In this second issue devoted to labio-maxillo-palatal clefts, we shall continue to emphasize the informational aspect that characterized the first issue. After presenting the specific fundamentals of management or clefts, we shall carefully consider the complementary disciplines that share in the overall care of cleft palate patients.

There are two principal indications for tonsillectomies or ablation of palatal tonsillar tissue: repeated episodes of tonsillitis (at least 5 times per year in two successive years) and obstructive tonsillar tissue as well as another, more rare, indication, highly asymmetrical blocs of tonsillar tissue that may suggest presence of a lymphoma. When tonsils are obstructive in patients suffering from sleep apnea, the indication for excision is formal and requires prompt attention. In other cases of enlarged tonsils the indication for surgery can be discussed but practitioners must inform parents of the possible maxillofacial complications that may develop because of chronic pharyngeal blockage.

Surgeons perform tonsillectomies on children under general anesthesia, protecting the lower airways by intubation. Post-operative pain after surgery is constant and practitioners must be prepared to manage it in conformity with the age of patients and the difficulties they have in swallowing.

Practitioners should aim to diagnose as early as possible the development of malfunction of the masticatory system, or temporomandibular disorder (TMD), that causes pain, discomfort and a decrease in functional efficiency, especially in those patients whose occlusion is being rehabilitated in the course of orthodontic treatment. This is particularly true for the segment of the patient population who are characterized by certain risk factors.

Armed with a good understanding of the diagnostic classification of TMD, orthodontists will be better prepared to pinpoint and diagnose TMD and, if necessary, adopt the most appropriate mode of therapy for treating it.

Thanks to a good understanding of TMD nosology, orthodontists will be able to distinguish between muscular and joint disorders and then manage patients in accordance with specific diagnostic criteria.

Orthognathic surgery has as its objective the repositioning of basal bone in the framework of maxillo-mandibular deformities. Its results are both esthetic and functional. For adults, improved aesthetics results is becoming increasingly important in these procedures to the point where some patients seek only an esthetic amelioration and not a functional one. To achieve their aesthetic purpose, it is becoming progressively more necessary for orthodontists, oral surgeons, and general dentists to collaborate effectively in a well-coordinated effort. In what has now become a true sub-specialty, orthognathic surgeons must master the complementary techniques of rhinoplasty, osseous apposition, aesthetic facial surgery, fat injection or injectable anti-aging tratments. In this article we propose a diagnostic classification based on the aesthetics of the adult smile and describe the therapeutic modalities appropriate for each element.

Since 2005 in France, the national technical committee of prenatal ultra-sound screening (CNTE) has recommended that pregnant women have a routine second trimester ultrasound screening for facial clefts. The view on the coronal reference plane visualizes the continuity of the upper lip, and makes it possible to detect most facial clefts, but not isolated palatal clefts.

Treatment teams use different approaches for correcting the alveolar cleft sector of labio-palatal clefts. Age of patient, whether or not bone grafts are used, and the type of bone grafted are some of the differences. Our team performs a gingivoperioplasty with a graft of iliac cancellous bone on patients 4 to 6 years old. This procedure is carried out within the framework of orthodontic treatment designed to restore transverse dimension pre-operatively with a quad helix and to retain the expansion with 6 months of retention. The gingivoperioplasty is accomplished in a zone free of any scar tissue that might have resulted from a primary cheiloplasty followed by closure of the palatal cleft. In our view all teams must eventually utilize cone beam X-rays for their radiographic evaluations because they are the only tool that provides results of objective analysis that are of high quality and have demanded a very low level of radiation.

A gummy smile is one in which excessive amounts of gingival tissue are revealed as individuals begin to laugh or when they show their teeth in a smile.

In addition to cosmetic methods of concealing this condition, a variety of orthodontic and surgical procedures can, independently or in conjunction, modify the structural elements that constitute a gummy smile.

Nevertheless marked gummy smiles are always characterized by specific dento-maxillary discrepancies, a global vertical maxillary excess or overdevelopment of the alveolar processes, the premaxilla and the proalveolus constituting excess anterior vertical dimension. For each of these instances, the author proposes therapeutic treatment plans and illustrates them with corresponding clinical cases.

By definition, orthodontists take special care in achieving a high quality occlusion when finishing cases, believing good contacts are essential to maintain dental health, function, and insure stable long-term of results. The T-scan III system provides a real-time digitized analysis of occlusion, in both static and dynamic modes, and records the distribution of occlusal forces within the dental arches in different clinical situations. While the first T-Scan generations versions showed weaknesses, recent technical improvements have made T-scan a reliable and reproducible tool, whose findings are independent of the operator. It is now possible to calibrate the sensitivity of the sensor for individual patients, and to evaluate the quality of records so that comparisons can be made between various stages of a patient’s treatment, as well as between patients. In addition to the accuracy of occlusal diagnosis, that often exceed clinical requirements, the T-scan III also can help understanding better each patient’s functional pattern. This article describes the T-scan III occlusal analysis system, reviews current literature that evaluated its clinical use, and outlines its principal indications in dentofacial orthopedics. Four clinical cases treated with full bonded lingual appliance will illustrate how the Tscan III influences orthodontic case finishing : one case of “occlusal discomfort” after completion of surgical and orthodontic treatments, a case of cervical abfraction lesions, a case of anterior deep bite restored with an implant-supported prosthesis, and a case of severe facial hemiatrophy treated with a complex protocol.

Many defects can affect the smile of our patients. For superficial enamel defects that may involve one or several natural teeth, we have perfected, after trying many different methods of treatment, a simple, rapid, atraumatic and very effective technique.

This method has five successive stages: a chemical whitening at the chair, an enameloplasty, a microabrasion, a careful polishing, and a remineralization treatment.

This method is especially used for patients who present superficial enamel defects (chalky white veils, leucomas, brown spots, pitting,…).

For deeper defects, it is sometimes necessary to complete this treatment with composite or ceramic restorations.

This article presents solutions to problems posed by missing teeth in the anterior sector of the arch by synthesizing three groups of parameters, those related to patients, those related to dentists, and those related to the orthodontist.

But the patient, or the parents of patients who are young children, in consultation with the treatment professionals, must make the final decision.

Dental wear is deterioration as a result of use. It has existed since the beginning of mankind in all civilizations and cultures. It occurred routinely and intensely in early populations but was considered to be a physiological process. Ideas about dental wear are not as clear today because while it is less pronounced it sometimes appears in pathological patterns. Moreover, it is produced by many complex mechanisms acting in synchrony or sequentially, in synergy or additive, in patterns that often mask its true origins. In an effort to ameliorate the means of preventing and diagnosing dental wear and improving our understanding of its diverse manifestations, the primary objective of this article will be to present the principal mechanisms that produce it as well as their consequences. To organize our presentation we have adopted a tribological approach, focusing on the friction, wear, and lubrication of interacting surfaces.

Dentists often use occlusal splints in the management of occlusodontic problems. Because they are considered to provide non-invasive and reversible treatment they are therapeutic devices that conform well to the current philosophy governing protocols for therapy of the masticatory system. Proper design and placement of occlusal splints requires that they respond to precise indications and that practitioners fabricate and maintain them with scrupulous care to assure that patients benefit from them. Splints help practitioners adjust the relationship between the jaws either by suppressing blockage of teeth to relax muscles or by repositioning the condyles in the articular fossas to recapture discs or to reduce painful excess intra-articular pressure derived from degenerative diseases.

Occlusal splints are also suitable as diagnostic tools to validate and evaluate contributions of behavioral, postural, and psychosocial factors to the multifactorial etiology of malfunctions of the masticatory apparatus. The simple introduction into a patient’s mouth of an appliance whose benefits have been well described to that patient will serve as a forward step in the psychological management of a TMD problem, especially if bruxism is one of its components.

Objectives: dental anomalies are more frequent for individuals with clefts than for the general population. Our objective is to evaluate the prevalence of dental ageneses in a sampling from Alsace made up of 124 children with clefts (81 boys and 43 girls, average age 12.5 years old).

Method: clinical and radiographic exams make it possible to specify the dental formula as well as the type of clefts that are divided into 4 groups: simple Labial Clefts (LC – 12.9%), Labio-Alveolar Clefts (LAC – 4%), Labio-Palatal Clefts (LPC – 49.2%) and Palatal Clefts (PC – 33.9%).

Results: 63% of the patients present one or more ageneses mainly involving the maxillary lateral incisors (54%) and the maxillary or mandibular second premolars (32%). The percentage of children with congenitally missing teeth is, in ascending order, minimal in the case of LC (33%), average in the case of PC (54%) and highest in cases of LPC (79%). The frequency of ageneses increases proportionally with the severity of the cleft. The left side is most affected (p < 0.01) regardless of the side of the cleft.

Conclusions: dental ageneses are more frequent on the left side, regardless of the side of the cleft. The greater prevalence on the left side could suggest the intervention of overlapping etiopathogenic factors when clefts and dental ageneses are involved.

At one time or another all orthodontists have to deal with a patient in their daily practice who sufferers from a temporo-mandibular disorder. Usually not well trained in this area they avoid the problem by referring the patient to an ‘‘occlusodontist’’ even though the majority of these TMD problems can be resolved by simple non-invasive techniques that any dentist can readily perform.

In this article I describe the therapeutic sequence of events. When pain is present, practitioners devote the initial appointment to establishing a diagnosis of ‘‘painful disorder.’’ At the same time they must explain to their patients what the different psychosocial components of the TMD are. While the clinical examination practitioners conduct next is simple and speedily completed, its correct execution requires a certain apprenticeship. The result of properly concluded procedures is a precise diagnosis of the functional TMD problem.

Then I review the wide range of therapeutic possibilities that are currently available, which are comparable to those employed in medical rheumatology.

Finally, I present the treatment of a patient with TMD to illustrate the clinical application of this up-to-date approach.

In France, the Public Health Code was amended in 2004, and now allows dentists to treat facial tissues adjacent to the mouth: and hence, they can now bridge the gap between maxillary sinuses and the mouth area by performing hyaluronic acid injection procedures in the perio-buccal soft tissues.

Accordingly, the National Council of the Order of Dental Surgeons authorizes the practice of hyaluronic acid injection for therapeutic use.

In this article, we will define the legal framework for which we will be held liable as it pertains to hyaluronic acid injection procedures.

After explaining the physico-chemical properties of hyaluronic acid, we will study the mechanisms of ageing, the architecture of the face and various methods of injection.

We will look at the indications and counter indications for the use of hyaluronic acid injection, particularly in terms of its therapeutic usefulness for rehabilitating soft tissue when transitioning from a maxillary full-arch prosthesis to an implant born bridge.

Hyaluronic acid makes it possible to offset the lack of buccal margin of the resin-based removable prosthesis.

The concept of the appliance we describe in this article is based on a number of technological advances. The brackets, created in accordance with CAD/CAM are the product of an original process that makes them resistant to de-bonding providing a high resistance to bracket loss. They are also compatible with the use of a veritable straight wire enabling the use of prefabricated standard wires. The manufacturing process uses a maximum of digitized resources to elaborate a numerical set-up usable by the practitioners. A 3D computerised treatment control is performed from the beginning to the end of the assembly line and warrants a perfect precision of the bonding placement.

Appliances are completely personalized for each patient taking into account particular anatomic features as well as the prescriptions of practitioners. As a result practitioners will benefit from a number of theoretical advantages making treatment more pleasant and functionally smoother at every phase of therapy. Managing the Lingualjet appliance is simple and transforms straight wire lingual therapy into a procedure comparable in every way to traditional use of the straight wire in buccally bonded attachments.

With an average frequency of 1/800 births in France, labio-maxillo-palatal clefts (LMPC) are among the most frequent congenital malformations. They raise functional, esthetic, psychological and socio-familial problems that must be managed with an interdisciplinary approach. Within the medical team, the dentist must, by way of prosthetic restorations, compensate for certain sequelae and deficiencies. According to the severity of the case and the success of the treatments, the typical restoration can be limited to replacing the missing lateral incisor, or the restoration may require undertaking comprehensive treatments involving a much more specialized arsenal of surgical and prosthetic procedures.