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ORIGINAL ARTICLE
Year : 2006  |  Volume : 24  |  Issue : 3  |  Page : 136-139
 

The effect of tongue appliance on the nasomaxillary complex in growing cleft lip and palate patients


1 Department of Orthodontics, Dental School, Islamic Azad University, Iran
2 Department of Orthodontics, Dental School, Shahid Beheshti University, Iran

Correspondence Address:
A Jamilian
No. 1479, Corner of Ravanpoor Alley, Next to Jame-e-Jam, Valiasr St, Tehran - 19668
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.27893

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   Abstract 

Midfacial deficiency is a common feature of cleft lip and palate patients due to scar tissue of the lip and palate closure procedure. The aim of this study was to evaluate the effectiveness of the physiological force of the tongue to move the maxilla in forward position. This research has been done experimentally by, before and after treatment following up in private practice. Ten patients (6 female, 4 male) with complete bilateral cleft lip and palate were selected. All of them had Cl III malocclusion with maxillary deficiency due to scar tissue of lip and palate surgery. Their age ranged from 7.6 to 9.8 years. All the patients were delivered tongue appliance to transfer the force of the tongue to maxillary complex. The mean observation time was 132 months to achieve positive overjet. Pre- and post-lateral cephalograms were compared to evaluate the skeletal changes with paired t-test. The results showed that after the application of tongue appliance, normal sagittal maxillomandibular relationship was achieved. SN-ANS angle was increased 1.91.8 - P < 0.05. Nasolabial angle was decreased 10.310.8 - P < 0.03. This study showed that the tongue appliance could transfer considerable force during rest and swallowing period to the maxilla. This method might be considered to improve the deficient maxilla by means of growth modification and redirect concept.


Keywords: Cleft lip, maxillary deficiency, nasomaxillary, palate, tongue appliance


How to cite this article:
Jamilian A, Showkatbakhsh R, Boushehry M B. The effect of tongue appliance on the nasomaxillary complex in growing cleft lip and palate patients. J Indian Soc Pedod Prev Dent 2006;24:136-9

How to cite this URL:
Jamilian A, Showkatbakhsh R, Boushehry M B. The effect of tongue appliance on the nasomaxillary complex in growing cleft lip and palate patients. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2019 Nov 19];24:136-9. Available from: http://www.jisppd.com/text.asp?2006/24/3/136/27893



   Introduction Top


Cleft lip and palate deformities are one of the most common congenital abnormalities in the craniofacial complex. Midfacial deficiency is a common feature of cleft lip and palate patients due to scar tissue of the lip and palate closure procedure.[1] Numerous appliance designs such as endosseous implants,[2] ankylosed teeth,[3] surgically assisted orthopedic protraction[4] and distraction osteogenesis[5],[6] have been introduced in attempts to achieve maximum skeletal effects. Treatment approach to improve the maxillary position was performed by using the face mask,[7],[8],[9] protraction headgear[10],[11] and suborbital protraction appliances.[12],[13] Protraction of the maxilla at either the primary or mixed dentition period may improve the nasomaxillary growth and soft tissue facial profile.[14],[15],[16] In addition to their esthetic aspect and large size of extraoral appliances, they need high cooperation. The extraoral appliances are not used properly by the patients and patients prefer to use small-sized and more convenient appliances in order to maintain their esthetics. Many researchers observed lack of cooperation by patients treated by extraoral appliances. The aim of the present study was to examine the effectiveness of tongue appliance to improve the growth of nasomaxillary complex in complete bilateral cleft lip and palate patients at mixed dentition period.


   Materials and Methods Top


Ten complete bilateral cleft lip and palate patients who had undergone orthodontic treatment were selected from private practice. There were six females and four males. Their age ranged from 7.6 to 9.8 years.

The surgical procedure for cleft lip closure had been done in the first 10 to 20 weeks by utilizing the Millard procedure and for cleft palate had been performed in the first 18 to 24 months by the V-Y 'push back' method. All the patients had CL III malocclusion due to maxillary deficiency. Each patient had anterior and bilateral posterior crossbite prior to appliance therapy. No abnormal mandibular asymmetry was observed clinically. None of these subjects had a history of orthodontic treatment and all of them were nonsyndromic. Tongue appliance was constructed by Adams clasp for first upper molars and C clasps in the anterior teeth in order to increase the retention. A screw was mounted in midpalatal area to correct bilateral posterior crossbite. The tongue appliance is shown in [Figure - 1]. It was activated at weekly intervals by the patient. Three to five separate tongue cribs were incorporated in the plate, between canine to canine area. These cribs were long enough to cage the tongue and were adjusted in the clinic to avoid traumatizing the floor of the mouth. This appliance was used for 22 hrs a day and each patient was evaluated at monthly intervals. The mean observation time was 13 2 months till positive overjet was achieved.

OPG, lateral cephalometric radiographs, dental casts and photographs of the face were taken for all subjects. For the purpose of this study, pre- and post-operative lateral cephalograms were analyzed. These cephalograms had been taken with the teeth in occlusion. The magnification factor was recorded for each radiograph. All radiographs were traced on acetate paper by one investigator. Since the 'A' point is not clear in cleft lip and palate patients, it was substituted by ANS. The following angular measurements were calculated. In this study, SN-ANS angle, SNB, IMPA, inclination angle, nasolabial, mentolabial, 1 to SN, mandibular plane angle, angle of convexity were recorded and angle of convexity was traced by the intersection of a line from nasion to point ANS with a line from point ANS to pogonion. The cephalometric data was collected before and after treatment and these findings were then compared with paired t-test.


   Results Top


[Table - 1] shows the changes that occurred during the 13 2 months of treatment observation period.

In all cases, the maxilla had advanced. The SN-ANS angle increased 1.9 1.8 - P < 0.05; and the nasolabial angle decreased 10.3 10.8 - P < 0.03. The angle of convexity had improved 2.78 3.1 - P < 0.05. IMPA reduced 2.6 4.9 - P < 0.2.

The profiles of patients before and after the application of tongue appliance are shown in [Figure - 2][Figure - 3] respectively.

The cephalograms of patients before and after appliance therapy are shown in [Figure - 4] and [Figure - 5] respectively.


   Discussion Top


Maxillary advancement with tongue appliance improved the facial profile by moving the nasomaxillary complex in a forward position, resulting in improving the facial concavity, increasing the angle of convexity, normalizing the nasolabial angle, moving the upper lip forward, balancing lip posture, improving the intermaxillary basal relationship and eliminating dysfunction.

Cleft lip and palate patients with maxillary deficiency are treated traditionally by maxillary protraction appliances,[7],[8],[9],[12],[13] reverse pull headgear,[11],[15],[16] endosseous implants,[2] surgically assisted orthopedic protraction,[4] ankylosed teeth and distraction osteogenesis.[5],[6]

Majority of children with cleft lip and palate show features of severe malocclusion at an early age due to scar tissue of the lip and palate closure procedure.[1] Early treatment reduced severe underlying skeletal discrepancy.[16],[17] Growth modification definitely influences facial appearance. Proffit[18] stated that patients with maxillary deficiency might be treated at the age of 8 years, although treatment should be continued till growth ceased.

The findings of this study are similar with respect to other extraoral appliances that are mentioned above. Tongue appliance and extraoral protraction appliances increase the profile convexity and push the nasomaxillary complex into the forward position. The results showed that protraction treatment improved the sagittal jaw relationship (SN-ANS angle by 12.3%) [Table - 1].

Angle of convexity was increased 2.7 due to forward movement of ANS and backward rotation of mandible.

In this study, nasolabial angle was decreased; this angle showed concurrent forward movement with the underlying skeletal structures and therefore the profile was improved. Such dental movement must be borne in mind by clinicians who use this appliance.

As reported in other studies, habit-breaking application to prevent the tongue thrust can move the maxilla in the forward position. When the tongue appliance is in the mouth, there is considerable pressure that might be transmitted to the deficient maxilla. The mechanism of this force is provided in the following two ways.

  1. The pressure of the tongue during swallowing might be 5 pounds in each swallowing. The frequency of swallowing might be 500 to 1,200 times in 24 h. This force is intermittent and transferred through the tongue appliance to the deficient nasomaxillary complex.
  2. There is considerable continuous force of tongue in the rest position because the tongue is caged behind the cribs. This force pushes the maxilla into a forward position.


Physiological position and functional activity of tongue generate these forces that are transmitted by tongue through the palatal cribs and finally to the nasomaxillary complex. The more anterior the tongue, the greater will be the force. The more posterior the crib, the greater will be the force. There is more concern about the imbalance of neuromuscular system and nasomaxillary complex in the patients when the tongue position moves inferiorly and anteriorly. In this study, inclination angle was increased. This finding showed that the anterior part of palatal plane moved superiorly (anteinclination) and posterior part of palatal plane moved inferiorly. In other words, the maxillary posterior teeth were extruded and therefore the mandible rotated in a clockwise direction. These changes led to a more successful and pronounced correction of the overjet and decreasing of SNB and enhancing of mandibular plane angle, although some of these changes might be related to growth.

The reverse chin cup application to improve the deficient nasomaxillary complex might have an unfavorable effect on the normal mandible, but the tongue appliance doesn't have this effect. This appliance is very simple and comfortable. It will be accepted better than other appliances as, it is less conspicuous. This appliance is relatively inexpensive and easy to construct. Cleft lip and palate patients have suffered right from birth and they can't stand more stress, this appliance is more acceptable as it generates the least stress to patients in comparison with other extraoral appliances.

In spite of the many advantages of the tongue appliance, this appliance has one disadvantage. Lower incisors are lingualized due to elimination of the pressure of tongue and acting force of orbicularis oris.

Therefore, IMPA was decreased by 2.6 and mentolabial angle was increased by 6.5 during the use of this appliance. After discontinuing the use of appliance, the IMPA is increased and the overjet is decreased.

In this research, all the patients had upper arch expansion to correct bilateral posterior crossbite. Expansion will open all maxillary sutures like pterygomaxillary, zygomaxillary thus, maxilla will move more in forward position.[19],[20],[21]

The 132 months of tongue appliance therapy produced statistically significant skeletal changes in sagittal plane during the mixed dentition stage in patients with complete bilateral cleft lip and palate. This study showed that tongue appliance treatment might be an effective method for normalizing the maxillomandibular discrepancy by improving the sagittal jaw relationship. The overjet correction was mainly a result of skeletal change due to moving of nasomaxillary complex in forward position.

 
   References Top

1.Delaire J. Anatomy and physiology of the nasolabial muscles in normal patients and patients with surgically treated cleft lips and palates outcome in the treatment of the surgical results during the orthodontic period. Arch Stomatol (Napoli) 1979;20:477-96.  Back to cited text no. 1  [PUBMED]  
2.Smalley WM, Shapiro PA, Hohl TH, Kokich VG, Branemark PI. Osseointegrated titanium implants for maxillofacial protraction in monkeys. Am J Orthod Dentofac Orthop 1988;94:285-95.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Omnell ML, Sheller B. Maxillary protraction to intentionally ankylozed deciduous canines in a patient with cleft palate. Am J Orthod Dentofac Orthop 1994;106:201-5.  Back to cited text no. 3  [PUBMED]  
4.Rachmiel A, Aizenbud D, Ardekian L, Peled M, Laufer D. Surgically-assisted orthopedic protraction of the maxilla in cleft lip and palate patients. Int J Oral Maxillofac Surg 1999;28:9-14.  Back to cited text no. 4  [PUBMED]  
5.Tae CK, Gong SG, Min SK, Oh WS. Use of distraction osteogenesis in cleft palate patients. Angle Orthod 2003;73: 602-7.  Back to cited text no. 5    
6.Swennen G, Colle F, De May A. Malevez C. Maxillary distraction in cleft lip palate patients: A review of six cases. J Craniofac Surg 1999;10:117-22.   Back to cited text no. 6    
7.Rehak G. Orthodontic use of the Delaire orthopedic mask. Fogorv Sz 1981;74:153-44.  Back to cited text no. 7  [PUBMED]  
8.Buschang PH, Porter C, Genecov E, Genecov D, Sayler KE. Face mask therapy of preadolescents with unilateral cleft lip and palate. Angle Orthod 1994;64:145-50.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Maren J, Gaukroger J, Bounds G, Noar JH. The use of a face mask for postoperative retention in cleft lip and palate patients. Int J adult orthod orthognath sury 2002;15:114-9.  Back to cited text no. 9    
10.Chen HK, So LL. Sagittal skeletal and dental changes of reverse headgear treatment in Chinese boys with complete unilateral cleft lip and palate. Angle Orthod 1996;66:363-72.   Back to cited text no. 10    
11.Tindlund RS, Rygh P, Boe OE. Orthopedic protraction of the upper jaw in cleft lip and palate patients during the deciduous and mixed dentition periods in comparison with normal growth and development. Cleft Palate Craniofac J 1993;30:182-94.  Back to cited text no. 11    
12.Delaire J, Verdon P, Lumineau JP, Cherga-Negrea A, Talmant J, Boisson M. Some results of extra- oral tractions with front- chin rest in the orthodontic treatment of class 3 maxillomandibular malformations and of bony sequelae of cleft lip and palate. Rev stomatol Chir Maxillofac 1972;73:633-42.   Back to cited text no. 12  [PUBMED]  
13.Delaire J, Verdon P. The use of heavy postero-anterior extraoral forces by an orthopedic mask in the treatment of dentomaxillary sequellae of labiomaxillopalatal clefts. Chir Pediatr 1983;24: 315-22.   Back to cited text no. 13  [PUBMED]  
14.Ranta R. Forward traction of the maxilla with cleft lip and palate in mixed and permanent dentitions J Craniomaxillofac Surg 1989;17:2-25.  Back to cited text no. 14  [PUBMED]  
15.Chen HK, So LL. Soft tissue profile changes of reverse headgear treatment in Chinese boys with complete unilateral cleft lip and palate. Angle Orthod 1997;67:31-8.   Back to cited text no. 15    
16.Thindlund RS. Skeletal response to maxillary protraction in patients with cleft lip and palate before age 10 years. Cleft Palate Craniofac J 1994;31:295-308.  Back to cited text no. 16    
17.Deguchi T, Kanomi R, Ashizawa Y, Rosenstein SH. Very early face mask therapy in class III children. Angle Orthod 1999;69:349-55.  Back to cited text no. 17    
18.Proffit WR. Orthodontic treatment planning: Limitations, controversies and special problems in: Contemporary orthodontics. 3rd ed. Mosby 2000. p. 270.  Back to cited text no. 18    
19.Rygh P, Tindlund R. Orthopedic expansion and protraction of the maxilla in cleft palate patients: A new treatment rationale. Cleft Palate J 1982;19:104-12.  Back to cited text no. 19  [PUBMED]  
20.Kawakami M, Yagi T, Takada K. Maxillary expansion and protraction in correction of midface retrusion in a complete unilateral cleft lip and palate patient. Angle Orthod 2002;72:355-61.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.Liou EJ, Tsai WC. A new protocol for maxillary protraction in cleft patients: Repetitive weekly protocol of alternate rapid maxillary expansions and constrictions. Cleft Palate Craniofac J 2005;42:121-7.  Back to cited text no. 21    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

    Tables

[Table - 1]


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