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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2011  |  Volume : 29  |  Issue : 6  |  Page : 39-43

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

1 Department of Orthodontics, Sharad Pawar Dental College and Hospital, Sawangi (M), Wardha, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Sawangi (M), Wardha, Maharashtra, India
3 Department of Prosthodontia, Sharad Pawar Dental College and Hospital, Sawangi (M), Wardha, Maharashtra, India

Date of Web Publication12-Dec-2011

Correspondence Address:
P S Daigavane
Sr. Lecturer, Department of Orthodontics, SPDC, Sawangi (M), Maharashtra
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Source of Support: Grant availability from Smile Train Project America, Conflict of Interest: None

DOI: 10.4103/0970-4388.90739

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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.

Keywords: Bilateral cleft, coil spring, permasoft, PD appliance

How to cite this article:
Daigavane P S, Hazarey P, Vasant R, Thombare R. Pre-directional appliance: A new approach to correct shifted premaxilla in bilateral cleft cases. J Indian Soc Pedod Prev Dent 2011;29, Suppl S1:39-43

How to cite this URL:
Daigavane P S, Hazarey P, Vasant R, Thombare R. Pre-directional appliance: A new approach to correct shifted premaxilla in bilateral cleft cases. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2023 Jan 29];29, Suppl S1:39-43. Available from: http://www.jisppd.com/text.asp?2011/29/6/39/90739

   Introduction Top

Cleft lip palate is a common congenital anomaly, with a prevalence rate of 1.22/1000 for non-syndromic cleft lip and palate. [1] Large defect in unilateral and unequal defects in bilateral cases pose a problem due to the distance the tissue has to be mobilized to unite.

Often, the surgeon requires two operative sessions (right and left) of lip repair in severely displaced premaxilla. In bilateral cases, if patient does not report for the second side lip surgery within 4 months, the premaxilla may remain shifted or may worsen due to tissue tension, thus posing a problem for lip closure. [2],[3] Lip closure is problematic either due to erupted teeth or due to transverse maxillary growth which can further worsen the defect. Minor cleft defects can benefit from surgical procedures alone, but severe defects or shifted premaxilla require presurgical orthopedics. [4],[5]

Various invasive and non-invasive techniques have been developed worldwide to correct, align and retract the premaxilla.

   Case Report Top

A male infant of 20days was seen with complete bilateral cleft lip and palate, with premaxilla shifted to right [Figure 1]a-c. After complete evaluation by Cleft Team, it was decided to reposition the premaxilla.
Figure 1: (a)Infant with complete bilateral cleft with premaxilla shifted to right
Figure 1b: Submentovertex view
Figure 1c: Pretreatment cast

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Method of fabrication of Pre-directional appliance

Pre-directional (PD) appliance, fabricated in heat-cure resin, is a modification of Grayson's presurgical naso alveolar molding (PNAM) appliance. [6] To make the anterior segment flexible, the appliance was modified by marking two parallel vertical lines and a transverse cut was given in the anterior segment of the appliance to separate it from the posterior segment. 1 mm acrylic was reduced from edges of both the segments. With the straight fissure bur, cuts were made on the vertical lines [Figure 2]a. Both these segments were repositioned on the cast; two 8-mm NITI coil springs were placed in the vertical cuts and rejoined with self-cure resin [Figure 2]b and c.
Figure 2: (a)Anterior segment separated from the posterior with a transverse cut, with two vertical cuts in both the parts
Figure 2b: Appliance connected with NITI coil spring
Figure 2c: Schematic diagram showing appliance with coil springs and application of permasoft

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Permasoft was applied on the inner surface of the anterior segment on the right side to push the premaxilla to left side, and also, on the medial aspect of the posterior alveolar segment for expansion [Figure 2]c. The appliance was retained with tapes (3M micropore surgi tape) and red elastics. The elastic force on both sides differed; on the right side it was kept inactive for appliance stability, while on the left side it was stretched double its diameter, exerting a force of 6 ounces [7] on the premaxilla [Figure 3]. The patient was evaluated weekly for correction.
Figure 3: PD appliance with different forces of red elastics

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   Results Top

On evaluation after 2 months 20 days, the premaxilla was shifted to the left side by 5.5 mm [Figure 4]a and b, the premaxilla and prolabium were positioned in the middle, facial symmetry was observed with both the nostrils equally visible [Figure 4]c and d. At this stage, the PD appliance was replaced by Grayson's PNAM appliance. Nasal stents were added for molding. The appliance was retained with elastic and tapes. For prolabium lengthening, a vertical tape was overlapped on two red elastics (knotted with eachother) placed on retentive buttons [Figure 5]. During suckling, stent forces the nose dome upward and forward, while the lip tape forces the prolabium downward, thus lengthening the collumella.
Figure 4: (a)Premaxillary correction (on cast)
Figure 4b: Schematic diagram showing premaxillary correction
Figure 4c: Prolabium in facial symmetry
Figure 4d: Submentovertex view

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Figure 5: Presurgical nasoalveolar molding appliance

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It was observed that after 2½ months, the premaxilla was retracted 4.5 mm uniformly with successful nasal molding. At 6½-7 months of age, both side lips were operated in the same operative session with Millard and Nordoff technique [Figure 6]a and b. On evaluation, at the age of 1 year 3 months, it was observed that facial symmetry, columellar lengthening, and nasal molding were maintained [Figure 7].
Figure 6: (a, b) Frontal. submentovertex view (post lip surgery)

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Figure 7: After 1 year 3 months

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   Discussion Top

Treatment of bilateral cleft cases poses a great challenge to all professionals related. It becomes near to impossible to treat shifted and rotated premaxilla. The surgical techniques are very invasive, require complete sedation and repeated procedures.

Presurgical orthopedics reduces operative sessions, corrects premaxilla toward anatomical position, improves esthetics and facial symmetry, decreases tissue tension during surgery and allows healed soft tissue to rest against normal bony anatomy. [3]

Few workers [8],[9] used preoperative methods with active appliances in which integral springs and screws, were used to reposition the cleft segments. These were retained in mouth by pins, drilled into the maxilla to move the cleft segments. Some studies [10],[11] have mentioned the use of elastic chain for premaxillary repositioning and alignment of alveolar segments and screw mechanism for expansion of the maxillary and retraction of premaxillary segments. All these are invasive methods.

Passive methods to align the protruding premaxilla in bilateral cleft, such as intraoral Hotz appliance and an extraoral appliance consisting of band on head and elastics, were also used. [12] Thermoplastic resin was also used to correct shifted premaxilla. [2] These designs are complex and encounter difficulties and patient incompliance.

This case report shows the use of PD appliance which was fabricated to treat the shifted premaxilla, with the help of anterior segment made flexible by NITI springs.

As this appliance could reposition the premaxilla within short duration, it was possible to do nasal molding utilizing the elasticity of the nasal cartilage. Alveolar segments were expanded to 1.5 mm, premaxilla was retracted symmetrically by 4.5 mm, facial esthetic was improved, prolabium was lengthened to 6 mm, no tissue tension was observed during surgery and satisfactory lip repair was accomplished in one stage [Figure 6]a and b. Studies have reported lip, nose and alveolus repair in one stage following PNAM technique. [13]


The appliance is inexpensive, easy to fabricate, does not require complicated laboratory techniques and gives quick results.

The rate of bone healing is inversely proportional to size of defect; thus, presurgical orthopedics favors bone formation. Presurgical orthopedics with PD appliance is worth in infants with shifted premaxilla in bilateral clefts.

   Acknowledgments Top

We acknowledge the Ethical Committee of Datta Meghe University of Medical Sciences, the Smile Train, Dr. S. Jaju (Plastic Surgeon) and the parents of cleft palate children.

   References Top

1.Cooper ME, Ratay JS, Marazita ML. Asian Oral - Facial Cleft Birth Prevelance. Cleft Palate Craniofac J 2006;43:580-9.  Back to cited text no. 1
2.Wang RR. Thermoplastic resin used to modify an alveolar orthopedic prosthesis in a patient with cleft lip before cheiloplasty: A clinical report. J Prosthet Dent 1998;79:13-6.   Back to cited text no. 2
3.Rosenstein SW, Jacobson BN. Early maxillary orthopedics: A sequence of events. Cleft Palate J 1967;4:197-204  Back to cited text no. 3
4.Albery EH, Hathorn IS, Pigott IW. Cleft lip and palate a team approach. 1 st ed. Great Britan: Wright printed; 1986.  Back to cited text no. 4
5.Berkowitz S. Cleft lip palate management and diagnosis. 2 nd ed. San Diego, London: Springer; 1996. p. 23-33.  Back to cited text no. 5
6.Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical Nasoalveolar Molding in Infants with Cleft Lip and Palate. Cleft Palate Craniofac J 1999;36:486-98.  Back to cited text no. 6
7.Langlade M. Optimization of Orthodontic Elastics. 1 st ed. GAC international Inc, Paris. 2000.  Back to cited text no. 7
8.McNeil C. Orthodontic procedures in treatment of congenital cleft palate. Dent Rec 1950;70:126. (Cited from - Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical Nasoalveolar Molding in Infants with Cleft Lip and Palate. Cleft Palate Craniofac J 1999;36:486-98).  Back to cited text no. 8
9.Latham RA, Kusy RP, Georgiade NG. An extraorally activated expansion appliance for cleft palate infants. Cleft Palate J 1976;13:235-61.   Back to cited text no. 9
10.Bitter K. Latham's appliance for presurgical repositioning of the protruded premaxilla in bilateral cleft lip and palate. J Craniomaxillofac Surg 1992;20:494-7.  Back to cited text no. 10
11.Georgiade NG, Latham RA. Maxillary arch alignment in the bilateral cleft lip and palate infant, using the pinned coaxial screw appliance. Plast Reconstr Surg 1975;56:52-60.  Back to cited text no. 11
12.Hotz M. Pre and early postoperative growth guidance in the cleft lip and palate cases by Maxillary orthopedics (an alternative procedure to primary bone grafting). Cleft palate J 1969;6:368-72.  Back to cited text no. 12
13.Cutting CB, Grayson BH, Santiago PE, Brecht LE. Presurgical Columellar elongation and Primary Retrograde Nasal Reconstruction in one - stage Bilateral cleft lip and nose repair. J Plast Reconstr Surg 1998;101:630-9.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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