A VIABLE SOLUTION TO IDEALIZED CLEFT PALATE TREATMENT (DEVELOPING AND MAINTAINING BILATERAL NASALIZED BREATHING FROM INITIAL SURGERY ON)
Talmant** has shown that good long term Maxillofacial growth begins with the development of bilateral nasalized breathing as a result of an initial, unique cleft side intranasal surgery with follow-up designed to promote bilateral nasalized breathing from the get-go and revised as necessary to maintain this most important breathing function throughout life. At age four orthopedic orthodontics, designed to broaden the width of the nasomaxillary complex and further improve bilateral nasalized breathing is introduced, followed by an alveolar bone graft to stabilize the correction. An active orthopedic/orthodontic device is inserted and held in place until the first molars erupt. At this age orthodontic treatment may be initiated to align the mal-posed dentition and adequate space made available to replace the congenitally missing cleft-side lateral incisor.
Why is this important?
- The width of the nasal cavity is determined by the width of maxilla and this dimension is most critical at the canine level. The pyriform nasal aperture is located midway between these two canine positions. The width of the pyriform aperture is a key element determining one’s ability to breathe well through the nose. The maxillary canines measurement should be, at least, six millimeters wider than the mandibular canine distance. It may be necessary to expand the mandibular dimension if the lower arch is constricted.
- Canine replacement of the congenitally missing cleft-side lateral incisor is a common practice in some cleft treatment protocols (NAM being one). On the surface, this seems a very financial solution to a dental problem. However, bilateral nasalized breathing is a much more important medical problem and canine replacement, often performed as a financial rationale designed to avoid a bone graft, implant and lateral incisor crown is a bad choice. This is a negative financial rationale when compared to the more important health issue from which the patient may suffer long term, untoward problems.
- Esthetically, canine replacement disturbs anterior dental balance and functionally, the canine (when in it’s proper anatomic position) is the cornerstone of a healthy functional occlusion. Absence of its critical role in functional occlusion may result in untoward dental problems in the future.
Cleft Palate Teams might consider a research program to evaluate and report on the effects of their treatment protocol long term.
- Document bilateral nasalized breathing beginning at an age when the child is able and willing to cooperate by closing off one nasal opening at a time and assessing airflow through the open nasal airway. Later use of Rhinomanometry as the vehicle to measure and document early and long term breathing capacity should be the standard measuring device.
- Frequency of missing or damaged maxillary teeth if you are using the* Latham, NAM or other pre-surgical treatments, such as, taping and a “nasal elevator”.
- Frequency of impacted maxillary* cuspids and supernumerary teeth.
- Nasal-maxillary growth* evaluated with photographic or radiological reports, over time.
- Reports of the necessary use of orthopedic face mask, LA fort osteotomy or distraction osteogenesis to manage the naso-maxillary skeletal development.*
- Early surgical alveolar bone grafting with or without gingiva-periosteo-plasty and BMP*
- 7. Frequency of canine* replacement protocol.
- Routine measurement width of maxillary canine to canine dimension relative to lower canine dimension.
What is so important about bilateral nasalized breathing in children, adults and, more specifically, cleft palate children?
It is well known that when there is a battle between muscle and bone, muscle always wins. it’s not well appreciated that when there is a battle between the airway and muscle the AIRWAY always wins!
This is of particular importance in growing children.
Human beings were designed to breathe through their noses. Since breathing is essential for life, if you cannot breathe through you nose you must breathe through your mouth. When you can breathe well through both sides of your nose the tongue will rest in the roof of your mouth where it was designed to rest (unless you have large tonsils or adenoids blocking the posterior airway). If you have large tonsils or adenoids blocking the flow of air through the posterior nasal airway and pharyngeal pathway, the mouth must open to breathe and the tongue must protrude to open the pharyngeal airway (large tonsils, adenoids) to allow you to breathe. The tongue is a powerful muscle. When parked in the roof of your mouth (where it was designed to fit when you are breathing and the jaws at rest). For good nasomaxillary growth this “normal” tongue position is designed to apply a forward pressure to the maxilla stimulating naso-maxillary growth while resisting the compression of the cheek muscles to collapse the posterior aspect of the maxilla. When not parked in the roof of the mouth the tongue creates all sorts of dentofacial problems (crooked teeth, open bite, cross bite, abnormal jaw growth, protruding upper front teeth etc. This is ALL due to a forced adaptation to our need to breathe.
How does this apply to cleft palate children who cannot breathe through their nose?
The really big problem for these children is the upper jaw has no motivation to grow forward or wider when the tongue is out of control. The nasomaxillary complex is locked in a trap of lack of poor growth stimulation from the tongue which, if not resolved while they a very young condemns them to a long and difficult life of jaw surgery, orthodontic treatment, speech therapy, psychotherapy and multiple other related treatment.
So why is so little attention paid to a vital bilateral nasal airway?
I do not have a clue accept to believe there has not been enough attention paid to this important aspect by the cleft palate teams.
This appears to be the situation. Interested Cleft Palate Surgeons must commit to learn a technique designed to successfully create a fully functional bilateral nasalized breathing protocol for all their cleft lip/cleft palate patients and their focus remain on this form of breathing throughout the life of these children. Otherwise we will continue to see mediocre to very poor long term treatment results still believing we provide the best cleft palate treatment on the planet.
If indeed, bilateral nasalized breathing from the initial surgery through adulthood is the missing link in idealizing long term facial development in cleft lip cleft palate children it would seem wise for cleft palate teams, desiring to learn and implement a protocol that will routinely promote well developed nasomaxillary growth, consider modifying their treatment protocol to focus on idealizing bilateral nasalized breathing as described by Tamant**. The focus must be on outstanding long term results achieved in the most precocious, thought provoking manner that every cleft palate team can provide routinely.
**Talmant, Jean Claude
Evolution of the Functional repair concept for cleft lip cleft palate patients
Indian J. Plast Surg 2006
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