Pre: Surgical orthopedic pre-maxillary alignment in bilateral cleft lip and palate patient
A 5-year-old male patient was referred to our department with parents complaining of difficulty in eating and also unhappy with the appearance of the child. Mother had a full term, normal uneventful pregnancy, and medical and dental history was non-contributory; family history revealed that parents were not of consanguineous marriage.\nExtra-oral and intra-oral examination revealed complete bilateral cleft lip and palate with pre-maxilla protruded and deviated to the right side from the midline. Presence of primary dentition is seen; in the pre-maxilla, 3 anterior teeth were seen with missing primary lateral incisor on left side.\nConsultation with the oral and maxillo-facial surgeon inferred that there were chances of failure of surgical lip closure due to tension if surgical procedure is carried out without retrusion of the protruding pre-maxillary segment. Hence, we planned for a custom made appliance that was used to retract the pre-maxillary segment in antero-posterior plane.\nInitial impression of the cleft lip and palate was made using fast setting alginate impression material. All the necessary precautions were taken during the impression procedure. A primary cast was prepared using dental stone, and undercuts were blocked. We prepared a custom-made orthopedic plate on the dental stone model incorporating an acrylic bulb covering the pre-maxilla. The pre-maxillary component of the acrylic was attached to the posterior component of the orthopedic plate by the use of two U loops of 21 gauges (0.7 mm) stainless steel wire, one on each side. The plate was made of self-cure acrylic resin of 2-3 mm thickness [].\nThis innovative self-retentive plate comprised of two parts. The posterior part, palatal plate, covered the palatal defect and served as a passive obturator, it also covered canine and molar teeth completely in the posterior palatal halves on both the sides, which aided in anchorage, thus in retention of the appliance. The anterior part of the plate extended as a bulb around the protruded and deviated pre-maxilla. The acrylic bulb acted as an active part to align and retract the malposed pre-maxillary segment.\nThe appliance was fabricated, finished and polished, checked for any rough surfaces and then delivered to the patient []. On delivery appointment, parents were advised, instructed, and demonstrated for the removal and placement of the appliance and it's cleaning. Parents were advised to ensure that the appliance is in place all the time.\nA twice-weekly activation of the appliance was done by compressing the u loops about 1mm on either sides of the appliance. It was made sure that the pre-maxilla was not deviated inferiorly to the maxillary arch. Measurements were taken and tabulated at each appointment by recording fixed hard and soft tissue reference points to check the activation and movement of the pre-maxilla [].\nConsidering deciduous 2nd molar to be constant in its position, the soft tissue reference points were taken from the soft tissue distal to 2nd primary molar to the prolabium to check the movement of soft tissue along with the pre-maxilla. The hard tissue reference points were taken from\nDistal end of the 2nd primary molar to the distal end of lateral incisor on right and central incisor on left side, respectively, and From distal end of primary 2nd molar to midline and Mesial end of canine to distal end of lateral incisor on right and central incisor on left side, respectively, in pre-maxilla. This helped to know the movement of the pre-maxilla and closure of the alveolar cleft, respectively.\nOver the treatment period, there was approximation and contact of the alveolar portion of the pre-maxilla and palatal vault on left side, thus the further movement of pre-maxilla is restricted []. The movement achieved was satisfactory and the patient was referred to department of oral and maxillo-facial surgery for further treatment []. Primary cheiloplasty and palatoplasty was done. Healing was uneventful []. Patient was planned for further follow up treatments.\nThe treatment was carried over a period of 3 months. During this period, incrementally force was applied and measurements were recorded []. Five mm of posterior movement of the pre-maxilla was achieved on the right side and 6 mm on left side, respectively, in antero-posterior plane.