June, 2006
BCP “Bilateral Cleft Palate” Appliance
Dr. Shaffee Mohamed Nayaz Mohamed, BDS and M Orth, Dr. Mohamad Azhar Ibrahim Kharsa, DDS and PhD (Ortho), and Dr. Khaldoon Showmal, BDS, Cert. Orth
Abstract
In this article, the authors describe an approach for treating the “bilateral cleft of the palate” in newborn patients, by a simple removable appliance called the BCP Bilateral Cleft Palate Appliance. The appliance is a removable acrylic plane, with Y-shaped three sectors; an expander “works as an intraoral retractor to retract the prognathic segment” and a string for appliance removal. This appliance is indicated for newborn bilateral cleft palate patients, especially during the first days after birth when the infant patient suffers difficulties in nursing and feeding. The appliance reduces the cleft palate, obturates the nasopalatine fistula, and is used to retract the anteriorly protruded prognathic segment, as well. The action of this appliance is orthopedic as it works to retract the prognathic segment by activation of the “opened central expander” that works as a “retractor and contractor.”
Introduction
Patients with bilateral palate clefting often have maxillary evolution disorders and hypoplasia. The first step in such cases is to start treating the patient orthopedically in the first month of the newborn’s life. The dilemma is that orthodontist has to do his utmost to retract the prognathic segment when the patient is unable to cooperate and the difficulties in the patient’s feeding and nurturing are most difficult, especially when a nasopalatine fistula exists Figure 1. Even after cleft repair and orthodontic treatment, a severe maxillary deficiency may persist. However, the earlier the treatment is begun the less complications there are in the future.
Figure 1. a bilateral cleft palate “palatal cast”; the prognathism, nasopalatine fistula and bilateral clefts are obvious.
Discussion
The BCP “Bilateral Cleft Palate” patients traditionally undergo repair with surgical approaches. These approaches may fail because of:
- Palatal scarring
- Soft tissue memory
- Scar formation
Orthopedic traction leads to slow retraction of the surrounding tissues, allowing the body to accommodate to the new position of the maxilla (Krimmel et al), what may enhance the circumstances of orthopedic and surgical procedure of the patient during his next years of growth.
Figure 2. BCP Appliance for prognathism retraction.
BCP Appliance
The BCP Appliance (Bilateral Cleft Palate Appliance) may act as an initial treatment. Figure 2. The appliance consists of a retractor (counter-expander) in the center of an acrylic plane, split into three Y-shaped sectors. By activation of the Central “Counter-Expander” of this appliance, the anterior portion of the appliance is drawn posteriorly, reducing the prognathic segment. This appliance works as an orthopedic therapy in such patients, whereas the acrylic plane in the base of this appliance. Insures the obturation of the nasopalatine fistula, if present. The appliance is activated by following the arrow marked on the screw Figure 3. The activation causes the anterior portion of the appliance to turn gradually back.
Figure 3. Activation of BCP Appliance, the left photo shows the appliance before its activation, whereas the right one shows it after activation. Notice the “posterior-traction” of the anterior part of the appliance in the right photo, after the activation. Figure 4.
Figure 4. BCP Appliance: Internal view
The activation average is ¼ turn per 72 hours, which insures regular prognathic segment retraction of almost 2mm. per month.
It is recommended that the appliance be highly polished on all surfaces to avoid any traumatic potential effect to the infant Figure 4. The string enables the patient’s parents to easily remove and withdraw the appliance. Figure 5.
Figure 5. BCP Appliance has a string that facilitates its withdrawal from the infant’s mouth
Conclusion
This appliance is a simple initial treatment of bilateral cleft palate in newborn patients. Such cases are really challenging to the team of orthodontists, orthopedists and maxillo-facial surgeons, as well. However, it is recommended that each case be studied, treated and approached as a unique entity. The BCP Appliance is NOT a panacea for all bilateral cleft palate cases, and practitioners are advised to take into account case severity, patient’s age, existence of systemic diseases or syndromes and patient’s parents’ cooperation and comprehension. In addition, the average degree of activation should be modified for each case in discussion with the entire team. Finally, cleft lip and palate cases need to have a high degree of teamwork to provide the best therapy for patients.
References
1. Bell WH: Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia: WB Saunders Co; 1992.
2. Graber TM, Vanarsdall RL: Orthodontics: Current Principles and Techniques. Year Book Medical Pub; 2000.
3. Epker BN, Stella JP, Fish LC: Dentofacial Deformities: Integrated Orthodontic & Surgical Correction. Year Book Medical Pub; 1998.
4. Handelman CS. The anterior alveolus: its importance in limiting orthodontic treatment and its influence on the occurrence of iatrogenic sequelae. Angle Orthod. 1996; 66:95–110.
5. Proffit WR. Contemporary Orthodontics. 2nd ed. St Louis, MO: CV Mosby; 1996:2–16.
6. Subtelny JD. The soft tissue profile, growth and treatment changes. Angle Orthod. 1961; 31:105–122.
Contributed by:
Dr. Shaffee Mohamed Nayaz Mohamed, BDS, M Orth
Specialist in Orthodontics, KFH, Madina, Saudi Arabia WFO Fellow
Dr. Mohamad Azhar Ibrahim Kharsa, DDS, PhD (Ortho)
Senior Registrar Orthodontist, KFH, Madina, Saudi Arabia ASLMS Scientist Fellow, WFO Fellow, AOS Fellow
Dr. Khaldoon Showmal, BDS, Cert. Orth
Orthodontist, KFH, Madina, Saudi Arabia.
