Department of orthodontics & dentofacial orthopedics

k.s.r.institute of dental science & research

CLEFT LIP AND PALATE

Guided byDr.S.Tamizharasi.M.D.SProfessor

Presented byDr.N.Meiyappan3rd yr PG student

Introduction

Epidemiology

Etiology

Classification

Diagnosis(Investigations) Of Cleft Lip And Palate

Orthodontic management

- Treatment In Primary Dentition

- Treatment In Mixed Dentition

- Treatment In Permanent Dentition

- Surgical management

- Distraction Osteogenesis

Conclusion

References

SYNOPSIS

INTRODUCTION

One in 700 live births globally.

Afghans (4.9%)

Negroids (0.4%)

In south india , cleft lip and palate is 1.15 and isolated

cleft palate 0.08 /1000

The incidence of oral clefts is seen more in males than

in females.

Text book of Orthodontics- O.P.Kharbanda

EPIDEMIOLOGY

Cleft lip alone- males › female

Cleft palate- females › males

Unilateral is more common than bilateral

Left is 2 times more common than right

Text book of Orthodontics- O.P.Kharbanda

ETIOLOGY

Heredity

Environmental

Malnutrition

Infections during pregnancy

ETIOLOGY

1) HEREDITY

Transmitted through a male as sex linked recessive gene.

a) Monogenic/ single gene disorder

b) Polygenic/ multifactorial inheritance

c) Chromosomal abnormalities:

- Down’s Syndrome

- Edwards Syndrome (Trisomy 18)

2. ENVIRONMENTAL FACTORS:

Usually occurs due to various influences

Excessive Alcohol

Cigarette smoking

Anti epileptic drugs. - diphenyl hydantion and

trimethadione

3. MALNUTRITION:

Folic Acid

Deficiency of folic acid affects the neural

tube- neural crest cell migration and differentiation.

4. INFECTION DURING PREGNANCY

Davis And Ritchie’s Classification -1922

Veau’s Classification - 1931

Fogh-anderson Classification - 1942

Schuchardt And Pfiefer’s Classification

Kernahan And Stark Classification - 1958

Kernahan’s Striped Y Classification

CLASSIFICATION

Millard’s Modification Of Kernahan’s Classification

Lahshal Classification

American Cleft Palate Association -1962

Internationally approved classification- 1967

VEAU’S CLASSIFICATION (1931)

KERNAHAN AND STARK CLASSIFICATION 1958

GROUP A : Clefts of the primary palate

GROUP B : Clefts of the secondary palate

GROUP C : Clefts of the primary and secondary palate

SCHUCHARDT AND PFIEFER’S CLASSIFICATION

LIP

ALVEOLUS

HARD PALATE

SOFT PALATE

KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971)

MILLARD’S MODIFICATION OF KERNAHAN’S CLASSIFICATION (1977)

LAHSHAL CLASSIFICATION

L - Lip

A - Alveolus

H - Hard palate

S – Soft palate

H – Hard palate

A - Alveolus

L - Lip

AMERICAN CLEFT PALATE ASSOCIATION

A. CLEFTS OF THE PRE –PALATE :

Cleft of the lip

Cleft o f the alveolus

Cleft of the primary palate

B. CLEFTS OF THE PALATE :

Cleft of the hard palate

Cleft of the soft palate

INTERNATIONALLY APPROVED CLASSIFICATION- 1967

DIAGNOSIS

PRENATAL DIAGNOSIS

Ultrasonography is a non invasive diagnostic tool which is now

routinely used as a part of prenatal diagnosis.

TIMING OF DETECTION :

Christ and Meninger :

Optimal imaging of the fetal face is not reliable with

transabdominal

ultrasonograpy until gestational week 15.

Robinsen et al :

Greatly improved when performed after 20 weeks of

gestation.

ADVANTAGES :

Psychological preparation of the parents and caregivers

Education of parents on management of cleft

Preparation for neonatal care and feeding

Opportunity to investigate for other abnormalities

DISADVANTAGES :

Emotional disturbance and high maternal anxiety

Chances to terminate pregnancy.

MANAGEMENT TEAM

NEONATAL AND INFANT MANAGEMENT

THREE MAIN PRINCIPLES:

Establishment Of Feeding

Pre-surgical Maxillary Orthopedics

Naso-alveolar Moulding

CLEFT PALATE :

1. Inability to create negative pressure for suckling

2. Nasal regurgitation

3. Chances of choking and cyanosis

4. Engulfing of trapped air which needs frequent

burping

ESTABLISHMENT OF FEEDING

FEEDING POSITION FOR A CLEFT CHILD

A semi upright position ( 30˚ to 45˚ ) – reduces nasal regurgitation

Feeding should not be hurried

FEEDING OBTURATOR

The feeding obturator is a prosthetic aid that is

designed to obturate the cleft and restore the

separation between the oral and nasal cavities.

INFANT / PRE SURGICAL ORTHOPEDICS

Pre surgical orthodontic or neonatal maxillary

orthopedics is initiated during the 1st or 2nd week

following birth.

Introduced by McNeil and popularized by Burstone

in 1950s .

Good functioning palate, normalise tongue

positions and help in speech development.

Two movements must be carried out

Expansion of the collapsed segments and

Pressure against pre maxilla to its correct position.

THE MILLARD LATHAM PROCEDURE

Split plastic appliance – pinned to

both lateral palatal segments for

maximum retention

S.S pin – 0.7 mm diameter.

Orthopedic force in newborn – 8

to 14 days

Followed by

alveoloperiosteoplasty

Palatal cleft space – closed with

Von Langenback procedure at

18 to 24 months

Seminars in Orthodontics – September 1996; Vol 2, No 3.

NASO ALVEOLAR MOULDING

Nasoalveolar molding is a new nonsurgical method of

reshaping the gums, lip and nostrils before cleft lip and palate

surgery, reducing the severity of the cleft.

Initiated within 4-8 weeks of birth and finished before primary

closure of lip.

Used for 4-6 months

ADVANTAGES

Proper alignment of the lip, alveolus and nose helps the

surgeon to achieve a better and more predictable surgical

result

The cleft deformity is significantly reduced in size.

Studies have demonstrated that 60 % of patients who

underwent NAM and gingivoperioplasty did not require

secondary bone grafting.

COMPLICATIONS

Irritation to the oral mucosa, gingival tissue or nasal mucosa.

Irritation to the cheeks

LIP CLOSURE

A good lip seal is essential for phonation ,

articulation and for optimal balance of muscular

forcesin the orofacial region.

TIMING OF LIP CLOSURE :

At the age of 3 months (or) 10 weeks.

Techniques

1. Tennison’s triangular flap

2. Millard rotation flap

‘THE RULE OF 10’

Weight - 10 lbs

Age - 10 weeks

Hb - 10 gm %

PALATE CLOSURE

Objective:

Join the cleft palatal edges,

Lengthen the soft palate,

The timing of closure is controversial. Can be

done early at 12-18 months or at 9-12year

Surgery and scarring shouldnot adversely affect

the dentition and growth of the maxilla

RECENT THOUGHT

Closure of soft palate –age of 12 month

Help in development of Speech

No growth retardation with early soft palate

closure

Closure of hard palate –age of 5-6year

Hard palate repair timing and facial growth in cleft lip and palate : A systematic

review - Yu-Fang Liao, Michael Mars . Cleft palate – Craniofacial Journal,

September 2006, Vol 43, No 5.

Velopharyngeal insufficiency is a disorder resulting in

the improper closing of the velopharyngeal sphincter

(soft palate muscle in the mouth) during speech,

allowing air to escape through the nose instead of the

mouth.

VELOPHARYNGEAL INSUFFICIENCY

During speech, the velopharyngeal sphincter must

close off the nose to properly pronounce strong

consonants such as "p," "b," "g," "t" and "d."

The two main speech symptoms of velopharyngeal

insufficiency are:

Hypernasality and Nasal air emission.

Speech Therapy

Some speech problems linked with VPI, such as

mispronouncing words, can be treated by speech therapy.

TREATMENT OF VPI

Sometimes an obturator is recommended to treat VPI.

Modified obturator called speech bulb appliances are

useful where palatal lift or soft palate closure is needed .

Pharyngoplasty and palate lengthening are performed to

maintain velo-pharyngeal seal

Orthodontic Intervention

During Mixed Dentition(7-

12 yrs )

GOALS IN MIXED DENTITION

Maxillary Expansion

Alveolar Bone Graft

Primary

Secondary

Aimed at providing a bony bridge to the cleft in the

alveolus area.

Primary - first few days – 2.5 yrs of age .

Early secondary - 2- 5 yrs

Intermediate or secondary – 6- 13 yrs

Late – after 13 yrs .

Primary and early secondary are not in practice bec of

additional surgery required.

ALVEOLAR BONE GRAFT

Boyne and Sands in 1972.

Aimed to bridge the cleft segment with grafted

cancellous bone.

MERITS

Elimination of bony clefts and encouraging normal

eruption of lateral incisor and canine through

cancellous bone.

Secondary alveolar bone grafting

Orthodontic closure of cleft space becomes possible .

Helps in closure of oronasal fistulas.

Provides bony support to alar base and improvement in

aesthetics.

Stabilization of maxillary segments – helpful during surgery

TIMING OF SURGERY

Based on root formation of lateral incisor and canine.

Favor of 8-10 year of age (when canines about to erupt-

one quarter to two thirds of root complete)- Bergland et

al

Erupting tooth is a potent stimulus for bone formation.

After tooth eruption is complete, it can be very difficult to

induce the formation of new bone.

PRE –BONE GRAFT ORTHODONTICS

Contributes to better access of site for the surgeon.

Maxillary arch expansion using Quad helix appliance

Bergland and coworkers – index to evaluate success of the

grafted bone based on the height of interdental septum on

IOPA .

TYPE I – normal

TYPE II – 75% of normal bone height

TYPE III- less than 75%

TYPE IV – no bony ridge

POST BONE GRAFT FOLLOWUP

Orthodontic management in permanent dentition stage

Two to three years after bone graftng ,

comprehensive orthodontic treatment can be

started.

If the lateral incisor is present and viable in cleft

region . Every attempt shouldbe made to preserve

it.

Completed by 15 yrs of age.

Rigid palatal retainers – wire framework soldered

on molar bands are considered to maintain arch

alignment and expansion.

ORTHOGNATHIC SURGERY COMBINED WITH ORTHODONTICS

Due to severe skeletal discrepancy, there is

Deterioration of esthetics and occlusion,

Psychological implications leading to low self

esteem,

Defective speech,

Oronasal fistulas.

Such cases require a combined orthodontic and

orthognathic approach.

Maxillary advancement

To correct the size and position of

maxilla.

Multiple segment LeFort I osteotomies –

To correct the transverse problem.

For a bilateral CLCP three-piece maxillary surgery (allows

rotation of segments )

For unilateral CLCP a two piece is sufficient.(Vlachos 1996)

SURGICAL PROCEDURES IN A CLEFT PATIENT

Severe cases - May require bi jaw surgery.

Proffit recommends overcorrecting the anterior cross bite

in excess of positive over jet- compensate for post surgical

relapse.

In cases with an over jet of more than 8mm mandibular

surgery (BSSO) also must be considered. Skeletal facial balance and harmony in the cleft patient- principles and

techniques in orthognathic surgeryIndian J Plast Surg 2009 vol 42 No 1

DISTRACTION OSTEOGENESIS

1903 .- Dr. Gavril of Russia-Bone lengthening of leg.

Introduced in ORTHODONTICS BY ILIZAROV IN 1950

It is a procedure by which formation of new bone is induced

by external tension created by distracting devices at the site of

osteotomy.

The distractor is gradually adjust over a period of days or week

to stretch the osteotomy site so that new tissue fills it.

Ross and Subtenly

Distraction osteogenesis

Allows soft tissue adaptation, including scar tissue.

Doesn’t cause a problem with velo- pharyngeal

insufficiency .

Distraction Of maxilla first proposed by Molina & Oritz-

Monasterio(1998)

Maxillary distraction devices

External distractors Internal distractors

External frame distraction of the midface in cleft palate patientsEur J Orthod 2009 vol 41

EXTERNAL DISTRACTORS

Advantage:

Direction of force is well controlled

Dis advantage:

Cranial surgery is required

Esthetics are compromised

INTERNAL DISTRACTORS

Advantage:

Esthetics

Psychological relief

Disadvantage:

Difficult to control the direction of force

Prosthodontic Treatment:

It may be required in cases where replacement of missing

teeth is essential. Removable or fixed prosthesis may be

given. It allows for improved speech and better esthetics.

CONCLUSION

Treatment of a child with cleft lip and cleft palate begins

from the day of born. psychological counselling of the

parent and full team effort in which an orthodontist plays a

vital role and works with various specialists to provide

quality care to the patient and to start hloistic treatment

planning.

REFERENCES

Orthodontic Current Principles and techniques –

Graber and Vanarsdall - 5th Edition

William R. Proffit. Contemporary Orthodontics. 5TH

Edition

Textbook of Orthodontics – O.P.Kharbhanda

Cleft lip and cleft palate – diagnosis and management

2nd edition – Samuel Berkowitz

Cleft lip and cleft palate – Seminars in Orthodontics –

September 1996; Vol 2, No 3.

Pre surgical Naso alveolar molding treatment in cleft

lip and palate patients – Barry H. Grayson, Indian

J Plast Surg Supplement 1 2009 vol 42.

Indian J Plast Surg Supplement 1 2009, vol 42.

External frame distraction of midface in cleft patients - Indian

J Plast Surg

supplement 1 2009 Vol 42.

Velopharyngeal impairment in orthodontic population-

Seminars in Orthodontics – September 1996; Vol 2, No 3.

Alveolar grafting - Indian J Plast Surg 2009 vol 42 no 1

Hard palate repair timing and facial growth in cleft lip and

palate : A systematic review - Yu-Fang Liao, Michael Mars .

Cleft palate – Craniofacial Journal, September 2006, Vol 43, No

5.

Thank you