Again these appliances cannot be fitted to a patient much before the age of fifteen, and the habit of defective articulation has been fully formed by that time. They also need constant renewal, and are thus a source of continual expense, putting them beyond the reach of hospital patients.
In spite, therefore, of the optimistic arguments so boldly maintained by our American dental confrères, and of the successes they claim to have attained by the use of these artificial means, I am driven to the conclusion that in the majority of cases of cleft palate operative interference, followed by a suitable educational course, will give results incomparably superior to these, and unattended by the above-mentioned disadvantages.
But whilst strongly maintaining the superiority of the treatment by operative rather than by mechanical means, I will readily grant the greater applicability of the latter in certain conditions; viz. in acquired defects of the palate, the results of syphilis, traumatism, or surgical operations involving extensive loss of tissue—as, for instance, after excision of the superior maxilla: obturators are almost invariably the only means by which these apertures can be closed. In cases of congenital cleft where the os incisivum has needed removal, leaving a broad anterior opening the closure of which by operation is often impossible ([p. 135]), the application of an obturator is similarly advisable; and one suggests this method of treatment the more readily from the ease with which it can be effected, inasmuch as it merely necessitates an extension backwards of the plate which carries the artificial incisors. The communication between nose and mouth is thus effectually closed, and the functional success of previous plastic work and subsequent educational efforts ensured.
In cases of hopeless deformity, where the palatal tissue is so attenuated that operative interference is impracticable, the recourse to artificial assistance is inevitable; but such cases are fortunately rare.
CHAPTER VIII.
RESULTS OF TREATMENT—AFTER-TREATMENT.
The typical result which we desire to gain after an operation for harelip is a symmetrical appearance of lip and nose, and a normal contour and projection of the parts as seen from the front and in profile. The cicatrix should be practically invisible, and the red margin of the lip continuous throughout. Unfortunately, however, in many cases these results are not easily attainable. The tip of the nose tends to become drawn down and depressed, especially when in double harelip the philtrum is poorly developed, or when a mistaken attempt is made to incorporate it between the segments of the lip. This stunted but thickened columna encroaches on and obstructs the anterior nares, whilst in unilateral cases the aperture on the affected side is apt to become dilated and distended from the absence in some instances of the osseous floor, but also from subsequent cicatricial contraction of the previously divided bands between the cheek and maxilla. The behaviour of young cicatricial tissue, moreover, is not always the same. In some young and feeble children it remains vascular for a long time, and at first tends to stretch and become more evident;[100] subsequently contracting, it may leave an indurated cord-like ridge. In addition to this, a longitudinal contraction takes place in direct proportion to the thickness of the cicatrix, reducing the length of the scar and the depth of the lip, thus bringing about the 𝖵-shaped notch in the lip margin, and assisting in the dilatation of the nostril.
In double harelip, where the os incisivum has been removed, it has already been mentioned that the upper lip sinks back, the lower lip projects forwards, and the profile resulting therefrom becomes very unsightly ([Fig. 75]).
Fig. 75.—Profile of a case of double harelip after operation with removal of the os incisivum, showing the falling in of the upper lip and the prominent projection of the lower. (Coles.)