Cleft lip and palate slideshare

CLEFT LIP AND

PALATE

Presented by:

Khushbu Agrawal

Dept of Orthodontics

CONTENTS

Introduction

Incidence

Embryology

Aetiology

Predisposing factors

Classification

Diagnosis

Problems associated with clefts

Syndromes associated with clefts

2

3

Management of Cleft lip and palate

• Timing of treatment sequence

• Presurgical Orthopedic treatment

• Nasoalveolar molding

• Alveolar Bone grafting

• Role of Orthodontist

• Orthognathic surgery

• Prosthetic rehabilitation

• Recent advances

• Other specialities

Conclusion

References

• Cleft lip and palate is the second most

common congenital anamoly after clubfoot

• Amoung the 15 types of orofacial clefting,

cleft lip and palate is the most common one.

4

INTRODUCTION

• Hippocrates (400 BC) and Galen (150 AD) mention cleft lip, but not

cleft palate in their writings

• Cleft palate – Fanco (1556)

• Repair of cleft lip – as early as 255-206 BC in China

• The first successful closure of a soft palate defect was reported in

1764 by LeMonnier, a French dentist.

5

Kingsley (1880)

- oral deformities as a branch of mechanical surgery

Calvin case (1921)

- a practical treatise on technique and principles of dental

orthopaedic and prosthetic correction of cleft palate

H.K.Cooper,Sr (1930’s)

- Introduced the integrated team concept and formed the Lanchester

cleft palate clinic

- True integration starts with a meeting of the minds of the individuals

who first examine the patient together and then agree on a program

together6

INCIDENCE

INCIDENCE

• Worldwide one in 600 (1:600)

• cleft lip with or without the cleft palate 9.92/10,000

• cleft lip 3.28/10,000, and cleft lip and palate 6.64/10,000

• Birth prevalence of clefts between 27,000 and 33,000 clefts per year

A child is born with a cleft somewhere in the world every 2 minutes

according to a WHO study published in 2001

Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189.

8

• Caucasian population, the prevalence of CL was 25%, CLP 50%,

and CP 25%

• In India meta-analysis of 25 early studies from 1960 to 1979 showed

incidence of CLP 1.08 and CL 0.23 in 100 live births

• In India alone the number of infants born every year with CLP is

28,600

78 affected infants are born every day, or 3 infants with clefts born

every hour


9

• More common clefts are –

• Unilateral clefts

• Males female ratio is 2:1

• Left sided

• Males more affected by cleft lip

• Females more affected by cleft palate

10


EMBRYOLOGY

EMBRYOLOGY

• Development of facial structures starts at the end of 4th week

• 5 facial prominences around stomatodeum

1. Unpaired frontonasal process

2. Paireed maxillary prominences

3. Paired mandibular prominences

12

Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

• In following 2 weeks –

• The 2 medial nasal processes fuse in midline – upper lip

• Mandibular processes fuse in midline – lower lip

13


• The maxillary and lateral nasal process separated by nasolacrimal

groove/duct

• Frontonasal process – bridge of the nose

• Medial nasal process – tip of nose and philtrum of upper lip

• Lateral nasal process – ala of the nose

14


• Primary palate – maxillary and medial nasal process merge

• Formation of intermaxillary segment from merged medial nasal

prominences

15


16


• Secondary palate – formed from 2 outgrowths from maxillary

prominences – palatine shelves

• Fuse in midline at 7th week

• Incisive foramen – midline landmark between primary and secondary

palate

17


Formation of clefts

• Failure of fusion of maxillary and medial nasal processes – anterior

to incisive foramen

• Failure of fusion of palatine shelves – posterior to incisive foramen

• Cleft lip – failure of proliferation of mesodermal cells in midline

18


Formation of clefts

19

ETIOLOGY

AETIOLOGY

Ancient Folk explanations

• Aztecs – eclipses occurred because a bite had been taken

out of the moon

• Prevented with an obsidian knife above the pregnant

abdomen

• Modern Mexico prevented with keys and safety pins

22

Early Chinese

• Eating rabbit “hare lip”

• Bad karma or wrong doings

Philippines

• Force to the fetal face

Familial or “In the blood”

23

Multi

factorial

Environ mental

Genetic

24

1] Genetic

• Genetic disorders are classified into 4 groups

1. Chromosomal

2. Single gene

3. Multifactorial – oral clefts

4. Mitochondrial

25

John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

2] Multifactorial because:

1) Chances increases if more than one family member if affected

2) More the severity, greater the chances of recurrence in sibling

3) Higher risk if affected individual is of less affected sex

4) Risk decreases in remotely related individuals

5) Consanguinity increases the rate because of sharing of genes

26

John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

2 unaffected parents with 1 child affected Risk for future children:

4.4% for CL+/-palate

2.5% for CP only

1 parent affected Risk for future children


6.8% for CP only

1 parent affected with 1 child affected Risk for future children


14.9% for CP only

27

3] Environmental factors

• Maternal smoking or tobacco exposure

• Viral infections

• Poor nutrition

• Certain Medicinal drugs

• Teratogens like:

Rubella virus, Cortisone/ steroids, Mercaptopurine,

Methotrexate, Valium, Dilantin

28

Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85

PREDISPOSING FACTORS

High maternal age

Diabetes

Toxemia

Reduced blood supply

Folic acid deficiency

Racial – mongoloids

Radiations

29

Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85

CLASSIFICATION

CLASSIFICATION

Bixler divided oral clefts into three groups

1. Syndromic / single-gene / chromosomal or environmental

1% of CLP AND 8% of isolated cleft palate

2. Familial

25% of CLP and 12% of isolated cleft palate

3. Isolated / non-familial

75% of CLP and 80% of isolated cleft palate

31

Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)

Davis and Ritchie’s classification (1922)

Group I: Prealveolar process cleft (clefts affecting the lip)1. Unilateral (right/left: complete/incomplete)

2. Bilateral (right: complete/incomplete; left: complete/incomplete)

3. Median (complete/incomplete)

Group II: Postalveolar process cleft (clefts affecting the palate)1. Soft palate

2. Hard palate

32


Group III: Alveolar process cleft (any cleft involving the alveolar

process)1. Unilateral (right/left: complete/incomplete)

2. Bilateral (right: complete/incomplete; left: complete/incomplete)

3. Median (complete/incomplete)

33


Victor Veau’s classification (1931)

A] Cleft lip

Class I : U/L notching of vermillion border, not extending into the lip.

Class II : cleft extending into the lip, but not including the floor of the nose.

Class III: extending into the floor of the nose.

Class IV: any b/l cleft of the lip, whether incomplete or complete.

34


35


B] Cleft palate

Class I : soft palate

Class II : soft/hard palate extending no further than incisive foramen.

Class III: complete unilateral cleft, extending from uvula to incisive

foramen, then deviating to one side

Class IV: two clefts extending forward from the incisive foramen into the

alveolus.

36


37


Fogh-Andersen’s classification (1942)

1. H arelip (single or double)

2. H arelip with cleft palate

3. Isolated cleft palate

4. R are atypical clefts, e.g., median cleft lip

38


Kernahan and Stark’s classification (1958)

1. Clefts of structures anterior to the incisive foramen

2. Clefts of structures posterior to the incisive foramen

3. Clefts affecting structures anterior and posterior to the incisive

foramen

39


American Cleft Palate–Craniofacial Association (ACPA)

classification (1962)

1. Clefts of the prepalate (cleft of lip and embryologic primary palate)a. Cleft lip (cheiloschisis)

b. Cleft alveolus (alveoloschisis)

c. Cleft lip, alveolus, and primary palate (cheiloalveoloschisis)

2. Clefts of the palate (cleft of the embryologic secondary palate)a. Cleft of the hard palate (uranoschisis)

b. Cleft of the soft palate (staphyloschisis or veloschisis)

c. Cleft of the hard and soft palate (uranostaphyloschisis)

40


3. Clefts of the prepalate and palate (alveolocheilopalatoschisis)

4. Facial clefts other than prepalatal and palatala. Cleft of the mandibular process

b. Naso-ocular clefts

c. Oro-ocular clefts

d. Oroaural clefts

41


Kernahan and Stark’s stripped Y classification (1971)

42


Spina’s classification (1973)

Group I: Preincisive foramen cleftsa. Unilateral

b. Bilateral

c. Medial

Group II: Transincisive foramen cleftsa. Unilateral

b. Bilateral

Group III: Post incisive foramen clefts a. Total

b. Partial

Group IV: Rare facial clefts43


Kernahan and Stark’s

stripped-Y:

Modification by Ehlsaky

(1973) and Millard

(1976)

44

Schuchardt and Pfeifer’s symbolic classification

left Right

Lip

Alveolus

Hard palate

Soft palate

Total cleft

Partial

45


LAHSHAL classification by Okriens (1987)

Lahshal is a paraphrase of the anatomic areas affected by the

cleft.

L – lip

A – alveolus

H – hard palate

S – soft palate

H – hard palate

A – alveolus

L – lip

46


DIAGNOSIS

DIAGNOSIS

• Prenatal ultrasound – 2D or 3D

• Prenatal counselling

• 22% to 33% rates for detecting facial clefts

• 73% - fetal cleft lip

• 1.4% - isolated cleft palate

• Color Doppler ultrasonography can also be used

48

Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012

Ultrasound technique

- Non-invasive diagnostic tool

- Confirm fetal viability

- Determine gestational age

- Establish number of fetuses and their growth

- Check placental location

- Examine fetal anatomy for detecting malformations

49


Transabdominal US

- Not reliable till gestational age of 15 weeks

- Done at 20 or more weeks of gestation

Transvaginal USG

- Earlier visualization (12 weeks)

- Better image resolution

- Greater specificity and sensitivity

50


Babcock and McGahan (1997)

- Starts with coronal plane

- Assessment continues in axial view

- Bilateral clefts: sagittal view

- Isolated clefts: axial view

51


Advantages of prenatal cleft diagnosis

- Psychological preparation for parents to have realistic expectations

- Parent education for cleft management

- Preparation for neonatal care and feeding

- Opportunity to investigate other abnormalities

- Possibility of fetal surgery

52


Disadvantages of prenatal cleft diagnosis

- Emotional disturbance

- High maternal anxiety and dysfunction

- Termination of pregnancy

53


PROBLEMS ASSOCIATED

WITH CLEFT LIP & PALATE

55

Dental

Skeletal

Nasal

Feeding

Ear problems

Speech

Associated anomalies

*Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20

DENTAL

Tooth agenesis, hypodontia (most common)

Supernumerary teeth (2nd most common)

Enamel hypoplasia (CI)

Crossbites

Ectopic eruption, transposition

Taurodontism, dilacerations

56

*Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20

57

SKELETAL

Maxillary deficiency

Mandibular prognathism

Class III malocclusion

Concave profile

*Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara, Dental Anomalies of Number in The Permanent Dentition of Patients

With Bilateral Cleft Lip: Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476.

58

FEEDING PROBLEMS

Oronasal fistulas

Draining of oral fluids in nasal cavity and vice versa

Bottle, cup and spoon, tube feeding

Infant held at 30-450 angle to aid swallowing

SYNDROMES ASSOCIATED

WITH CLEFT LIP & PALATE

SYNDROMES

Around 400 syndromes

Chromosomal anomalies

• Trisomy 13 (Patau)

• Trisomy 18 (Edward)

• Trisomy 21 (Down’s)

• Velocardiofacial syndrome (22q11 deletion)

60

*Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994

Inherited syndrome

• Sticklers (Autosomal dominant)

• Treacher Collins (AD)

• Van der Woude (AD)

Non-inherited syndrome

• Pierre Robin Syndrome – triad of cleft

palate, glossoptosis, retrognathia

• Goldenhar syndrome

61


Teratogenic

• Fetal alcohol syndrome

• Fetal phenytoin syndrome

• Fetal valproate syndrome

62


MANAGEMENT OF CLEFT LIP

& PALATE

64

MULTIDISCIPLINARY MANAGEMENT

CLEFT TEAM

Dentist

Surgeon

Nursing

Genecists

Social worker

Ophthalmologist

Psychologist

Paediatrician

Speech therapist

ENT/ audiologist

65

TIMING AND SEQUENCING OF CONSERVATIVE

SURGICAL-ORTHODONTIC TREATMENT (1980s)

*Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod 1996;2:169-184

66


Philadelphia Centre for research in Child growth-

Wilton Krogman (1947-71)

Divided the treatment into 8 phases:

• First stage – Prenatal phase

Complete history of gestation and maternal health, counseling of the parents

Genetisist and other Social workers

67

• Second stage – at birth

Pediatrician discusses the condition with the parents,

Surgeon advises about the operative plan,

Dental specialists appraises the arch relationships

• Third stage – birth to 1 year

Pediatrican - advises about the feeding

Surgeon - carries out the lip closure (rule of 10)

Dental specialist - secures the models and radiographs

Speech therapist - discusses about the insufficiency and incompetence of the

pharyngeal seal68

• Fourth stage – 1-2yrs

Pediatrican - takes care of the health and nutrition.

Surgeon carries out the closure of the hard palate 1:2 soft palate 1:6

Speech therapist - monitors the vocabulary and option of a prosthetic

replacement

ENT - monitors the ear condition.

• Fifth stage – 2-6 years

Orthodontist – arch relations, crossbites, developing malocclusion

69

• Sixth stage – 6-12 years

Surgical corrections - secondary closure /repair of palate, lip and the nose

• Seventh stage – 12-18 years

Surgical follow up on the lip and nose correction, orthodontic treatment is

continued

• Eighth stage – 12 years onwards

Regular patient follow-up

70

1. No preoperative orthopedics.

2. Closure of Cleft lip in infancy – Millard procedure -3 months

3. Closure of the remaining isolated cleft – Von Langenbeck -18

months.

4. Secondary operations 18-30 yrs of age.

71

Cleft Lip and Palate Patients Management in OSLO-

Norway (1948)

1. Pre dental treatment-1-18 months of age.

2. Deciduous dentition 3-6 yrs of age-full eruption of primary dentition.

3. Early mixed dentition 7-9 yrs- after or during the eruption of

permanent maxillary incisors.

4. Late mixed and early permanent dentition 9 ½ yrs onwards

72

FISHMAN

1. Infancy – before the initial surgical repair of the lips.

2. During late primary and early mixed dentition.

3. Late mixed and early permanent dentition.

4. Late teens (after completion of facial growth in conjunction with

orthognathic surgery).

73

PROFITT

74

*Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.

Neonatal • Birth to 1 year

Deciduous dentition

• 1 to 6 years

Mixed deentition

• 6 to 12 years

Permanent dentition

75

• 12 years and adult

• Hoffman (1678) – extraoral devices to retract protruding premaxilla

• McNeil (1950s) – presurgical orthopaedic

• Hotz – premaxilla is normally placed, by age 10, face grows

downward and forward into balance with premaxilla

76

NASOALVEOLAR MOULDING


• Grayson (1993) – first technique to correct the alveolus, lip and

nose in cleft infants

• Matsuo (1988)

- Research for cartilage moulding

- high maternal level of estrogen at the time of birth correlates with an

increase in hyaluronic acid, which inhibits the linking of the cartilage

intercellular matrix

77


• Matsuo used a stent, silicone tubes to shape the nostrils

• Grayson (1999) adapted his nasal stent to extend from the anterior

flange of an intraoral molding plate.

• This new technique was named – “ Nasoalveolar molding”

78


Objectives:

• Reduce severity of initial cleft deformity

• Columella – Nonsurgical lengthening (in bilateral clefts) and uprighting (in

unilateral clefts)

• Reduction in the width of the alveolar cleft segments until passive contact

of the gingival tissues is achieved.

79


80

Procedure:

• A heavy-bodied impression material is used to take the initial

impression as soon after birth as possible.

• Grayson and Maull (1999) held infant in upside down position to

keep the tongue forward which permitted fluids to draw off the oral

cavity when impression tray is placed

• Yang (2003) took the impression using a pre-trimmed customized

pediatric tray with the baby being held in the erect position,

by one of the parents


• Prashanth (2013), Mishra (2010) obtained impression when the infant

was awake in a prone position on the dental chair, the child is held

on the lap of their parents with no anesthesia.

• Dubey (2011) made impression of the cleft region upper arch using

ice cream stick and impression compound.

81


• Plate – clear self-cure acrylic, trimmed with a denture soft material

• 2–3 mm in thickness

• The retention arm – 40 degrees to get appropriate activation and to

avoid dislodgement of the NAM plate from palate

82


• The nasal stent is added to the intraoral molding plate when the

cleft alveolar gap is reduced to 5mm or less

• Stent – 0.036-in gauge round stainless steel wire

• The intranasal portion is formed from hard acrylic, covered with a

thin layer of soft spongy acrylic denture liner

83


• Elastics used are 0.25 inch and it should be stretched about two

times the diameter for activation force of about 2 Oz

84


85


86

Complications and disadvantages:

• Irritation of the oral mucosal or gingival tissue

• Ulceration of intraoral tissues

• The intranasal lining of the nasal tip can become inflamed

• Skin irritation due to tape usage

• Parent compliance required

• Moulding plate may get dislodged and obstruct the airway


87

Benefits:

• Short-term: the tissues are well aligned prior to primary lip and nose

repair

• Long-term:

• change in nasal shape is stable

• Reduced number of surgical revisions

• Reduction of treatment cost

• Shetty V et al (2017) - improves arch symmetry and stability, and thus

may prevent arch collapse in the long term


CLEFT LIP REPAIR

88

• Goal: improve facial aesthetics by restoring nasal and lip contour

• Timing: 3 to 6 months

• Millards “RULE OF TEN”

[term coined by Wilhelmmesen and Musgrave in 1969]

• 10 weeks (age)

• 10 pounds (weight)

• 10 gm/dl (Hb)

89

Techniques:

1. Tennison – Randall (Z-Plasty)

2. Millards rotation advancement repair

3. Rose – Thompson straight line repair

PRESURGICAL ORTHOPEDIC TREATMENT

90

Presurgical orthopedic treatment (PSOT) ?????

Many authors – many minds

PSOT beneficial or not ??


1920s -1930s – repair the defect by establishing an anatomical

continuity

Priority of treatment

- Improve speech ability

- Dental function

- Facial aesthetics

Importance of growth not recognized

91


1950s – Two schools of thoughts

92

• McNeil and Burston

• Align palatal segments

• Delay palatal closure till 5-9 years of age

Presurgical Orthopedics

• Led by Pruzansky

• Did not favour PSOT

• Palatal closure at 2-4 years of age

Immediate surgery


A Millard-Latham Procedure

93

Latham manipulated the palatally pinned presurgical

orthopaedic appliance – mechanical expansion of the

lateral palatal segments is followed by the retraction of the

protruding premaxilla into position within the arch

Floor of nose is surgically closed

Gingivoperiosteoplasty – migration of alveolar bone cells –

close alveolar gap


94

Modified appliance – a premaxillary stainless steel

pin 7/10 mm in diameter is inserted through the

posterior stem of the premaxilla.

3 Oz force per side for premaxilla retraction

Premaxilla retraction and expansion

8-14 days – premaxilla is positioned within the

palatal segments


95

CHANGING SURGICAL CONCEPT FROM 1920S TO

1950S

• Graber (1950s) – surgery performed early, caused severe midfacial

deformity later

• Brophy, first proponent of surgical technique – steel-clamp and

silver-wire bony closure technique

• von Langenback soft tissue procedure alone to approximate lateral

halves of maxilla and reduce intermaxillary width


• Graber, Slaughter and Brodie (1950s-1960s) – negative reports on

surgical procedure done at an early age

• “No palatal surgery at an early age” (before 12 months)

• James Scott (1956) – Sutural growth theory

• McNeil and Burston – adopted his theory – functional paediatric

prosthesis – palatal closure between 5 to 9 years of age

96


• Melvin Moss (1968) – functional matric theory – septal cartilage

grows as a secondary response

• McNeil – Father of presurgical orthopaedics – supported Scott’s

theory

• Burston – premaxilla was normal and lateral palatal segments were

retruded in face

• Presurgical orthopaedics + primary bone grafting within first year of

life

• Prusanky – opposed the same

97


CLAIMED BENEFITS OF PSOT

• Control and modify postnatal development of maxilla

• Early alignment for better occlusion and function – swallowing and

speech

• Reduce middle ear infections

98


• Berkowitz (1978) – “State of art”

• Primary bone grafting – deleterious effects on midface

• No evidence that PSOT normalize feeding, tongue posture,

swallowing or growth

99


CONSERVATIVE TREATMENT – THE BEST APPROACH

• Same surgery performed can cause in different results at different

ages:

1. The cleft defect

2. The facial growth pattern

3. The surgical procedure

100


101

CLEFT PALATE SURGERY TIMING AND SPEECH

OUTCOME

1970s

• Mid to late 1970’s – 18 to 24 months surgical palate repair

• General trend of better speech results with earlier ages at surgery

• Jolleys (1954) – approximately 90% of children who underwent

surgery before the age of 2 years had good or excellent speech

• General age range for surgery – 6-9 months, before 8 months, 1

year range, between 2 to 3 years

*Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191

1980 – 1990s

• Kaplan (1981) – palatal closure between age of 3 to 6 months

• Dorf and Curtin (1982,1990) – importance for phonemic

development or articulation age

• Greater discrepancy in speech performance between the "12

months and younger group" and the children operated on over the

age of 12 months

• Ross (1987) – slightly better facial growth if surgery done in the first

year of life

102

*Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191

SURGERIES FOR CLEFT PALATE

1. Von Langenback

2. V-Y palatoplasty by Veau

3. Furlow’s technique

4. Wardill Kilner’s push back

103

104

BONE GRAFTING FOR ALVEOLAR CLEFT

DEFECTS

BONE GRAFTING

Primary bone

grafting

First 2 years of life

Secondary bone

grafting

Early – 2 to 5 years of life

Late – 11 to 14 years of life

*Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196

OBJEVTIVES FOR SURGICAL GRAFTING:

• Stabilization of segments

• Improved oral hygiene

• Nasal secretions prevented from draining into the mouth

• Unites maxilla to better withstand occlusal forces

• Bony base for teeth eruption

• Improves nasal symmetry

• Provide feeling of normalcy and improve social acceptance

105


BONE GRAFTING AND ORTHODONTIC TOOTH MOVEMENT

• A general rule – “orthodontic tooth movement performed with

improved outcomes after the bone graft has been completed”

• Tooth movement initiated 1 to 3 months after grafting into the grafted

area

106


SURGICAL MANAGEMNT OF ALVEOLAR CLEFT

• Ideal timing:

- 9 to 11 years of age

- Before canine eruption, canine root is 1/3rd formed (Bergland et al)

• Best source of bone graft: (autologous cancellous bone)

- Anterior portion of iliac crest

- The rib, tibia

- The cranium

- The mandible

107


109

ROLE OF ORTHODONTIST

*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.

A] NEONATAL MAXILLARY ORTHOPAEDICS

• McNeil (1950)s – Father of presurgical orthopaedics

• Rationale – realignment of collapsed segments

• Active or passive orthopaedic appliances

110


B] ORTHODONTIC-ORTHOPAEDIC TREATMENT IN DECIDUOUS

DENTITION

• Problems in deciduous dentition:

- Delay in eruption in vicinity of cleft

- Malformed or congenitally missing lateral incisor

- Anterior or posterior buccal crossbite

- Functional shift

111

*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204

• Turvey (1982) believe that orthodontic treatment in the deciduous

dentition, although possible, is contraindicated

• Rygh and Tindlund (1988) – Growth modification at this stage has

been proposed

• They recommend utilization of a quad-helix appliance soldered to

bands on the primary second molar teeth and canines to expand the

upper arch

• Alongwith protraction face mask to modify and redirect growth

112


C] ORTHODONTIC TREATMENT DURING THE MIXED DENTITION

• Bone grafting:

• 5 to 6 years of age

• After 8 to 9 years of age

• Radiographically, after root of unerupted canine is half or one-third developed.

113

*Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204

• Orthodontics – 6 months before grafting

• Fixed appliance in upper arch

• Objectives at this stage:

- Expansion of maxilla,

- elimination of crossbites, derotations of malposed teeth,

- improve dental and aesthetic function

• Spontaneous canine eruption (27%), surgical uncovering (17%),

combined surgical and orthodontic traction (56%)

• Orthodontics resumed 3 months after graft placement

114


Expansion appliances for cleft palate patients:

1. Telescopic maxillary expander

2. Fan shaped maxillary expander

3. Butterfly maxillary expander

4. Spring jet for slow expansion

5. Banded / bonded rapid palatal expansion

6. Modified hyrax appliance

7. Quad helix115

Protraction Facemask Therapy:

• Can be used before bone grafting in mild midfacial deficiency

• Increased growth at circumaxillary sutures

• Orthopaedic force – 350 to 500 gram/side

• 10-12 hours a day

• 12-15 months

116

D] ORTHODONTIC TREATMENT DURING THE PERMANENT

DENTITION

• Decision – orthodontics alone OR orthodontic combined with

orthognathic surgery

• Ross (1987) – 25% require surgery

• 3 consecutive cephalogram, 6 months apart showing no change in

length of mandible can be used

117


TREATMENT BY ORTHODONTICS ALONE

1. Tooth alignment

2. Establishment of a continuous maxillary arch with favourable archform

3. Correction of anterior and/or posterior crossbites

4. Stability of occlusion in the presence of dental compensations

5. Favourable dentofacial esthetics

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TREATMENT BY ORTHODONTICS COMBINED WITH

ORTHOGNATHIC SURGERY

• Severe skeletal discrepancy, oronasal fistulas, speech deformity

• Maxillary surgery – multiple segment Le Fort I osteotomy with down-

grafting

• Presurgical orthodontic treatment – 12 months

• AP discrepancy – more than 8mm – bijaw surgery needs to be

planned

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• Unilateral clefts – 2 piece Le Fort I osteotomy

120

*Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14

• Bilateral clefts – 3 piece Le Fort I osteotomy

121

*Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14

• Post-surgical orthodontic – 4 to 6 months

• Transverse maxillary stabilization by transpalatal arch or piggy-back

overlay arches

• Immediate retainers – Hawley’s type

• Cemented lingual arch in maxilla

• Vaccum formed retainers not indicated

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• Ambrose Pare (1565) – prosthesis to obturate palate

• Obturators using sponges, wax, and silver to more modern

materials

• Latham appliance (1980) – unilateral or bilateral clefts

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PROSTHETIC REHABILITATION FOR CLEFT PALATE

PATIENTS

*Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19

Restorative treatment options in permanent dentition

• Partial overdenture

• Removable partial dentures

• Fixed prosthetic rehabilitation

• Implant prosthodontics

• Restoration – laminates and veneers

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Velopharyngeal impairment – insufficient contact

between the velum and the posterior and lateral

pharyngeal walls

Velopharyngeal insufficiency – deficiency

Velopharyngeal incompetence – neuromuscular

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VELOPHARYNGEAL IMPAIRMENT

*Dalston R. Velopharyngeal Impairment in the orthodontic patients. Semin Orthod 1996;2:220-7.

Treatment

1. Speech therapy

2. Non-surgical or speech aid prosthesis

• Obturators

• Transitional appliance in growing patients

3. Surgical

• Palatoplasty, Sphincter pharyngeoplasty

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• Fetal surgery – done in intrauterine life (prior to 20 weeks)

• Non-life threatening defects like cleft lip, cleft palate, Pierre Robin

syndrome, Treacher-Collins syndrome, craniofacial microsomia

• Open fetal surgery

• Feto-endoscopic approach

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RECENT ADVANCES

*Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607

ADVANTAGES

1. Provide a scarless repair, “ripple effect” is eliminated

2. Correct the primary deformity,

3. Prevent secondary deformities, and

4. Give the parents a "normal“ - appearing child at birth

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*Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607

CONCLUSION

• Oral clefts are the second most common congenital anamoly, having

multifactorial origin

• A considerable knowledge about the etiology and embryology is

required for proper diagnosis and treatment planning of such patients

• Treatment begins soon after birth and continues till adulthood

requiring a team approach.

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CONCLUSION

• Multiple problems and syndromes with clefts

• Multidisciplinary approach for management, patient-centered

• Variations in treatment sequence

• Role of orthodontists

130

REFERENCES

• Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra

Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–9.

• Allori AC et al. Cleft lip and palate classification: Then and Now. Cleft

Palate–Craniofacial Journal 2016;53(1)

• Graber Vanarsdall and Vig. Orthodontics: Current Principles and

Techniques. Elsevier 2012.

• John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification,

etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168

• Inderbir Singh. Human embryology. Macmillan India. Seventh edition 2001.

• Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85

131

REFERENCES

1. Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012

2. Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate

Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20

3. Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara,

Dental Anomalies of Number in The Permanent Dentition of Patients With Bilateral Cleft Lip:

Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476.

4. Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994

5. Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate

Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin Orthod

1996;2:169-184

6. Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech

Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod

1996;2:185-191

132

7. Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.

8. Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-

196

9. Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-

204

10. Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod

1996;2:205-14

11. Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod

1996;2:215-19

12. Dalston R. Velopharyngeal Impairment in the orthodontic patients. Semin Orthod

1996;2:220-7.

13. Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new

perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607

14. Chang J. Fetal plastic surgery: a review and preview. © Chang www.thefetus.net/

133

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