Institute for Orthodontics

Patients with cleft lip and palate

In our cleft consultation, we treat patients with cleft lip, jaw and palate. The spaltsprechstunde takes place in the outpatient clinic of the Clinic and Polyclinic for Oral and Maxillofacial Surgery in Liebigstraße 12, House 1 (ground floor).

The aim of the consultation is to examine all cleft patients of the University Medical Center Leipzig once a year in an interdisciplinary manner (maxillofacial surgery, orthodontic and speech therapy), and to advise on the rehabilitation of patients with cleft lip, jaw and palate in accordance with the Leipzig concept and to coordinate further treatment measures. For this purpose, patients should register for their month of birth. At the beginning, the treatment with drinking plates is carried out to make it easier for the babies to eat and to prepare the tissues for upcoming surgical procedures.

A number of treatment measures are necessary, which take place in a certain sequence of time. This currently ensures an optimal supply of the gap formation.

Orthodontic treatment in infancy up to surgical palate closure with the trinkplatt

In newborns with a cleft lip and palate, the mouth and nasal cavity are not separated. This leads to impairment of drinking function, breathing, swallowing, sound formation and facial expressions.

In order to improve these vital functions, orthodontic treatment of the infant by means of a drinking plate should be sought already in the first days of life. Furthermore, the jaw shape is also strongly changed by the gap. With the help of the drinking plate, growth can already be controlled in the first weeks of life.

Failure to treat or not to wear the plate makes it difficult at a later stage and usually only possible through additional operations to correct the malposition of the jaw, milk teeth and permanent teeth.

Function of the drinking plate

Normalization of drinking function

The normally existing separation of mouth and nose is achieved in infants with cleft lip and palate through the drinking plate. As a result, a certain negative pressure can be achieved during sucking and the food intake is improved. Often, with the help of the drinking plate and a lot of patience, even breastfeeding of the child is possible.

Normalization of the tongue position

Another important function of the palate plate is the normalization of the tongue position. The storage of the tongue in the cleft area is prevented and the actual positioning of the tongue on the palate roof is favored. The correct position of the tongue is of crucial importance, especially in language development and in the formation of the swallowing pattern.

Correct adjustment of the maxillary segments

Due to the cleavage of the jaw and palate, there is a shape deviation of the jaw arch. The jaw segments have usually collapsed, i.e. the distance between the jaw halves is too small. At the same time, the large segment in particular has swung upwards to the nose. With the help of the drinking plate, it is possible to specifically influence the growth in the area of the gap poles by hollow laying or free grinding of the plate. Force impulses of the tongue on the plate also shape the segments and influence the position of these to each other advantageously.

Stimulation of the lip muscles

The expansion of the drinking plate not only includes the cleavage area on the palate but extends into the fold of the envelope. The muscles are thereby stimulated, and the infant tries to fix the plate muscularly as far as possible in the correct position. A strengthening of the lip muscles is the desired result in order to be able to achieve the best possible result with lip closure with 4 - 5 months.

Production of a drinking plate

For the preparation of the drinking plate, it is necessary to take impressions of the upper and lower jaw already in the first days of the infant's life with a cleft lip and palate, reflecting the exact situation of the jaws. A Model measurement is carried out and thus enables accurate diagnostics for a targeted influence on the growth of the jaw segments.

The expansion of the drinking plate extends over the entire palate and over the cleft segments to the fold of the envelope. At the same time, the plate ends on the posterior palate with a palate process, which is intended to stimulate the muscles of the palate in this area and at the same time allow separation from the nose when swallowing. The drinking plate is made of two types of plastic. In the palate area, hard plastic is used to provide sufficient stability and in the area of the jaw comb and the hard-remaining core covering, soft-staying plastic is used. The latter can adapt to the jaw at body temperature and thus prevents the formation of pressure points.

Handling of the plate

The drinking plate should ideally be worn immediately after birth to improve the functions described above and to ensure rapid habituation of the infant. A constant wearing should - not only when drinking ! - be guaranteed. The infant can achieve a certain vacuum when sucking with the help of the plate and the special design in the front palate area allows the child to breastfeed. After each meal, the drinking plate should be cleaned with lukewarm water. The palate plate therapy is continued until the surgical closure of the palate in the 9th - 11th month of life. Check-ups take place every 2 weeks and every 4 weeks a new drinking plate is usually made.

Orthodontic pre-treatment for the closure of the jaw cleft

The closure of the jaw gap is necessary for the classification of the gap-limiting teeth and the stabilization of the maxillary arch. The most favorable time for the closure of the jaw gap is given when the root of the gap-limiting tooth is formed to 2/3. As a result, the tooth can be brought in line during the further breakthrough in the dental arch and stabilize the bone insert in the jaw gap through remodeling processes.

Depending on the course of the gap, the closure of the jaw gap may be necessary for the classification of the lateral incisor (Fig. 1) or for the classification of the canine tooth in the case of an existing (Fig. 2 and 3) or aplastic (not applied) lateral incisor. The closure of the cleft jaw is carried out by storing the body's own bone, which is taken from the pelvic crest during the operation. The prerequisite for this is the corresponding width of the upper jaw, since the segments of the upper jaw are fixed to each other by the storage of bone and a stretching of the upper jaw is then difficult to achieve and usually leads to the fact that the inserted bone disappears.

Fig. 2

Fig. 3

Since patients with cleft lip, jaw and palate have a narrow upper jaw due to cleft, orthodontic pre-treatment in the sense of stretching the upper jaw is usually absolutely necessary for the operation. The elongation of the upper jaw is carried out depending on the extent of the discrepancy between the upper and lower jaw with a removable plate (Fig. 4) or a fixed palate suture extension apparatus (Fig. 5).

Fig. 4	Fig. 5
Oberkieferdehnplatte	Gaumennahterweiterungsapparatur

Both devices have a screw, the activation of which stretches the upper jaw. In the case of a transverse discrepancy (width discrepancy) between the upper and lower jaw up to 4 mm, the upper jaw is stretched with the maxillary stretch plate (Fig. 4). The maxillary stretch plate is a removable brace that has a screw in the middle to widen the upper jaw.

The screw is activated every 5 days in the direction of the arrow by a quarter turn (= 0.24 mm) until the desired width of the upper jaw is reached. It should be worn day and night if possible and should only be taken out for eating, sports and cleaning. If the upper jaw is widened by more than 4 mm, this is carried out with the palate suture extension apparatus (Fig. 5). This is a fixed apparatus in which the expansion screw is activated 1 or 2 times a day (= 0.24 to 0.48 mm), depending on the instructions of the orthodontist.

With this apparatus, a strong stretching of the upper jaw can be achieved in a relatively short time. This should be done only under the strict control of the orthodontist ( every 7 - 10 days). Due to the rapid widening of the upper jaw, a tooth gap initially arises between the two middle incisors of the upper jaw (Fig. 6), which then closes partially or completely again in one of about 2 - 3 months (Fig. 7).

Fig. 7

Fig. 8

After healing of the bone stored in the cleft of the jaw (6 - 8 weeks), orthodontic further treatment is usually carried out with a multiband apparatus (fixed braces) to shape the tooth (Fig. 8).

Orthodontic pre-treatment of secondary corrections in patients with cleft lip, jaw and palate

As soon as it is foreseeable that the cleft-related deviations cannot be treated purely by orthodontics or would only be achievable by risky tooth movements, a surgical secondary correction should be considered. The decision for a secondary correction is made after breakthrough or adjustment of all permanent teeth. If a decision for a secondary correction is made at this time, there is usually an orthodontic treatment break first, since the surgical secondary corrections can only be carried out after the growth has been completed, i.e. in girls at the earliest between the ages of 17 and 18 and in boys at the earliest between the ages of 18 and 19.

Orthodontic pre-treatment for the surgical procedures begins about 1-1.5 years before the surgical procedure. The aim of the pre-treatment is to correct the compensatory position of the teeth caused by the individual anomaly in such a way that each jaw has a harmonious dental arch on its own. This usually leads to the fact that the degree of expression of the anomaly initially intensifies, i.e.B. an open bite opens further or an inverted anterior tooth overbite intensifies. This is the only way to ensure that the two jaws fit together optimally after the final surgical procedure. After the surgical procedure, orthodontic follow-up treatment is required to stabilize the result.