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Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 1-3

Kal, aaj, aur kal (yesterday, today, and tomorrow)

Department of Orthodontics, IDST, Modinagar, Uttar Pradesh, India

Date of Web Publication8-Feb-2018

Correspondence Address:
Dr. Puneet Batra
Department of Orthodontics, IDST, Modinagar, Uttar Pradesh - 201 204
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_3_18

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How to cite this article:
Batra P. Kal, aaj, aur kal (yesterday, today, and tomorrow). J Cleft Lip Palate Craniofac Anomal 2018;5:1-3

How to cite this URL:
Batra P. Kal, aaj, aur kal (yesterday, today, and tomorrow). J Cleft Lip Palate Craniofac Anomal [serial online] 2018 [cited 2019 Dec 8];5:1-3. Available from: http://www.jclpca.org/text.asp?2018/5/1/1/224899

The usage of this title which is a classic Indian movie as well as a pun intends to pay homage to the patient and highlight the rewarding journey that cleft orthodontics has been in the past century. Looking across the same and the way the future is shaping up, it looks like we are at the precipice of something remarkable.

“So much of whom we are (as cleft orthodontists) has a lot to do with where we have come from” – this beautiful albeit slightly modified quote from William Langewiesche summarizes the long torturous yet fruitful journey that cleft care (orthodontics included) has undertaken in the past century. A recent guest editorial in the AJODO systematically and thoroughly encompassed the past 100 years of cleft care with a special focus on Cleft Orthodontics. They go on to note that cleft care has had a leapfrog jump, especially in the past 50 years, owing to the advances in diagnosis, treatment planning, surgical and medical care, and better understanding of the oro-facial complex as a biomechanical system.[1] Furthermore, outcome reports of years of treatment protocols have reinforced the old saying of “Change” being the only constant.[2],[3] Here, the “change” refers to the ever-evolving treatment paradigm followed in cleft lip and palate patients. This paradigm has and will continue to change as more evidence is brought to light. The change of the role of an orthodontist from an isolated entity to being a part of the multispecialty interdisciplinary team is one of the best examples that crosses one's mind. It is now more than ever more pertinent to distinguish the difference between multi- and interdisciplinary care, especially in cleft care. Needless to say, the field of cleft orthodontics differs considerably from a typical 2-year comprehensive orthodontic treatment by extending treatment from the neonatal period with treatment of displaced alveolar segments, to management of the skeletal and dental components of the developing dentition starting with the deciduous dentition, through treatment of the mixed dentition, and into adolescence and adulthood.

  What Do We Know and What Have We Learned? Top

Socioeconomic, gender, quality of care, and treatment access inequalities, especially with regard to the urban and rural areas along with community stigmatization, mobilization, and acceptance of care, are usually the biggest challenges faced in the delivery of cleft care, more so in developing countries.[4] While several treatment protocol updates [5] (owing to field enhancements; both medical and technological such as temporary anchorage devices [6] and distraction osteogenesis [7]) and outcome assessment reports have streamlined the pathway for cleft orthodontics, one cannot help to notice that there are still certain gaps either in planning or outcome reporting. For example, the long-term benefits of presurgical infant orthopedics is still inconclusive.[8],[9] In addition, the introduction of prognostic yardsticks such as the GOSLON scale [10] has helped in determining the treatment planning and subsequent prognosis. Its reporting in many prominent outcome reports [1],[2],[3] is unfortunately not depicted accurately as it continues to be reported with a cumulative mean score while this yardstick is a median-based nonparametric one. Coming onto the positives, the use of facemask therapy to protract the maxilla in cleft patients with the concurrent use of the rapid maxillary expander has become a common practice; however, the extent of maxillary expansion required to disarticulate the circum-maxillary sutures was a gray area until the introduction of the Alternate Rapid Maxillary Expansions and Constrictions protocol [11] which was based on the simple rocking and jiggling motion a tooth undergoes during extraction. This protocol was paradigm shifting as the unnecessary overexpansion for the disarticulation could be avoided, leading to better and more stable maxillary protraction in cleft patients. Moreover, this protocol, as new literature has shown, can widen the age range of the patient to be treated, allowing for late adolescent maxillary protraction, this serves as a very good alternative to orthognathic surgery wherever it can be implemented.[12] Furthermore, the advent and advancement of temporary anchorage devices [6] have certainly widened the envelope of treatment [13] that can be administered, especially in cleft palate care, where it has a plethora of applications from aligning the cleft and premaxilla segments to anchoring the distraction devices, not to mention the absolute anchorage it renders for complex tooth movement.[1] Looking along with orthodontic-surgical lines, a treatment modality in the last two decades that has garnered attention and importance is that of distraction osteogenesis. From McCarthy's introduction [14] of the same in craniofacial deformity treatment, distraction osteogenesis possess a unique potential of instigating hard and subsequent soft-tissue generation which can be extremely useful in the cleft areas which are deficient in both. In addition to this, the new concept of eliminating the tediously and sometimes long presurgical orthodontics via the “surgery first concept” also provides a new dimension for faster treatment not only by eliminating the presurgical phase but also by fastening postsurgical tooth movement mediated through the regional acceleratory phenomenon.[15],[16]

  What Is in a Nam(E)?? Top

Naso-alveolar molding (NAM)[17] has gained significant worldwide reach and acceptance and its advocates promote its use in light of the treatment's ability to reduce the cleft defect and improve the naso-labial esthetics; there is still considerable controversy regarding its long-term impact on the overall maxillary growth, thereby affecting final treatment prognosis even though it was considered to be a giant leap when compared to the invasive pin-retained appliances such as Latham.[9],[10] Thus, in response to this, newer techniques such as DynaCleft ®[18] and Dynamic Presurgical Nasoalveolar Remodeling [19] were introduced which claimed to be less invasive, growth restrictive, and easier to use. Like any new technique marketed, it should be approached with caution unless backed by conclusive research which so far is inconclusive.[20] Therefore, while the debate still continues over preinfant orthopedics or NAM, the jury is still out on the final verdict.

  What Lies Ahead? Top

“The burden of proof lies with those who advise the introduction of a new technique, or the adaptation or modification of an older method” – Roberston.[21]

Although this statement is over three decades old, its veracity still holds strong today. As mentioned in the introductory portion, we as cleft orthodontic caregivers are on the horizon which is set to unveil the dramatic and remarkable modalities in cleft care. However, we must caution ourselves not to overzealously indulge and experiment in modalities that only for namesake seem and appear to be newer. Several exciting modalities have been or are constantly being reported which hold untapped potential in lieu of its applications in cleft care. Bioink-based three-dimensional (3D) bioprinting technologies are being employed to engineer experimental models of tissue and organ substitutes;[22] while this was considered pathbreaking in itself, 3D bioprinting lacks a crucial element for appropriately mimicking native live tissues: the ability to acutely change according to functional status and changes in the environment. Hence that, this is why now leading research groups are focusing on 4D bioprinting as an enhanced approach for tissue engineering and regenerative medicine. 4D bioprinting aims to include the ability of promoting dynamic changes of the structure, improving the functional response of the construct which uses stimuli–responsive biomaterials.[23] The scope of application in the repair of cleft defects whether in its usage as graft scaffold, presurgical orthopedic plate material, or even a simple obturator is truly exciting to imagine.

In addition, the recent usage of subcutaneous platelet-rich plasma has demonstrated not only faster movement but also an increase in the alveolar bone volume.[24] This exciting new modality would also have a good place in the future of cleft orthodontics, where not only the alveolar architecture is comprised but would also shorten the long duration of treatment which risks in burning out both the patient and the caregiver. The use of recombinant bone in the place of autogeneous one which causes unavoidable patient morbidity, however low it may be, is also attracting new research as the initial reports show no considerable difference between the two, paving the road of its potential use in secondary alveolar bone grafting.[25] The use of low-intensity pulsed ultrasound stimulation to increase the rate of tooth movement along with increasing the rate of remodeling in fracture/distraction sites also seems to be an interesting avenue which could be of meritorious use in cleft orthodontics.[26]

While it is also noteworthy to mention that a good amount of research is being conducted to a) identify the markers and pathways involved in cleft pathogenesis and b) its consequent scope of reversal at the quiescent stage; whatever the therapy may be, proper protocol design, administration and follow-up should be strictly adhered to which is based on several multinational (especially in developing countries), multicentric trials. This has to be supplemented by proper outcome reporting of the same, focusing on and from both aspects, i.e., caregiver and caretaker. This would serve as the ultimate guide to reach persevered goal of excellence and someday perfection in cleft orthodontics and care. care.

“So we all embark wondering what lies over the horizon, what's around the next bend. And in the end, isn't that what drives us?”

- Blake Crouch.

  References Top

Vig KW, Mercado AM. Overview of orthodontic care for children with cleft lip and palate, 1915-2015. Am J Orthod Dentofacial Orthop 2015;148:543-56.  Back to cited text no. 1
Shaye D. Update on outcomes research for cleft lip and palate. Curr Opin Otolaryngol Head Neck Surg 2014;22:255-9.  Back to cited text no. 2
Thierens L, Brusselaers N, De Roo N, De Pauw G. Effects of labial adhesion on maxillary arch dimensions and nasolabial esthetics in cleft lip and palate: A systematic review. Oral Dis 2017;23:889-96.  Back to cited text no. 3
Mossey P, Little J. Addressing the challenges of cleft lip and palate research in India. Indian J Plast Surg 2009;42 Suppl: S9-18.  Back to cited text no. 4
Shetye PR. Update on treatment of patients with cleft-timing of orthodontics and surgery. Semin Orthod 2016;22:45-51.  Back to cited text no. 5
Proff P, Bayerlein T, Gedrange T. Special features of planning and application of orthodontic miniscrews in cleft patients. J Craniomaxillofac Surg 2006;34 Suppl 2:73-6.  Back to cited text no. 6
Zemann W, Pichelmayer M. Maxillary segmental distraction in children with unilateral clefts of lip, palate, and alveolus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:688-92.  Back to cited text no. 7
Grayson BH, Garfinkle JS. Early cleft management: The case for nasoalveolar molding. Am J Orthod Dentofacial Orthop 2014;145:134-42.  Back to cited text no. 8
Hathaway RR, Long RE Jr. Early cleft management: In search of evidence (Point/Counterpoint). Am J Orthod Dentofacial Orthop 2014;145:135-42.  Back to cited text no. 9
Mars M, Plint DA, Houston WJ, Bergland O, Semb G. The Goslon yardstick: A new system of assessing dental arch relationships in children with unilateral clefts of the lip and palate. Cleft Palate J 1987;24:314-22.  Back to cited text no. 10
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. 11
Yen SL. Protocols for late maxillary protraction in cleft lip and palate patients at Children's Hospital Los Angeles. Semin Orthod 2011;17:138-48.  Back to cited text no. 12
Graber LW, Vanarsdall RL, Kathreine WL. Orthodontics: Current Principles and Practices. 5th ed. St. Louis, Missouri: Elsevier Publishing; 2012. p. 15-7.  Back to cited text no. 13
McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH. Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1-8.  Back to cited text no. 14
Villegas C, Uribe F, Sugawara J, Nanda R. Expedited correction of significant dentofacial asymmetry using a “surgery first” approach. J Clin Orthod 2010;44:97-103.  Back to cited text no. 15
Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR, et al. Surgery- first accelerated orthognathic surgery: Postoperative rapid orthodontic tooth movement. J Oral Maxillofac Surg 2011;69:781-5.  Back to cited text no. 16
Grayson BH, Cutting C, Wood R. Preoperative columella lengthening in bilateral cleft lip and palate. Plast Reconstr Surg 1993;92:1422-3.  Back to cited text no. 17
Berggren A. Surgical Tape and the Nasal Alar Elevator-Two Simple and Useful Tools in the Early Preoperative Treatment of Cleft Lip Patients. Presented at the International Congress of Cleft Lip-Palate and Craniofacial Anomalies; June 25–29, 2001; Goteborg, Sweden; 2001.  Back to cited text no. 18
Bennun RD, Figueroa AA. Dynamic presurgical naso alveolar remodeling in patients with unilateral and bilateral cleft lip and palate: Modification to the original technique. Cleft Palate Craniofac J 2006;43:639-48.  Back to cited text no. 19
Monasterio L, Ford A, Gutiérrez C, Tastets ME, García J. Comparative study of nasoalveolar molding methods: Nasal elevator plus DynaCleft® versus NAM-Grayson in patients with complete unilateral cleft lip and palate. Cleft Palate Craniofac J 2013;50:548-54.  Back to cited text no. 20
Robertson NR. Recent trends in the early treatment of cleft lip and cleft palate. Dent Pract Dent Rec 1971;21:326-38.  Back to cited text no. 21
Ji S, Guvendiren M. Recent advances in bioink design for 3D bioprinting of tissues and organs. Front Bioeng Biotechnol 2017;5:23.  Back to cited text no. 22
Morouço P, Lattanzi W, Alves N. Four-dimensional bioprinting as a new era for tissue engineering and regenerative medicine. Front Bioeng Biotechnol 2017;5:61.  Back to cited text no. 23
Liou EJ. The development of submucosal injection of platelet rich plasma for accelerating orthodontic tooth movement and preserving pressure side alveolar bone. APOS Trends Orthod 2016;6:5-11.  Back to cited text no. 24
  [Full text]  
Hammoudeh JA, Fahradyan A, Gould DJ, Liang F, Imahiyerobo T, Urbinelli L, et al. Acomparative analysis of recombinant human bone morphogenetic protein-2 with a demineralized bone matrix versus iliac crest bone graft for secondary alveolar bone grafts in patients with cleft lip and palate: Review of 501 cases. Plast Reconstr Surg 2017;140:318e-25e.  Back to cited text no. 25
Hui X, Jun Z, Michelle YC, Hong Z, Yinzhong D. The effects of low-intensity pulsed ultrasound on the rate of orthodontic tooth movement. Semin Orthod 2015;3:219-23. Available from: http://www.semortho.com/article/S1073-8746(15)00040-7/abstract.  Back to cited text no. 26


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