Soft Tissue Molding Technique in Cleft Lip and Palate Patient Using Laser Surgery in Combination with Orthodontic Appliance: A Case Report

Abstract

Clefts of the lip and/or palate (CLP) was one of the most common craniofacial birth defects and had the incident rate up to 2.49 per 1,000 of new born babies in Thailand of which the highest incidence in the world 1) Still CLP has been one of the major public health problems in Thailand and globally. This also affected quality of life of patients and their parents due to a long term medical treatment over 15 years. Owing to the multi-deformity defects related to structural and functional development of oral and maxillofacial organs, these required a series of treatment beginning at birth until adolescence period or longer depended on the severity of deformity by a multidisciplinary team approach. The major purpose of treatment was to correct deformities and create a normal function. Current concept of treatment for normal occlusion required both orthodontic treatment and several surgical interventions such as cheiloplasty, palatoplasty, alveolar bone grafting, orthognathic surgery, distraction osteo-One of the crucial interventions was alveolar bone grafting used an autogenic iliac crestal bone for cleft site reconstruction. In order to gain full soft tissue coverage for ensuring success of bone grafting into the cleft site, the designs of local flap for this purpose inevitably resulting tension of the surrounding soft tissue. The post-operative excessing of soft tissue at the cleft site, tethering scar at the alveolar ridge of incisors and shallowing of vestibule were usually found 2) Even in complete healing, the soft tissue encroaching gingivae surrounding teeth was still remarked. All of these post-operative soft tissue characters clinically appeared to restrict tooth movement, compromise periodontal health and trend to limit the maxillary growth. Regarding the correction of soft tissue defects from post-operative procedure, this required a combination of surgical treatment and orthodontic appliance to reshape defected areas. However, conventional surgery with scalpel had some limitations due to scar formation and high rate of relapse at defected area from secondary intention healing. Consequently, there were several post- operative complications such as bleeding, high level of inflammation which result in delayed healing process and large exposed wound area leading to surgical trauma pain 3) These resulted no possibility for patients to wear orthodontic appliance for preserving corrected soft tissue. Laser surgery was an alternative treatment for correcting defects adjuvant to conventional surgical technique due to ease of use and reduced postoperative complication 4) The advantages of using laser surgery as an complimentary technique to conventional method were surgery with hemostasis, providing clear filed of operation, less operative time, less postsurgical pain and discomfort, no suture required, sterilization of wound during operation and reduced risk of postoperative infection 3, 5) Moreover laser surgery had minimal wound contraction allowing the better outcome of treatment for wearing prosthesis after laser surgery 6) There were many types of laser efficiently used for soft tissue surgery such as 1064 nm neodymium yttrium aluminium garnet (Nd: YAG) laser, 800 to 900 nm diode laser, 10600 nm carbon dioxide (CO2) laser and 2940 nm Erbium YAG (Er: YAG) laser. Among all types of lasers for oral soft tissue surgery, the COz laser was a high absorbed by specimen containing large amount of water and organic matter such as soft tissue. Moreover, CO2 laser could coagulate small blood vessels providing sufficient coagulation without extensive lateral heat effect. Subsequently, surgical pain usually persisted for only few seconds after finish of ablating 7) which gains more compliant of patients. Supporting from the in vivo study of Fisher and Frame 8) which created CO2 laser wounds on buccal mucosa, floor of mouth, tooth and alveolar mucosa of dogs. The visual inspection revealed that there was no undue pain among all subjects and all could continue their diet without difficulty. From the histological investigation from the study of Fisher et al 9) which compared the healing from CO2 laser and conventional excision of dog's buccal mucosa, there were minimal damage to adjacent tissues which led to less inflammation of surrounding tissues and fewer myofibroblasts resulting in little wound contraction. The less numbers and activity of myofibroblasts found after COz laser surgery compared with scalpel incision were also shown by the study of Zeinoun et al in dorsal tongue mucosa of rats 10) This study clearly illustrated the result from immunohistochemical staining of vitamin and alpha-smooth muscle actin represented expression of myofibroblasts revealed that the maximum level of myofibroblasts in scalpel excision was almost 3 times higher than CO2 laser. There were some studies regarding the appliances for correcting oral soft tissue defects. According to the study of Arikan and Turker 11) reported that the use of stent could prevent muscle rettachment after free gingival graft for correcting shallow vestibule. Therefore, the CLP patients undertaken surgical vestibular extension were also needed vestibular stents. The stents were required for shaping surgical areas after periodontal surgery and preventing relapse 11-12). Regarding the orthodontic appliance, we proposed a design of buccal shield to maintain and guide soft tissue to be healed in the accurate shape as performed after laser surgery and improve soft tissue function allow healing with less tension and tethering scar. The stent consisted of molar tubes to support two buccal arms of the upper labial stent that places at the surgical labial vestibular site to mould the surgical area as surgeon's plan.