Initial experiences with NAM-assisted primary repair of the BCLP deformity.

BACKGROUND: Primary surgical repair of the bilateral cleft lip and palate (BCLP) deformity is challenging. Infant Orthopedic (IO) procedures are often used to assist surgical reconstruction of normal anatomy. Nasoalveolar molding (NAM) is a presurgical infant orthopedic procedure that attempts to reduce the cleft nasal deformity, in addition to the lip and alveolus, leading to an esthetic primary surgical repair. OBJECTIVE: NAM provides the surgical team with a better foundation for an easier and more esthetic single stage repair at the level of nose in addition to the lip and alveolus. METHOD: Infant nasal cartilages are amenable to correction with NAM in the first few weeks of infancy when they retain their plasticity. NAM-assisted surgical repair of a complete BCLP infant is discussed. Postoperatively nasal stents were used to retain results and minimize relapse. RESULTS: NAM helped correct premaxillary deviation and protrusion, reduce alveolar cleft width and improve the nasal morphology prior to surgery in the BCLP infant. CONCLUSIONS: NAM helped reduce the severity of the cleft deformity in the BCLP infant and facilitated an easier and esthetic single stage primary surgical repair.

Effect of Three-wall Bony Defect along Various Root Surfaces on Position of Center of Resistance: A 3D Finite Element Analysis.

INTRODUCTION: Increase in adult orthodontic patients has increased the challenges faced by orthodontists, as they often present themselves with a varying degree of dental and peri-odontal compromise, in which the entire orthodontic treatment planning will revolve around maintenance and augmentation of supporting apparatus. One of the many factors to be considered during treating an adult patient is the height of alveolar bone and its effect on center of resistance (CRes). MATERIALS AND METHODS: Eight 3D analytical models of upper central incisor were designed using 'Solid Works Office Premium'. The models were subjected to 3 and 6 mm bone loss along all four surfaces, i.e. labial, lingual, mesial and distal. One Newton of retraction force was applied on labial surface of tooth on model number 1, 2, 5 and 6 and 1N of distalization force was applied to model number 3, 4, 7 and 8. The relative location of the CRes to the total root length was taken as 41.8% of total root length from the root apex. The ANSYS software was used to evaluate the change in CRes on all the models. RESULTS: It was observed that CRes shifted apically from its relative location (41.8% from apex); however, this shift was clinically insignificant. Minimum deflection of CRes, 0.0122 mm, was seen when a distalization force was applied on model with 6 mm bone loss on distal surface, while maximum deflection of 0.0245 mm was seen when retraction force was applied on model with 6 mm bone loss on labial surface. CONCLUSION: The resultant displacement in position of center of resistance is negligible; hence, there is no need of changing biomechanics during orthodontic treatment for a tooth with three wall infrabony defects. However, it is necessary to further study other infrabony defects like two wall or one wall defect, and their effect on position of CRes.

A New Classification System for Unilateral Cleft Lip and Palate Infants to assist Presurgical Infant Orthopedics.

The proposed advantages of pre-surgical naso-alveolar moulding (PNAM) are easy primary lip repair which heals under minimum tension reducing the scar formation and improving the aesthetic results in addition to reshaping of alar cartilage and improvement of nasal symmetry.However, the anatomy and alveolar morphology varies for each cleft child; the procedure for PNAM differs accordingly. In an attempt to categorize unilateral cleft lip and palate cases as per anatomical variations, a new classification system has been proposed. This classification aims to give an insight in unilateral cleft morphology based on which modification in PNAM procedure could be done.

Efficacy trial of Camouflage Syringe to reduce dental fear and anxiety.

AIM: Dental fear and anxiety in early childhood are widely prevalent and contribute to dental problems and behaviour in adulthood. Novel ways to reduce dental fear and anxiety in children are needed. Our aim was to conduct an efficacy trial of a novel Camouflage Syringe to reduce dental fear and anxiety in children. STUDY DESIGN: randomised controlled trial of efficacy of the Camouflage Syringe. We designed a Camouflage Syringe with a toy-like appearance that veils the conventional syringe to permit topical application and injection of local anaesthesia and ensure more involvement of the patient in the treatment process. We conducted a concurrent parallel, randomised controlled trial (NCT01398007) on the efficacy of this Camouflage Syringe to reduce the dental fear and anxiety in children seeking dental treatment who required the use of local anaesthesia. RESULTS: Using Venham's clinical rating scale, Venham's picture test, parental stress questionnaire and recall questionnaire, the efficacy of the Camouflage Syringe to reduce dental fear and anxiety ranged from 82% to 97% for various outcomes and from 60% to 100% for prevention of related adverse outcomes. For all outcomes, the number needed to treat was close to unity. CONCLUSION: Our results strongly favour the use of Camouflage Syringe to reduce dental fear and anxiety in children.

Alternative approaches to managing the cleft alveolus.

The cleft alveolus component of the oral cleft deformity is addressed with a separate surgical stage. Several host and operator related factors affect the surgical outcome. When factors that increase the likelihood of secondary alveolar bone graft failure are identified, alterative methods like dentoalveolar distraction (DAD) may be employed. In infants, molding of the alveolar segments is possible and when a synergistic surgical approach is used, the possibility of successful alveolar cleft repair is increased. The authors present two case reports wherein the use of nasoalveolar molding (NAM) and DAD helped to tackle the alveolar cleft deformity.

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

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.

Presurgical nasoalveolar molding assisted primary reconstruction in complete unilateral cleft lip palate infants.

BACKGROUND: Various methods have been described for the primary surgical reconstruction of the unilateral cleft lip and palate deformity (UCLP) in infants. There have been several attempts at restoring the normal anatomy of the nose at the time of lip repair in the affected individuals with varying degrees of success. Presurgical nasoalveolar molding (PNAM) is a presurgical infant orthopedic procedure that attempts to target the nasal deformity leading to a more esthetic surgical repair. OBJECTIVE: At our center we aimed to use PNAM to help in providing the surgical team with a better foundation for an easier and more esthetic single stage repair at the level of nose in addition to the lip and alveolus. METHOD: The infant nasal cartilages are amenable to correction in the first few weeks of life when they retain their plasticity. Three infants with complete unilateral cleft lip palate (CUCLP) were operated upon after a course of PNAM. No nasal stents were use after repair to retain the results. RESULTS: PNAM reduced the extent of the cleft deformity and improved the anatomic relationship between the affected structures. Postoperative recovery was uneventful. Subjective evaluation immediate post surgery and at the time of palate repair reveals adequate nasolabial esthetics. Long-term results of PNAM assisted repair are to be ascertained. CONCLUSIONS: The use of PNAM enables in reducing the severity of the deformity the surgical team has to tackle thereby enabling in a better and esthetic primary repair.

Changes in maxillary alveolar morphology with nasoalveolar molding.

AIM: To evaluate the changes in maxillary alveolar morphology in unilateral cleft lip palate infants treated with nasoalveolar molding (NAM). SETTING AND DESIGN: Study was carried out in the orthodontic department associated with a operating cleft unit in a rural region of central India. Ten UCLP (unilateral cleft lip palate) infants less than 6 weeks of age were treated with NAM prior to surgical repair. MATERIALS AND METHODS: Pre NAM and Post NAMstudy models of the UCLP infants were analyzed. Critical linear dimensions including inter- canine width, inter-tuberosity width, arch length and midline deviation were recorded at the different stages using a digital vernier caliper and compared. Statistical analysis were performed using SPSS 13.00 statistical software. RESULTS: Results from this study showed that the width of the alveolar cleft showed a significant decrease with NAM. The arch length and width of the arch in the anterior region also showed a reduction with NAM. The intertuberosity width showed a statistically significant increase during treatment. The arch perimeter showed a significant increase with NAM. CONCLUSION: NAM was effective in reducing the severity of the initial cleft deformity mainly at the anterior portion of the maxillary arch.

Scanning electron microscopic study and shear bond strength measurement with 5% and 37% phosphoric acid.

Direct bonding of orthodontic attachments has become a clinical reality with the application of the acid etch technique, using 37% phosphoric acid. The objective of this study was to detect the etch pattern with scanning electron microscopy and the shear bond strength with a Hounsefield tensometer (Nene Instruments Ltd., Northampton, England) by using 37% and 5% phosphoric acid (H3PO4). It was observed that with 5% H3PO4 there was minimal enamel loss compared with 37% H3PO4. There was no significant difference in shear bond strength, when enamel surface was etched with 5% H3PO4 and 37% H3PO4.