Facemask Therapy in Unilateral Cleft Lip and Palate Patients.

BACKGROUND: Midfacial hypoplasia is a common feature in patients with combined cleft lip and palate. The current study was done to assess the effect of facemask (FM) therapy in patients with unilateral cleft palate.
MATERIALS AND METHODS: A total of 16 patients with unilateral complete cleft lip and palate were treated with maxillary transversal discrepancy with rapid maxillary expansion (RME) followed by FM therapy. After the completion of the RME treatment, the same appliance was used for protraction. Radiographs were taken after removing the RME appliance (T1) and at the end of the FM treatment after removing the appliance (T2).
RESULTS: There were 5 males and 11 females. SNA was 73.1° and 79.4°, SNB was 75.2° and 72.4°, ANB was -3.21° and 2.90°, SN-PP was 11.2° and 10.4°, Co-A was 84.3 mm and 87.5 mm, A-HR was 55.2 mm and 57.8 mm, A-VR was 62.4 mm and 64.7 mm, and SN-MP was 38.2 mm and 41.5 mm before and after treatment, respectively.
CONCLUSION: FM proved to be beneficial in causing significant improvement in patients having combined cleft lip and palate. Copyright:

INTRODUCTION

In pediatric patients suffering from cleft lip and cleft palate, midfacial hypoplasia remains a frequent feature.[1] In the field of orthodontics and dentofacial orthopedics, treatment planning of retrognathic maxillary arch along with the presence of retroinclined anterior teeth is a significant problem.[2] The commencement of concept and advancements in facemask therapy had given rise to new horizons, thereby creating new potentials for orthodontic therapy in patients having cleft lip and palate. Compared to previous trials conducted by pioneer researchers, where anteriorly focused extraoral forces were obtained from chin caps, facemask protocol appears to have significantly enhanced control and a wider variety of force submissions.[3]

In cleft patients, aging and associated growth usually result in growth deficiency of the midfacial region. Skeletal incongruities between both the dental arches commonly generate cross-bites. Once created, these are the most tedious part of the therapy protocol for a clinician to manage.[4] For correction of transverse discrepancies in such patients, orthodontists may employ rapid maxillary expansion (RME), and further, for rectifying sagittal discrepancies, the facemask (FM) is used.[5] Hence, given the data mentioned above, the present study was undertaken for assessing the effect of FM therapy in cleft palate patients.

MATERIALS AND METHODS

The present study was done in the Department of Orthodontics and Dentofacial Orthopedics of the Dental College. The dental institution approved the ethical clearance for the study. All the patients were informed regarding the study, and their consent was obtained. Sixteen patients agreed to participate in the present study. Only those subjects included unilateral complete cleft lip and palate and were scheduled to undergo treatment with the FM. Demographic and clinical details of all the patients were separately recorded. All the patients were thoroughly examined for the presence of any other developmental anomaly. The patients were treated using the same techniques and appliances by the same orthodontist. Before facemask therapy, all of the patients had RME treatment to correct the maxillary transversal discrepancy. The same appliance was used for protraction after the completion of the RME treatment. Radiographs were taken after completing RME treatment (T1) and at the end of the FM therapy (T2). All the results were entered into a Microsoft Excel sheet and analyzed using IBM IBM SPSS software version(Statistical Package for the Social Sciences, IBM, USA) 20. Chi square test and Mann–Whitney U test were used for the evaluation of the level of significance.

RESULTS

The present study was done in the Department of Orthodontics and Dentofacial Orthopedics of the Dental College. A total of 16 patients agreed to participate in the present study. Table 1 shows that there were 5 males and 11 females. Table 2 show that SNA (o) 73.1 and 79.4, SNB (o) was 75.2 and 72.4, ANB (o) was −3.21 and 2.90, SN-PP (o) was 11.2 and 10.4, Co-A (mm) was 84.3 and 87.5, A-HR (mm) was 55.2 and 57.8, A-VR (mm) was 62.4 and 64.7, and SN-MP was 38.2 and 41.5 before and after treatment, respectively. The difference was considered statistically significant if P < 0.05.

Table 1

Distribution of patients

Gender	n (%)
Male	5 (31.25)
Female	11 (68.75)
Total	16

Table 2

Cephlometric changes in patients before and after facemask therapy

Parameters	Before treatment	After treatment	P
SNA (°)	73.1	79.4	0.02
SNB (°)	75.2	72.4	0.04
ANB (°)	−3.21	2.90	0.04
SN-PP (°)	11.2	10.4	0.01
Co-A (mm)	84.3	87.5	0.05
A-HR (mm)	55.2	57.8	0.02
A-VR (mm)	62.4	64.7	0.05
SN-MP	38.2	41.5	0.02

DISCUSSION

Midface hypoplasia and skeletal Class III is commonly seen in patients with cleft lip and palate who have undergone primary palatal surgery. This unesthetic appearance leads to a low quality of life in these patients. The retruded maxilla along with the uncomplimentary mandibular growth makes their treatment more challenging. At the anteroposterior level, there is a variable hypoplasticity of the maxilla. This manifests at younger ages and gradually increases with age. Thus, the maxillary sagittal discrepancy may ensue, along with the inclination of palate in the anterior maxillary region. Finally, after the cleft is repaired surgically, instabilities are also detected in the vertical plane. Early orthopedic treatment is considered beneficial in cleft lip and palate patients to treat the problems above. Hence, to improve the occlusion in cleft lip and palate patients, maxillary protraction in early stages via FM exerting extraoral forces has been recommended.[6789] Hence, under the light of the data mentioned above, the present study was undertaken for assessing the effect of FM therapy in cleft palate patients.

In the present study, there were 5 males and 11 females. We found that SNA (o) was 73.1 and 79.4, SNB (o) was 75.2 and 72.4, ANB (o) was − 3.21 and 2.90, SN-PP (o) was 11.2 and 10.4, Co-A (mm) was 84.3 and 87.5, A-HR (mm) was 55.2 and 57.8, A-VR (mm) was 62.4 and 64.7, and SN-MP was 38.2 and 41.5 before and after treatment, respectively. Dogan[1011] treated 20 patients with unilateral cleft lip and palate (UCLP) with the FM and studied the FM's effect on growth. In the UCLP group, the mandible was rotated posteriorly and inferiorly (P < 0.05), whereas the control group showed anterior and inferior changes. In a previous study conducted by Ahn et al.,[12] the authors evaluated two study groups: a UCLP group and a bilateral cleft lip and palate group. There were no differences in mean age and values of variables at the T1 stage and protraction duration between the two groups. Many studies investigated the effectiveness of FM therapy, amount and direction of forces, in spite of the variability in age, type of intraoral appliance, treatment length, and duration of daily use. They showed that favorable results were seen with maxillary protraction.

Moreover, if magnitude , duration, and direction of force in FM therapy in Class III patients for maxillary protraction is concerned then it is indicated that there should be 180°–800°g force per side, for a duration of 10 to 14 h per day, and direction of force vector should be parallel to the occlusal plane or between 20° and 30° from the occlusal plane. The force ranged up to 500°g per side in the previous studies while daily duration of appliance wear varied from 14 to 16 h, and force direction between 10° and 30° below the occlusal plane The values obtained in the present studies are in line with the above studies. Borzabadi-Farahani et al. as per the Alt-RAMEC used a Hyrax expander; however, the forward movement of the maxilla is not affected by the expansion devices or the protocols used with FM therapy.[131415]

CONCLUSION

Because of the above-obtained data, the authors found that FM proved to be beneficial in causing significant improvement in patients having cleft lip and palate.

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Conflicts of interest

There are no conflicts of interest.