Pre-directional appliance: A new approach to correct shifted premaxilla in bilateral cleft cases

Abstract

Management of bilateral cleft lip and palate cases is a challenging task, and if the premaxilla is shifted to either side, it poses a problem for the surgeon to operate and also for the orthodontist to do the orthodontic alignment. The aim of this study was to reposition the shifted premaxilla for better retraction with presurgical infant orthopedics, thus reducing the tissue tension and further scarring which have detrimental effects on maxillary growth. The innovative technique with pre-directional (PD) appliance is easy to fabricate and use and works in this direction. Acrylic, springs, permasoft liner, elastics, retentive tapes. Previous approach for the shifted premaxilla was more focused on the surgical correction. In adults, surgery with osteotomy is the only option, with its own limitations and disadvantages, in repositioning the shifted premaxilla. Thus, PD appliance aids to correct the shifted premaxilla in presurgical molding stage. The premaxilla was thus shifted 5.5 mm to the left side, with premaxilla in facial symmetry, with the PD appliance. Presurgical orthopedics with PD appliance is worth in infants with shifted premaxilla in bilateral clefts cases.

The First-Year Follow-Up of a Cleft Lip and Palate Patient Treated With Nasoalveolar Molding (NAM)

“…The practice of NAM offers some significant benefits to the patient. The objectives of NAM, as described by many authors (1)(2)(3)(4)7,12,14,16){Punga, 2013 #164} are to provide symmetry to severely deformed nasal cartilages, to achieve projection of the flattened nasal tip, to provide nonsurgical elongation of the columella, to improve alignment of the alveolar ridges, and to reduce the distance between the cleft lip segments. NAM can be applied to the entire range of cleft deformities, including complete clefts without an intact nasal floor (5) in corroboration with our case.…”

“…a complementary technique to NAM therapy. Another alternative to the treatment is pre-directional appliance (16) which is the modification of Grayson's pre-surgical nasoalveolar molding. This technique has presented excellent results in a case report that the pre-maxilla was shifted to the left side by 5.5 mm in one patient with bilateral fissure and projected pre-maxilla asymmetry (16).…”

“…Another alternative to the treatment is pre-directional appliance (16) which is the modification of Grayson's pre-surgical nasoalveolar molding. This technique has presented excellent results in a case report that the pre-maxilla was shifted to the left side by 5.5 mm in one patient with bilateral fissure and projected pre-maxilla asymmetry (16). This finding is compatible with our study, which also showed success in the centralization of the maxilla through the approximation of the segments, with a 7 mm retraction of the pre-maxilla and was displaced to the right side in 11 mm.…”

Nasoalveolar molding: A review

“…Active maxillary appliances use controlled forces to move the alveolar cleft segments in a predetermined manner, but passive appliances act only as a hinge on which the forces produced by surgical lip closure, shape and mold the alveolar segments in an expected manner. [16][17][18] …”