March, 2002
Cleft Palate Molding Technique
Dr. Barry Grayson and Dr. Court Cutting
After a healthy nine-month pregnancy while living in Spain, Annette and Valdemar felt like the luckiest couple on earth. But the joy they shared turned to anguish in the delivery room when they discovered that their baby girl, Natasha, had a facial deformity-bilateral cleft lip and palate-appearing as two wide gaps extending from the roof of her mouth through her lip and nose.
Figure.
In the midst of their shock and grief, they struggled to sort out their daughter’s treatment needs. By the time Natasha was five weeks old, they had scheduled the first of many surgeries-complex procedures that were expected to span her childhood and adolescence.
A Big Move
Then the family received a phone call from a family friend. They had no idea that the conversation would change Natasha’ s young life. The concerned friend was a 27 -year-old man who wanted Natasha to avoid the anguish he had endured, having undergone more than 20 operations to correct his cleft lip and palate.
The friend begged them to contact Court Cutting, MD, a plastic surgeon at New York University Medical Center, where a new corrective technique had been developed that could dramatically reduce Natasha’s need for surgery. Best of all, the new technique promised to provide Natasha with excellent cosmetic results long before starting school, sparing her the teasing and isolation children with facial deformities often bear.
A New Philosophy: Treat Early in Life
“It wasn’t enough to turn out good-looking l8-year-olds,” says Dr. Cutting. “My goal is to get kids looking good while they’re still infants, so they will not have to go through childhood with major facial deformities.”
“In the old days, surgeons had to operate in stages,” Dr. Cutting recalls. “The first procedure pulled the lip together; another one was for the nose, then another-often including a bone graft-would close the palate, and so on. Today we put our efforts into the child’s first operation, so we can get a normal looking kid in one procedure.”
Molding
Figure. Dr. Grayson (left) and Dr. Cutting (right)
To accomplish this goal, Dr. Cutting teamed up with orthodontist Barry Grayson, DDS, who works with infants for several months prior to surgery to reduce the severity of the cleft and deformity of the nose.
During the first two weeks of life, using a technique called nasal and alveolar molding, Dr. Grayson inserts a custom-fitted denture (molding plate) in the baby’s mouth. Every week, he carefully adjusts this molding plate to gradually reshape the roof of the mouth and gum pads. The plate causes the bones of the upper jaw to grow toward each other and the space between the gum pads to narrow. It also separates the oral and nasal cavities, which are open to each other in babies with cleft lip and palate.
Reshaping Dr. Grayson found a way to use the molding plate to correct a deformity of the nose commonly associated with clefts. “Most children with cleft lip and palate have collapsed nasal cartilages that cause a noticeable flattening of the nose,” says Dr. Grayson. “Children endured teasing about their misshapen nose even after the cleft was repaired. We can now reshape a baby’s nose without surgery, especially during the first few months of life, when the nasal structures are highly malleable.”
To accomplish this, Dr. Grayson developed a nasal extension that rises up from the forward edge of the molding plate and lifts the nose and nasal cartilages into place. Dr. Grayson’s adaptation also helps children with severe clefts on both sides of the mouth who are missing all or most of the columella-the structure above the lip that separates the left and right nostrils. Dr. Grayson’s technique enhances the columella, eliminating the need for extensive surgical reconstruction.
Figure. Molding plate with nasal extension
Figure. Molding plae in place
Ready for Surgery
“Dr. Grayson’s presurgical work makes my job easier and allows me to accomplish more,” says Dr. Cutting. ” After the molding, the gum pads are lined up instead of wide apart, so I can usually repair the gums without a bone graft. In children with bilateral clefts, the nose can be repaired at the same time. The net result is that in one operation, I can repair the lip, gums, and nose.”
“We’re also getting improved results in closing the palate,” Dr. Cutting adds, “using a technique of dissecting out misplaced muscles in the soft palate that would otherwise interfere with complete closure. The usual success rate in achieving a fully closed palate is about 80%; ours is 96%. A more complete closure has dramatically improved the ability of children with cleft lip to speak more clearly.”
Orthodontics and Surgery: Melding Two Traditions
The success of Drs. Cutting and Grayson’s approach requires close collaboration between surgeon and orthodontist. “Orthodontists are very patient,” explains Dr. Cutting. “It is interesting that Dr. Grayson’s hobby is bonsai. He’ll take a very young tree and hang a small weight on one branch and it will slowly bend; or he may use a wire to gently change the direction of growth of a branch. Little by little, with small forces, you can completely shape a miniature tree.
“Orthodontists routinely do something very similar in correcting the teeth with braces. With a little bit of force applied over a long period of time, the braces manage to move a child’s teeth through bone into a new pattern,” says Dr. Cutting. “Surgeons, in contrast, like to get in there and ‘fix it now. ‘ We’re bringing the best of these two different traditions together and getting wonderful results.”
Figure.
The Truest Measure of Success
At 1 1/2 years old, Natasha is confident and sure of herself. “The months she had to wear the molding plate were sometimes hard,” reflects the mother. “But as much as I hated to see my baby cry, it’s better than having her come home from school in tears later on. We’re sure we made the right decision. We look at Natasha’s face and we know we couldn’t have gotten this result anywhere else in the world.”
Contributed by:
Dr. Barry Grayson and Dr. Court Cutting
