Cleft / Craniofacial / Distraction

Our teams are highly experienced and recognized for their expertise in treating cleft lip and palate.  Dr. Jay Neugarten serves as the oral and maxillofacial surgeon for the New York Presbyterian Weill Cornell Medical Center craniofacial team in New York city. Dr. Stephan Sachs and Stephanie Drew are highly involved with the Hagedorn Cleft Palate and Craniofacial Center and Dr. Ruggiero is strongly involved with the Stonybrook Cleft Team in Eastern Long Island.

Perhaps no conditions other than cleft lip and palate and oral cancer assemble teams of dentists and physicians intensely focused on treatment and rehabilitations. The oral and maxillofacial surgeon's role is often pivotal especially in the 20-year term of care for the child born with a cleft lip and palate deformity (CLPD). Issues of basic orofacial functions of mastication, respiration and communication overlay human considerations of self-esteem and image. From the moment of birth the child with a CLPD is special and challenged. Early issues concern parent and family acceptance and insuring basic life functions. While not generally a part of the immediate surgical unit, the OMFS often provides surgical consultation, educational and emotional support for the family. A clear picture must be painted of the treatment that will unfold over the next two decades. Realistic optimism is the watchword. Indeed, today there is every reason to anticipate an outcome that will result in a balanced, functional and esthetic face. The following are services that the OMS performs:

• Palatal Prosthesis
• Bone Graft
• Dental Implant
• Orthognathic Surgery
• Distraction/Osteogenesis

Reconstruction of the alveolar cleft and closure of concomitant oral nasal fistulae are the primary responsibilities of the oral and maxillofacial surgeon. There are several clinical indications to repair this defect. Placing bone into this site provides a substrate for the eruption of the proximate teeth. Separating the mouth from the nose eliminates the embarrassing and unpleasant flow of fluids from the mouth to the nose and visa versa Reconstruction of the nasal aperture provides support for the alar base and a solid foundation for future nasal reconstruction. The effect of anterior oral nasal communications on speech is not clear. However, there is no doubt that large palatally placed defects produce a hypernasal resonance that improves after surgical closure. Finally, patient and family perceive a great psychological lift when the left is finally completely eliminated. When present, the alveolar cleft is a funnel-shaped defect that extends from the nasal aperture to the alveolar crest (Figure 3). Typically, it is lined with an epithelial tract that extends from the nasal cavity to the mouth. Often this soft tissue fistula extends into the labial vestibule and onto and through the hard palate. Invariably, the bony defect is considerably wider than the clinical examination suggests. The goal at surgery is to partition the mouth and nose. Flaps are elevated, which permits direct closure of the nasal mucosa, and allows placement of the bone graft and complete closure with a "water tight" layer of oral-attached mucosa. While various homografts and alloplasts have been used for this purpose, the material of choice is autologous bone. This graft is harvested from the ileum, calvaria, mandible, tibia and rib. In our experience hip grafts are performed in over 90 perfect of cases. The timing for alveolar cleft reconstruction is both critical and controversial. Some teams advocate early grafting (before age two). Typically that approach involves onlay grafts of rib. This technique often falls short in bone stock and is reported to have a negative effect on facial growth. The mainstream thinking today is that this graft should be performed between the ages of six and nine. The decision regarding when to graft depends on the regional dental development. When a useful lateral incisor is present or a central incisor may be jeopardized if it erupts or is orthodontically guided into the cleft site, the procedure is done early (age six). When the lateral incisor is absent then the general rule is to allow the cuspid root to develop 50 percent of its root length and then graft. Prior to grafting, the field should receive a dental prophylaxis. Late grafting is performed when the dentition has already erupted. This represents a failure in the system. As time passes, the interproximal bone on the cleft side is lost, creating significant periodontal bone loss and early tooth loss. In addition, the lining mucosa becomes hyperplastic and difficult to mobilize and suture. After grafting. The orthodontist develops proper arch form and monitors the eruption of teeth adjacent to the grafted cleft. Occasionally the cuspid requires surgical exposure and orthodontic traction, and from time to time, attached tissue grafting is indicted (X-ray series).

In about 50 percent of cases there is a congenitally absent lateral incisor. When this occurs there are several treatment alternatives. The first is to allow the erupting cuspid to lateralize; and when orthodontics is completed, this tooth can undergo odontoplasty. Another approach is to allow the cuspid to erupt into its proper anatomic position while maintaining the lateral edentulous position. When growth is completed, an osseointegrated implant can be placed. This is a technique that was introduced by Frank Verdi and is, perhaps, the favored approach, as it maintains proper arch form and tooth mass, thus providing support for the overlying facial soft tissues. Care must be taken that there is adequate projection of the graft. If not, lateral bony augmentation must be performed prior to implant placement. A final approach is to construct a fixed anterior dental bridge. This requires preparation of healthy teeth in young individuals and is the least preferred solution.

Deficient midfacial growth is the hallmark of CLPD. While sometimes mild, growth deficiency in all planes of space characterizes these patients. At times, mandibular growth is excessive. Often, however, a pseudo prognathic appearance results from the overclosed, counterclockwise-rotated position of the mandible occluding with a vertically deficient maxilla. As discussed earlier, this hypoplasia is only minimally related to the intervention and secondary scar formation. Indeed, a study of totally unrelated clefts in Sri Lanka demonstrated wide-open clefts in patients with normal facial proportion and development. The approach to this problem is multifaceted and is dependent on the degree of deformity and the age of the patient. In the young patient, five to ten years old, the transverse and anterior posterior deficiency of the maxilla can be approached with a nonsurgical orthopedic widening and protraction of the midface. While still a subject of study, this approach seems to have some control over excessive mandibular growth, which would magnify the jaw-to-jaw discrepancy. In a cooperative patient this technique is exciting and dramatic. Another opportunity to treat maxillary horizontal deficiency presents itself in the early adolescent phase. This approach involves surgically assisted osteodistraction. The final approach involves surgically assisted osteodistraction. The final approach involves formal orthognathic surgery. This is indicated in approximately 25 percent of CLPD patients. Formal osteotomy for advancement is routinely and safely performed. At the time of this surgery, residual fistulas and additional bone grafting can be performed. In a review of 300 CLPD patients operated on at our center, 15 percent required orthognathic surgery. More than half of the cases required both upper and lower jaw corrections. It appears that the number of double jaw cases is declining, which may be a consequence of aggressive growth enhancement by the orthodontists on our team with a secondary containment of compensatory mandibular excess.