum is incised from the dorsal nasal spine to the tip of the uvula along the cleft equator. The nasal and oral mucosa is dissected carefully from the anterior muscle bundles. These are cut off the nasal spine and retropositioned so far as possible to be joined to each other in the midline. The nasal mucosa is sutured from dorsal to anterior so far as the lateral traction allows. The muscles are sutured together and finally covered with the oral mucosa. The anterior part of the velum remains open and the slots, where the muscles were, simply closed by suturing the oral mucosa to the nasal mucosa. (2) Through a paracentral incision, the serous fluid or 'glue' is sucked out of the tympanic cavity and Goode tubes are inserted. (3) Closure of the alveolar cleft is not a direct functional restoration but the newly created premaxillary-maxillary suture is an object for functional influences. An open cleft is a 'dead space'. Only a bone suture can be stimulated to grow (Latham 1980). To close the cleft, the Millard-Latham-modification of a periosteoplasty is used (Millard 1980). Figure 3 outlines the incisions: The tissue is elevated subperiosteally along the natural junction between nasal and oral mucosa to close the nasal floor above the alveolar process and in the anterior part of the secondary palate. This nasal closure follows Veau's
Incision-linesfor closure of the nasal floor according to Veau and for gingivo-periostealflap raising. See also Figure 4.
Fig. 3 -
Closure of the nasal floor on the left side. Closure of the oral layer on the right side.
Fig. 4 -
Fig.
5 Definitiveclosure from the oral aspect.
procedure exactly. On the oral side, 3 interdigitating gingival flaps are raised from the cleft borders (Fig. 4) and sutured together to bridge the alveolar and anterior palatal cleft (Fig. 5). A tunnel is created between the nasal and oral layer bordered by two bony surfaces. Initially filled with a blood clot, bone is expected to grow across the tunnel and close the cleft. (4) The gingivo-periosteoplasty incisions are continued into the lip and lip closure in terms of an adhesion achieved. The technique of lip adhesion is modified several times but principally to restore a closed orbicularis muscle ring. Two months after the first operation the patient comes back to the operating room for definitive lip
102 Journal of Cranio-Maxillo-Facial Surgery correction. The technique consists of shaping a normal philtrum island by shifting the lateral excess prolabial skin into the 'whisker' position and closure of the muscle ring behind the philtrum island. Technical details are extensively outlined by Millard (1977b, 1986a). Restoring muscular function anterior and posterior to the maxilla stimulates bone growth. F r o m this follows spontaneous narrowing of the still open hard palate Cleft. On average a year later, it can be closed by suturing the nasal floor in its natural borders and by moving two narrow bridge flaps from the palatal shelves to the midline. The columella is lengthened by cutting the prolabial flaps out of the 'whisker' position and advancing them to a proportional columella shape. Cephalometry was done with calipers to avoid Xrays. This measurement system has been developed recently (Bitter, unpublished data, in preparation).
metrical position of the lateral maxillary segments 15.06.90-Lip adhesion (Fig. 7C) transformed into definitive lip repair (Fig. 7D); Fig. 7 E shows the palatal situation at this time: on the right side enhanced eruption of a supernumerary deciduous tooth, vomer less but still slightly curved; Fig. 7E shows the child at 14 months of age; closure of the hard palate and columella lengthening is scheduled for October 1991. Figure 7F shows the lateral cephalogram. The Latham appliance achieved a perfect relationship between the premaxilla and the maxillary segments. Nevertheless the angle Tragus-Nasion-Maxilla is still of too high degree compared to the normal average of 74° (Bitter, unpublished data). This means, the Latham appliance moves the premaxilla in part backwards and the maxillary segments in part forwards. Overall, the maxillary complex remains in an anterior position and is further integrated into normal midfacial relations by time. The follow-up of this child will reveal, whether there is a potential hazard to forward growth capacity or not.
RESULTS
Case 3
Since June 1988, to date 41 patients with complete bilateral clefts of lip and palate have been treated according to the procedure described. A statistical analysis still remains incomplete because of the relatively low number of cases and the short observation time. Instead, 5 representative cases will be shown here. Case 1 Patient D.S. male, born 1.4.88, birth weight 3600 g, uneventful pregnancy, family history: one cleft palate case known. 02.04.88 - H o t z appliance inserted 11.06.88- Latham appliance inserted (Fig. 6A) 08.07.88- Appliance removed (Fig. 6B); the impression was taken immediately after removal, so that the irritation of the mucosa is still visible intravelar veloplasty, gingivo-periosteoplasty and lip adhesion, insertion of ear tubes 10.09.88 -Transformation of lip adhesion into definitive lip reconstruction (Fig. 6 C and D) 07.09.90 -Closure of the hard palate (Fig. 6E) Note in Fig. 6E the notching of the alveolar process on the left side, reflecting, that the gingivo-periosteal flaps have been retracted inward. Spontaneous bone formation might be hampered (?). Figure 6F shows a lateral directly measured cephalogram (Bitter, unpublished data); length of the measurements and the angles are within the normal range. So far, the maxilla has not shown any lack of forward and downward growth. In September 1991 columeUa lengthening is scheduled. Case 2 Patient M.K. born 21.12.89, male, birth weight 4000g, family history without clefts, uneventful pregnancy. 22.12.89 - Hotz plate inserted 27.02.90- Latham appliance inserted (Fig. 7A) - 29.03.90- Latham appliance removed (Fig. 7B) intravelar veloplasty, gingivo-periosteoplasty; lip adhesion; insertion of ear tubes; note the slightly curved vomer, depending on the asym-
Patient Y.t)., born 3.9.89, male, birth weight 1700 g, 10 weeks before E.T., uneventful pregnancy, family history unremarkable, in addition to the cleft: club foot and slight signs of midline malformation. 10.09.89 - Hotz plate inserted 17.01.90 - Latham appliance inserted without prevomerine clip, because of total maxillary collapse the site was inaccessible (Fig. 8A) 19.02.90- Prevomerine clip inserted 13.03.90- Latham appliance removed (Fig. 8B); perfect alveolar alignment but still collapse in the posterior palatal region dependant on the appliance mechanism; intravelar veloplasty, gingivo-periosteo-plasty, lip adhesion, ear tubes inserted 15.05.90 - Lip adhesion (Figs 8 C and E) transformed into definitive lip repair, still has notching of the alveolar process 13.03.91 -Closure of the hard palate. Fig. 8D shows the lip at that time and Figure 8 F the intraoral aspect of the maxilla. Figure 8 G shows the lateral cephalograms : growth up to 18 months of age uneventful. Case 4 Patient M.W. born 12.7.89, male, birth weight 4000g, uneventful pregnancy, family history unremarkable. 15.07.89 - Hotz plate inserted 01.11.89- Latham appliance inserted (Fig. 9A), the cast shows complete afiterior maxillary collapse 07.12.89-Scheduled operation had to be cancelled because of a severe virus infection; the appliance remained in place inactively as a retainer 18.01.90-Latham appliance removed; mucosa more irritated because of the time interval (Fig. 9 B), intravelar vdoplasty, gingivo-periosteo-plasty and lip adhesion; ear tubes 10.05.90 - Lip adhesion into definitive lip repair (Figs 9 C and D). The alveolar process is closed, but the premaxilla seems to be pinched forwards 08.03.91- (Figs 9E and F) closure of the hard palate and columella lengthening; since May 1990 the arch has been moulded perfectly by normal
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
28 mths Nose
//
103
12 mths Tragus
Maxilla Mandible
Fig. 6 A - F - Case 1. Average case with symmetrical moderate protrusion of the premaxilla and slight collapse of the lateral segments. (A) maxilla before appliance; (B) 4 weeks after appliance; (C) situation of lip adhesion; (D) definitive lip reconstruction with prolabial excess in 'whisker' position; (E) hard palate after 28 months; (F) lateral cephalometry within normal range.
104 Journal of Cranio-Maxillo-Facial Surgery
14 mths
S i
,- 16 mths . " f 2 mths / Tragus
Nose,
Maxilla
F
Mandible
Fig. 7 A - F - Case 2. Moderate protrusion of the premaxilla and asymmetrical collapse of the lateral segments, (A) before appliance; (B) after appliance, 4 weeks later. Note the thickening of the vomer; the curvature depends not on buckling but on the asymmetrical position of the lateral segments; (C) lip adhesion; (D) definitive lip, prolabium flaps in the 'whisker' position; 0g) hard palate after 6 months; (17) lateral cephalogram within the normal range.
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
Fig. 8A-F - (for legend see page 106).
105
106 -Journal of Cranio-Maxillo-Facial Surgery
18 mths // 8mths f 6 mths Nose r ~
Tragus
Maxilla
G
Mandible
Fig. 8A-G- Case 3: Severeprotrusion of the premaxilla and total collapse of the lateral segments. (A) before appliance: total collapse of the lateral maxillary segments; (B) after appliance, 8 weeks later; (C) lip adhesion; (D) definitivelip repair; (E) maxilla after 8 months; (F) maxilla at 18 months of age; (G) lateral cephalogram.
muscle function. On the left side a second incisor, in palatal malposition, had to be removed because of tongue injury. Lateral cephalogram normal (not shown). Case 5 Patient P.S., born 25.11.88; birth weight 3750g, family history unremarkabte, placental bleeding since fourteenth week of pregnancy. 28.11.88 - Hotz plate inserted 02.02.89-Latham appliance inserted; Fig. 10A shows severe asymmetry depending on a tiny mucosal bridge of the nasal floor above the alveolar process 29.02.89 - Latham appliance removed (Fig. 10B), intravelar veloplasty, gingivo-periosteo-plasty, insertion of ear tubes. Gingivo-periosteoplasty on the left side was difficult because of a mucosal'supernumerary tooth 15.06.89- Definitive lip repair (Fig. 10D) 26.10.90-Closure of the hard palate and gingivoperiosteo-plasty on the left side repeated. Figure 10D shows the lip and the columella lengthening flaps still in the 'whisker' position. Figure 10E shows good alveolar alignment and the deep notching of the left alveolar cleft. Lateral cephalogram (Fig. 10F) reveals normal forward growth of the maxilla.
D I S C U S S I O N AND C O N C L U S I O N S It is well accepted, for several reasons, that a cleft lip and palate has to be closed stepwise. Regarding the array of surgical steps, innumerable schedules have been developed to date. To rationalize this apparent confusion, one has to define the problems, a newborn baby with an open cleft, which one of these deserves priority? First of all lack of different functions are determinative and secondly aesthetic considerations are of importa~ace.
Lack of function means: 1." Dys- or non-functioning velum 2. Dysfunction of the Eustachian tube 3. Mal- or dysfunction of the labial muscle system 4. Overwhelming tongue forces especially in the dorsocranial direction, i.e. into the cleft space. Closely related to muscle function is growth of the supporting bones (Functional Matrix, Moss, 1969). Besides the intrinsic growth capacity the skeleton needs muscular stimulation for normal development. The sutural growth mechanism is not cleaHy, understood; but in close analogy with skull growth one can suggest, hypothetically, that bone is formed in a suture under appropriate traction. If there is an open cleft instead of the suture, the traction forces only will displace the adjacent bones. Aesthetic problems, i.e. visible lip cleft and nose deformity are less important due to the baby's unawareness of it's own disfigurement. Extensive i n f o r m a t i o n - given to the p a r e n t s - calms the whole family and enables the surgeon to follow a rational treatment plan. These reflections clearly demand an early reconstruction Of the whole malformed muscle system. The dislocation of the maxillary segments, however, usually hinders the surgery unless the segments are presurgically relocated in their normal position or at least are brought as close together as to achieve an anatomically correct muscle system. The 'feeding plate', even when inserted early, does nothing more than impede the tongue pressing into the cleft. Narrowing of the cleft margins is observed in greater or lesser degree, but not sufficient for early surgery. Thereforel Latham's appliance seems to facilitate the most rational approach so far. Even when repositioning of the maxillary segments is achieved rapidly some questions of potential disadvantage arise. First, does the pinning to the palatal shelves and premaxillary neck and the forced
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
107
1
Fig. 9 A - F " Case 4: Moderate protrusion of the premaxilla and total anterior collapse of the lateral segments. (A) before appliance; (B) after appliance, 9 weeks later; (C) lip adhesion; (I)) maxilla with lip adhesion: the premaxilla seems to be pinched forwards; (E) lip at 20 months of age; (F) maxilla at 20 months : alveolar arch perfectly moulded by tongue and lip, note the left lateral incisor in palatal malposition.
108
Journal of Cranio-Maxillo-Facial Surgery
23 mths /6.5 mths mths,
////3
Tragus
Nose
M
F
a
x
l
l
l
a
~
Mandible
Fig. I O A - F - Case 5: Severe asymmetrical protrusion of the premaxilla depending on aSimmonart's band on the right side, no lateral collapse; (A) before appliance; (B) after appliance, 3~ weeks later; (C) lip adhesion; (D) definitive lip repair; (E) maxilla at 23 months of age; (F) lateral cephalogram.
Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate
backward traction of the premaxilla do any harm to the forward growth of the maxillary complex? The pinning is a microtrauma, much less then surgery, necessary for closure of wide clefts. Careful comparison of the vomer shape before and after L a t h a m ' s appliance shows, that the vomer does not buckle but thickens, depending on tissue inflow. The early cephalometric measurements reveal an unimpaired forward growth of the maxilla after a short interval of stand still. An interesting observation is that the premaxilla remains protruded after the presurgical repositioning, though the relationship to the lateral segments is perfect. This can only be explained by a forward movement of the lateral segments. This anterior shift does not cause any intramaxillary elongation of P-S or P1-S1 but induces postmaxillary bone apposition, i.e. the normal growth mechanism ( R o s s , 1990). G e o r g i a d e and coworkers (1989) published results of patients treated with the M a r k appliance more than 15 years ago. So far, no growth inhibition has been observed. Nevertheless, no report was given with regard to the concomitant orthodontic therapy. M i l l a r d and L a t h a m (1991) follow their patients for about 12 years without having recognized any forward and downward growth inhibition. B e r k o w i t z (1991) points out that closing the alveolar cleft after repositioning potentially creates an anterior cross bite in those cases with missing lateral incisors. The radius of the anterior alveolar process is too small to fit the mandibular alveolar arch. This type of crossbite does not reflect a malposition of the maxillary base. But, if the tongue will not expand the dental arch, early insertion of an orthodontic appliance is necessary. Another crucial question is, is there spontaneous bone formation after the gingivo-periosteal closure of the alveolar cleft? S k o o g (1965) developed the principle of shifting periostium from the cleft vicinity to the cleft itself. He succeeded in producing bone, but subsequent authors could not reproduce the same success rate. M a s s e i (1986) modified the technique by preparing a periosteal flap that remained attached to the overlying cheek tissue and obtained a sufficient amount of new bone in about 50 % of the patients. 2.5% of the clefts did not develop bone at all; 3 % were ' i n a d e q u a t e ' and the rest, 45 %, showed some bone, which required further bone grafting. M i l l a r c f s and L a t h a m ' s gingivo-periosteal-plasty differs completely from S k o o g ' s and M a s s e i ' s proCedure. Regarding the fact, that the alveolar segments are in a butt joint, only the cleft gingiva and mucoperiostium are necessary for the closure. This means minimal trauma but the surgical preparation is difficult in view of the tooth buds. M i l l a r d and L a t h a m (1990) clearly demonstrated bone formation in the alveolar tunnel. To date, they have not-needed for secondary bone grafting. The number of cases, however, is too small, to judge definitely. Regarding my own cases, I have the feeling that the width of the alveolar cleft at the time of the gingivo-periosteal-plasty is ~of prime importance. T h e r e is some degree of competition between spontaneous bone formation' and collagen
109
filaments. I f the gap between the bone surfaces is too wide, there is a definite collagen build up that cannot be penetrated by bone. The alveolar notching reflects this situation. On the other hand, in every case some degree of notching is visible but it disappears by bony fusion and merging. It seems reasonable to relocate the alveolar cleft margins as close together as possible. The narrower the bony gap, the greater the chance of bony bridging. An appreciable side-effect of the presurgical repositioning is facilitation of the lip surgery. A rational anatomical reconstruction is possible and columella lengthening can be advanced to an earlier date, as the skeletal platform is correct. References Berkowitz, S. : Pers. comm. (1991) Braithwaite, F.." Cleft palate repair. In: Gibson, T. (Ed.):
Modern trends in plastic surgery. Butterworth, Washington 1964, 35-43 Burston, W. R. : The early orthodontic treatment of cleft palate
conditions. Dent. Pract. 9 (1958) 41-53 Georgiade, N. G., R. A. Mladnik, F. L. Thorne : Positioning of the
premaxilla in bilateral cleft lip by oral pinning and traction. Plast. Reconstr. Surg. 41 (1968) 240249 Georgiade, N. G., R. A. Latham : Maxillary arch alignment in bilateral cleft lip and palate infant, using the pinned coaxial screw appliance. Plast. Reconstr. Surg. 56 (1975) 52-59 Georgiade, N. G., R. Mason, R. Riefkohl, G. Georgiade, W. Barwich: Preoperative positioning of the protruding premaxilla
in the bilateral cleft lip patient. Plast. Reconstr. Surg. 83 (1989) 32-43 Hotz, M., W. Gnoinski: Comprehensivecare of cleft lip and palate children at Ziirich University: A preliminary report: Am. J. Orthod. 70 (1976) 481-489 Kriens, O.: An anatomical approach to veloplasty. Plast. Reconstr. Surg. 43 (1969) 29-37 Kriens, O.: Fundamental anatomic findings for an intravelar veloplasty. Cleft Palate J. 7 (1970) 27-36 [~atham, R. A. : In: Millard, D. R. : Cleft Craft Vol. III. Little / Brown, Boston 1980, 284-298 JLatham, R. A. : Orthopedic advancement of the Cleftmaxillary segment: A preliminary report. Cleft Palate J. 17 (1980) 227-233 Massei, A. : Reconstruction of cleft maxilla with periosteoplasty. Scand J. Plast. Reconstr. Surg. 20 (1986) 41-53 McNeil, C. K. : Orthodontic procedures in the treatment of congenital cleft palate. Dent. Res. 79 (1950) 126-133 Millard, D. R. : What 'to do or not to do' about the projecting premaxilla. In: Millard D. R. (ed): Cleft Craft Vol. II. Little Brown, Boston 1977a, 40-80 Millard, D. R. : Details of closing a complete bilateral cleft and banking the fork. In: Millard D. R. (ed): Cleft Craft Vol. II. Little Brown, Boston 1977b, 359-374 Millard, D. R. : Gingivo-peri0steoplasty.In: Millard D. R. (ed): Cleft Craft Vol. III. Little Brown, Boston 1980, 289-298 Millard, D. R. : Principlization of plastic surgery. Little Brown, Boston, 1986a, 361-363 Millard, D. R. : Principlization of plastic surgery. Little Brown, Boston, 1986b, 1-18 Millard, D. R., S. Berkowitz, R. A. Latham, S. A. Wolfe:
Discussion of presurgical orthodontics in patients with clefts. Cleft palate J. 25 (1988) 403-412 Millard, D. R., R. A. Latham: Improved primary surgical and dental treatment of clefts. Plast. Reconstr. Surg. 86 (1990) 856-871 Millard, D. R., R. A. Latham : Personal Communication i1991) Moss, M. L: The primary role of functional matrices in facial growth. Am. J. Orthod. 55 (1969) 565-571 Rosenstein, S. W., C. W. Monroe, D. A. Kernahan, B. N. Jacobson, B. J. Griffiths, B. S. Bauer." The case for early bone
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grafting in cleft lip and cleft palate. Plast. Reconstr. Surg. 70 (1982) 297-307 Rosenstein, S. W., D. V. Dado, D. Kernahan, B. H. Griffith, M. Graseshi: The case for early bone grafting in cleft lip and
palate: A second report. Plast. Reconstr. Surg. 87 (1991) 644-654 Ross, R. B. : Facial growth in cleft lip and palate. In: McCarthy, J. : Plastic surgery, Philadelphia, Saunders, Vol. 4, 1990, 2553-2580 Skoog, T.: The use of periosteal flaps in the repair of cleft of the primary palate. Cleft Palate J. 2 (1965) 332-347
Prof. Dr. Dr. K. Bitter
Johann-Wolfgang-Goethe-Universit/it Abt. MnndKiefer und Gesichtschirurgie Theodor-Stern-Kai 7 W-6000 Frankfurt/Main 70 Germany Paper received 4 September 1991 Accepted 15 November 1991
