Spring 2014

Challenging Smiles

Dentistry needs to improve outcomes for children with cleft lip and palate, says Tufts orthodontist

By Jacqueline Mitchell

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Hemanth Kunduru, D14, right, talks with David Leader, D85, MPH13, associate professor, at this year's Bates-Andrews Research Day. Photo: Kelvin Ma

Craniofacial malformations such as cleft lip and palate are among the most common birth defects in the United States, occurring in one of every 1,000 newborns, according to the National Institutes of Health. While no one knows precisely what causes them, the good news is that specialists now are quite skilled at repairing or restoring the missing or malformed hard tissues. Oral surgeons can graft in new bone tissue to restore the jaws, and orthodontists can guide the teeth and jaws into their correct positions.

Soft tissues, such as the lips, cheeks and nose, present a different challenge, said Carroll Ann Trotman, professor and chair of orthodontics at Tufts School of Dental Medicine, who gave the keynote speech at Bates-Andrews Day, the school’s annual student research forum, in March.

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Carroll Ann Trotman

The confounding factor is the child’s own growth. Surgeons and orthodontists can’t predict precisely how their young patients will heal after the surgeries to repair their lips and palates. But it turns out that the surgery itself and any resulting scarring can slow or restrict soft tissue growth. That can mean lopsided lips, undefined cupid’s bows or disproportionately small mouths. These aren’t just superficial complaints, Trotman emphasized, noting that studies have linked cosmetic deficiencies in cleft palate and cleft lip treatment with diminished levels of educational achievement and socioeconomic success.

“So it has far-reaching effects,” she said, showing slides of affected children. In attempting to smile, one little girl could only grimace, while an adolescent boy appeared to purse his lips.

“You can imagine when he looks in the mirror he’s not pleased with what he’s seeing, especially in the teenage years. We need to get better at this.”

That’s why Trotman has dedicated her career to finding ways to improve outcomes of cleft lip and palate surgeries. One way to do that is to reduce the number of procedures children undergo to reduce the possibility that scarring will stunt or alter the growth of the area around the mouth, including the lips, cheeks and nostrils.

In 2007, Trotman and her colleagues found surgeons’ decisions about whether a child should have surgery were completely subjective; they found no professional agreement when showing a panel of physicians headshots of the same children.

In an effort to develop a more objective means of determining the need for lip surgery and evaluating its outcomes, Trotman and her team used 3D motion analysis technology. The technology, Trotman points out, is not new; it has had diverse applications for years in rehabilitation centers, athletic training centers and even Hollywood’s special effects studios. But Trotman and her colleagues were the first to apply 3D motion analysis to kids with cleft lips or palates.

In a study published in the Journal of Dental Research in 2010, Trotman and her colleagues describe placing reflective markers on facial landmarks such as the tip of the nose, the tip of the chin and the peaks of the cheekbones. Then the researchers videotaped kids as they smiled, pursed their lips, puffed out their cheeks and opened wide. The resulting data give surgeons a quantitative measure of a child’s existing impairment or limitations. The data also help assess the potential costs and benefits of undergoing yet another procedure.

“It’s important that we limit the burden of our care,” she said. “And the treatment—I don’t need to tell this crowd—must be based on sound evidence of success.”

For a list of the Bates-Andrews Day student research awards and more photos, visit go.tufts.edu/bates2014.

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