The designation labio-maxillo-palatal cleft is used to describe two types of congenital malformations of the palate. The mechanisms that create them occur in the early weeks of fetal life by an alteration of embryological message delivery that researchers have been able to analyze. But they have not as yet been able to discern the multi-factorial causes of this alteration.

Morphological embryology and its chronology are important because researchers use an understanding of them to distinguish between different entities of clefts on the basis of the stage of palatal formation in which they began to develop: the numerous molecules involved In cell development are already well known, but researchers have not yet precisely identified those that are associated with the various stages of palatal morphogenesis. But it is clear that genetic alterations, which are now being pin-pointed, trigger developmental malfunctionings that are later intensified by faulty interactions in the fetal-maternal environment because.

Conclusion: Although researchers are progressively gaining a better understanding of the mechanisms of the intra-uterine formation of labio-maxillo-palatal clefts, we have not yet acquired the broad range of data that would make it possible to correct defective palatal formation before birth.

Pierre Fauchard (1678-1761) is known as the father of dentistry. This division of medicine participated fully in the enlightenment. After a second reading of his book, The Dental Surgeon, an examination of recent publications of 18th century practitioners, and the discovery of new documents, we have gained a better understanding of the man, the dental surgeon, and the place of scientists in his century.

In an article published in the ODF Review in 1987, we described the static relationships existing between and among the different components of the temporomandibular joint. This new article completes that work by supplying a dynamic vision of the range of movement, as well as recent anatomical and electromyographic data concerning the lateral pterygoid muscle.

Any attentive observer of families who have a child afflicted with a cleft lip whether or not associated with a palatal cleft would be certain to be impressed by the importance of the psychological context of their interpersonal exchanges and the risks of a breakdown in the parent-child relationship adversely affecting the child’s development. The birth of a child with a cleft lip inevitably becomes a painfully stressful and traumatic event for its parents.

In the framework of the Programme Hospitalier de Recherche Clinique (PHRC) we have evaluated the psychological perceptions of parents of cleft lip and palate patients during the child’s first year of life in a multi-disciplinary and multi-group prospective study. Our goal is to analyze both the child’s psychic suffering and the parent-child relationship. We compared the results obtained in four hospital centers using different surgical protocols, distinguishing between the sub-groups of parents who had learned of the defect from an in utero examination and parents who did not become aware of the cleft until the child was born.

We analyze for the parents the psychic and psychological dimensions of the deformity and its correction, touching on the importance of a prenatal diagnosis, the development of a relationship with the child, self-images, and the quality of life as well focusing on the infant’s distress and eventual recovery from it. The results of this study should make it possible for health care workers to construct new ways of attenuating, insofar as possible, the psychological impact of the deformity on parents and their children and to improve long term care for these patients.

The diagnosis of functional temporo-mandibular and cervical problems depends to a great extent on subjective information provided by patients. As a result, it is difficult to arrive at a substantiated assessment of the prevalence of these disorders. Based on the data reported from large-scale epidemiological studies, it appears that nearly 50 % of the populations of developed countries have symptoms of musculo-skeletal problems. The over-abundance of diagnostic tests suggested for assessing this problem adds confusion to this murky area. The purpose of this article is to precisely evaluate the pertinence of the various tests used to establish a clinical diagnosis.

No one before Pierre Fauchard had claimed to be able to move teeth except Celsus who suggested applying finger pressure to a tooth that was erupting in the wrong direction.

Fauchard advised dentists to examine a patient’s mouth and occlusion first and then, if necessary, to use one of a number of methods he proposed to “straighten” irregular teeth. The principal device was a “plate,” a small segment of thin metal attached to anchor teeth from which force could be exerted on mal-positioned teeth. He uprighted teeth leaning inward by luxation with a “pelican.”

The two chapters of his book that were devoted to “straightening” teeth constitute the origin of modern orthodontics.

It is generally agreed that cephalometric analyses of the Americans Ricketts, Steiner, and Tweed are of questionable utility. The C.R.A.N.I.O.M group has formulated a new method of using cephalometric measurements that it believeswill be moderately helpful to orthodontists in making their diagnoses. We analyzed 83 young adults in Class I occlusion who had had no orthodontic treatment.

The most interesting new formulation of our plan was to examine the extremes of the variables that we considered in this population. These figures constituted limits that differed widely fromeach other: there wasmore than a 30° gap between the measurement of the incisor inclined furthest buccally and the one inclined most lingually (or palatally).

Accordingly, for these lower anterior teeth inclinations to Downs’s mandibular plane ranging from 78 to 114° were acceptable. And for the maxillary incisors inclinations to the Frankfort plane varying from 97.5 to 130.1° are considered to be in a standard range. The need to reposition incisors in order to conform towhat we can now see as an abusively rigid normal accordingly occurs much less frequently.

For this reason, orthodontists will find far fewer indications for the extraction of bicuspid teeth than they would in rigidly adhering to the standards imposed by the Ricketts, Steiner, and Tweed cephalometric analyses. We believe that measurements of skeletal, osseous structures merely differentiate between various typologies and do not describe forms that constitute anomalies.

The C.R.A.N.I.O.M group affirms that cephalometrics occupies a position in the array of orthodontic diagnostic tools that comes after the assessment of esthetic, periodontal status, and muscular equilibrium.

Over the last 50 years, the dominant conception of the etiology of facial clefts postulated that they resulted from a mesodermal deficit that accounted for the primary hypoplasia and the unpredictable nature of subsequent oro-facial growth. Because of this notion, rigid dogmatic interdictions, with no allowance for nuanced treatment adjustments were issued banning sub-periosteal and sub-perichondrial dissections as well as the undertaking of any nasal surgery during the growth period. These prohibitions have had a grave braking effect on the development of treatment for cleft lip and palate patients.

With a new comprehension of the important role that the dynamics of fetal ventilation plays in the development of the airways and its influence on maxillary growth researchers no longer have any doubt that normal growth mechanisms operating under abnormal anatomic conditions created by the cleft are the actual causes of the malformations and the facial growth deficit suffered by children born with clefts. It now seems likely that the nasal septum plays only a passive role in growth, as Moss believed, rather than the active one that Scott as well as Delaire defined, calling it the driving force of maxillary development. They advocated re-inserting the lateral muscles on the anterior nasal spine. But practitioners who limit their functional approach to this procedure risk being deceived. In addition this focusing on muscles distracts us from what is essential, nasal ventilation, whose rehabilitation beginning with the first operation and preservation throughout treatment are absolutely necessary to ensure the normal unfolding of a cleft palate patient’s facial growth.

To achieve this goal surgeons must complete anatomic reconstruction with precisely timed, ambitious surgery carefully designed to control scar formation. Whether their procedure is unilateral or bilateral surgeons make this correction of the nasal malformation best if they operate when patients are six months old and close the lip defect at the same time. During this procedure surgeons close the soft palate defect using the Sommerlad technique taking advantage of the shrinking of the hard palate gap that closes enough to allow for simple, complete surgical elimination of the cleft in two layers without leaving dense scar tissue or denuded areas. By the time patients are 4 years old orthodontists have expanded the anterior maxilla to establish good canine function and surgeons can close the alveolar cleft with a gingivoperiosteoplasty and an iliac graft. Each procedure conserves the width of the piriform orifice, the nasal fossae and the anterior, incisor-canine sector of the arch. Nasal ventilation, as well as symmetrical, centered mastication, is required for normal facial growth.

The masticatory apparatus, which serves numerous functions in the life of humans, is constantly active and, as a result, can be the victim of a variety of malfunctions, even trauma. which occurs suddenly, often brutally enough to provoke patients to seek a consultation with a specialist in the masticatory apparatus, that is, an orthodontist.

What attitude should we adopt when examining a patient with myalgia, a subluxated or ‘‘locked’’ mandible, or sudden onset of arthralgia, pain in the temperomandibular joint? Finesse in clinical diagnosis and a profound knowledge of disorders of the masticatory apparatus are essentials in dealing with emergency visits from patients who have suffered a traumatic incident. We should devise prompt, prudent, and appropriate treatment to help them.

Current evidence based data found in the scientific literature recommend that the therapeutic management of patients suffering from temporomandibular disorders (TMD) should be based initially on simple, conservative and reversible procedures including exercise therapy. The integration of this message into oral health instructions for patients makes it easy for them to keep informed about TMD and aware of the steps they can take to deal with their symptoms. The integration of exercise therapy into structured patient education programs provides patients with information about TMD and suggests methods to deal with it. This medical approach is similar to those used to treat other joints in the musculoskeletal system.

Easy to set up, this exercise therapy helps patients suffering from temporomandibular disorders to become partners in the conduct of their treatment plan of reducing pain and restoring functional comfort.

Dr. Olivier REVOL, a pediatric psychiatrist, is the chief of the Neuropsychiatric Service at Pierre-Wertheimer Neurological Hospital of Lyon. In practice for more than twenty years, Dr. Revol has been the director of a reference center for learning disorders for the last seven years. He has written two books14,15 and many articles devoted to precocious intelligence, hyperactivity, and problems young people have adjusting to school for national and international publications. In his service, Dr. Revol gives hope to many children and their parents every day and fights tirelessly to insure that all students, no matter what level of competence they may have, discover the pleasure of learning in school.

Last June, at the invitation of the Association of the Revue d’O.D.F, Dr. Revol presented a captivating all day conference on the topic, “Adolescence, are we making it a disease?” whose proceedings the Revue d’ODF published in full16.

Parents want their children’s’ faces, the most visible part of their bodies, one that marks their identity throughout life, to be perfect. To satisfy this understandably urgent desire, a high quality of primary treatment for cleft lip and palate is essential and must satisfy a double objective: restore normal morphology and normal function. The functional, morphological, and esthetic prognoses depend on the character of the defect, whether it stands alone or is associated in a syndrome with other malformations. Important sequellae flow from the quality of the initial repair, as a consequence of the surgery and other therapies as well as from the deformity itself.

Before the year 2000, the Maxillo-facial and Plastic Surgery Service at the Armand Trousseau Hospital of the Pierre and Marie Curie Faculty of Medicine adhered to the protocol that Malek had described, making an initial repair of the soft palate at 3 months and then a cheiloplasty, with upper and lower triangles, and closure of the hard palate at 6 months. Since then we have adopted the more functional approach that Talmant described, integrating systematic nasal surgery and the type of lip surgery that Millard suggested without leaving any residual exposed bone after closure of the osseous cleft. We then perform gingivo-periosteal surgery with bone grafts on patients when they were between 4 and 6 years of age, after orthodontic therapy had been completed. This constitutes the last stage of primary treatment.

The therapeutic approach we have been using on our service, which has evolved of over the last 20 years, has come to define its principal objective as integration of extensive rehabilitation into the very first stages of our multi-disciplinary therapy so as to minimize the establishment of faulty functioning of phonation, lip competence, and ventilation while avoiding any intervention that would have a harmful impact on facial growth. This multi-disciplinary approach, which integrates surgical evaluation and protocol, is indispensable and fully justifies treatment of patients with cleft lip and palate at accredited centers.

Miniscrews are the most important recent innovation in orthodontics and have won a place, we believe, in the routine appliance design of everyday orthodontic practice. They are, we think primarily applicable in the treatment of the most prominent feature of the malocclusions orthodontists regularly confront, an antero-posterior discrepancy. Accordingly we discuss the protocol for full banded and bonded Class II mechanotherapy with miniscrew anchorage for:

     • Global arch or anterior sectional displacement;

     • Direct or indirect mechanics;

     • Sliding or loop mechanics.

We then demonstrate clinical procedures: placement of miniscrews, static and mobile sectors, strengthening sectorial anchorage, active forces, and space management.

Next we analyze the mechanics of treating complex cases with vertical as well as antero-posterior problems.

Throughout the article we illustrate the text with sketches and clinical records.

Labio-maxillary-palatal clefts, which are caused by fetal nasal buds failing to fuse with the maxillary bud, disrupt the ensemble of the structures that support and interact with the nose and upper jaw creating a rupture of balance that becomes an increasingly exacerbating vicious circle. In correcting these defects practitioners must effect a compromise between the need to re-unite separated parts – under as little tension as possible – and the need to preserve the interrupted potential for growth in the affected facial region. They must carry out this compromise in the double sense of topography and chronology.

Adhering to this therapeutic philosophy, the Nancy protocol closely associates orthopedic preparation and surgical treatment of patients to obtain:

     – high quality morphology,

     – an unblocked, sufficiently broad maxilla,

     – correct nasal breathing,

     – velo-pharyngeal competence.

We use a tibial periosteal graft to repair the oral cleft as an important element of our procedures.