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Cleft lip and palate by almuzian Cleft lip and palate by almuzian Document Transcript

  • Cleft Lip & Palate From Orthodontic Point of View Doctorate of Clinical Dentistry in Orthodontics (Notes) Orthodontic Dept. University of Glasgow By: Mohammed Almuzian 2012
  • Table of Contents Table of Contents......................................................................................................................2 Definition .................................................................................................................................6 Incidence...................................................................................................................................6 Syndromic and non-Syndromic clefting................................................................................8 Embryology of clefts of the lip and palate................................................................................8 Lip development ......................................................................................................................8 Abnormal lip Development.................................................................................................10 Development of the palate ....................................................................................................11 Theories of palatal shelf elevation. (Ferguson 1981)..............................................................11 Abnormal palate Development...........................................................................................13 Aetiology.................................................................................................................................13 Classifications.........................................................................................................................15 Descriptive method by Veau...............................................................................................15 Symbolic method using the “stripped Y” Kernahan 1971 ......................................................16 LAHSHAL classification developed by Kriens 1989..................................................................16 Preventive treatment..............................................................................................................17 CSAG Report (Clinical Standards Advisory Group) by Shaw 1995..........................................17 Indices and grading used in cleft cases...................................................................................19 Index of 5-year old children (Attack et al., 1997):...................................................................19 Grading ..........................................................................................................................19 GOSLON index (Great Ormond Street, London and Oslo Net) Yardstick (Mars et al., 1987)...21 I.Anteroposterior Assessment of labial segements.........................................................21 II.Vertical Assessment.....................................................................................................22 Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 2
  • III.Transverse Assessment...............................................................................................22 Ranking of GOLSON index.......................................................................................................22 Bergland index for secondary ABG outcomes.........................................................................22 Kindelan score ........................................................................................................................23 Problems Associated with Cleft Lip and Palate.......................................................................24 I.General difficulties ...............................................................................................................24 II.Dental disturbances in both repaired and unrepaired cleft cases ......................................24 III.Skeletal Features of unrepaired cleft lip and palate ...........................................................25 IV.Skeletal Features of repaired cleft lip and palate (Shaw 1990)...........................................25 Iatrogenic effect of surgery.....................................................................................................26 Ideal Cleft palate Team...........................................................................................................26 Summary of the whole Treatment .........................................................................................27 In details:................................................................................................................................30 Prenatal age............................................................................................................................30 At Birth ...................................................................................................................................30 SIX Months of age...................................................................................................................32 D.Dental roles:................................................................................................................33 6-12 Months of age.................................................................................................................34 A.Palatal Repair...............................................................................................................34 B.Sometime Lip and soft palate repair undertaken at 6 months at one time.................35 C.Dental roles:.................................................................................................................35 D.Pharygoplasty:.............................................................................................................35 Aetiological factors pf speech problems:-.......................................................................35 1-5 Years of age......................................................................................................................36 1.Lee records at 5 years stage ........................................................................................36 2.Assessment using the 5-year-old index introduced by Attack 1997 ...........................36 Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 3
  • 3.Interceptive Orthodontic treatment ...........................................................................36 4.Dentist roles.................................................................................................................36 7-10 years of age.....................................................................................................................37 1.Lee’s records................................................................................................................37 2.GOSLON Yardstick (Mars 1987)....................................................................................37 3.Secondary alveolar bone grafting:...............................................................................37 The main aims secondary ABG........................................................................................39 Surgical technique of ABG...............................................................................................39 Postoperative instruction................................................................................................40 Postoperative assessment..............................................................................................40 The complications...........................................................................................................41 Influencing success.........................................................................................................41 Segmental Surgery at the same time of the secondary alveolar bone grafting, Harris 2008 ............................................................................................................................................42 Lesser Segment Alveolar Distraction ..................................................................................43 11-15 Years of age..................................................................................................................43 Pharyngoplasty...............................................................................................................43 Orthodontics..................................................................................................................44 18+ Years of age......................................................................................................................44 1.Lee’s Records ..............................................................................................................44 2.Orthognathic surgery...................................................................................................44 Secondary surgical correction for CLP patient........................................................................44 Specific Problems in Cleft Patients .....................................................................................44 Treatment Planning for CLP................................................................................................45 The Choice of Operation for CLP.........................................................................................46 Airway Considerations for CLP during surgery........................................................................49 Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 4
  • Postoperative considerations for CLP.................................................................................49 3.Secondary plastic procedures......................................................................................50 Terminology ...........................................................................................................................50 (SIGN 1993 section 47) caries management...........................................................................51 Risk category...........................................................................................................................51 Caries risk factors....................................................................................................................51 Clinical evidence.....................................................................................................................51 Dietary habits..........................................................................................................................51 Social history...........................................................................................................................51 Use of fluoride........................................................................................................................51 Plaque control.........................................................................................................................51 Saliva.......................................................................................................................................51 Medical history.......................................................................................................................51 Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 5
  • Cleft Lip & Palate From Orthodontic Point of View Definition Incomplete fusion of hard and /or soft tissue structures of the lip and palate. Incidence A. Genetic risks • One affected parent, risk of the first child 2% • One affected child, risk of next child with is (4%). • One affected parent, one affected child 10% • Two affected parents, risk of first child 60% B. Prevalence in the UK population • UCLP 40% • CP 30% • BCLP 10% • CL 10% • Submucous cleft or soft palate cleft 10% C. CLP Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 6
  • Incidence of unilateral CL(P) varies with race: 1. In Negros is around 1 in every 2000 live birth. 2. In UK 1 in every 700 live births 3. In Caucasians it is about 1 in every 750 live births (Mitchell, 2000). 4. In oriental populations is around 1 in very 600 live births. 5. Left side is more affected than the right side (2:1). 6. More common in male 3:1 D. CP: • Prevalence around 1:2000 live births. • 55% Associated with syndromes such as Down, Treacher- Collin, Pierre-Robin Syndromes. • CP the incidence is higher in females overall (3:2). E. Gender distribution: • CLP has greater incidence in males 3:1 • CP the incidence is higher in females overall (3:2). • There is a male predominance of submucus clefts. • There is equal gender incidence of isolated soft palate clefts Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 7
  • z Syndromic and non-Syndromic clefting 15% of cleft children have additional malformations especially BCLP and CP to have additional malformations (400 syndrome) , example: 1. Van der Woude • 1:28000 • Autosomal dominant. • Lower lip pits • +/or CL/P or CPO (2% of cleft cases). • Hypodontia. • No other anomalies. 2. Pierre Robin sequence. Triad of cleft palate, micrognathia, macroglossia 3. Treacher Collins Embryology of clefts of the lip and palate Lip development • Facial development begins at 4-6 weeks • 5 facial prominences. Frontonasal process ‘’FNP’’ (unpaired), Paired maxillary process and Paired mandibular process Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 8
  • • By four weeks of development the two mandibular processes are the first to unite and give rise to the lower lip, lower portion of the cheeks and other mandibular structures. • By five weeks of development, medial and lateral nasal processes form within the enlarged frontonasal process to surround an early ectodermal thickening, the nasal placode. The nasal placode gives rise to highly specialized olfactory receptor cells and nerve fibre bundles innervating the future nasal cavity. As the medial and lateral nasal processes enlarge, the nasal placodes sink into the nasal pits, which demarcate the nostrils. • Medial growth of the maxillary processes dominates subsequent development of the face, resulting first in contact and then fusion with the lateral nasal processes (6 weeks IU) to form: 1. Nasolacrimal duct 2. Cheek 3. Alar base of the future nose. • Further growth towards the midline pushes the lateral nasal processes superiorly and allows fusion of the maxillary processes with the medial nasal processes inferiorly, merging them together in the midline to form: 1. Central portion of the nose; 2. Upper lip philtrum; 3. Primary palate. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 9
  • • Thus, the upper lip is formed from the maxillary processes laterally and the medial nasal processes in the midline (Jiang et al, 2006). • Posteriorly, from the medial sides of the maxillary process, the secondary palate is formed via growth, elevation and subsequent fusion between the paired palatine processes. These processes also fuse with the nasal septum superiorly and the primary palate anteriorly, ultimately separating the oral and nasal cavities. The essential features of the human face have formed by eight weeks of development. Abnormal lip Development Defective fusion at any of the sites highlighted in the above figures may result in a facial cleft. 1. Cleft mandible 2. Lateral facial cleft 3. Oblique facial cleft Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 10
  • 4. Cleft Lip (Unilateral or Bilateral) 5. Median cleft Development of the palate • 1° palate is made up of the medial nasal process. It contains the first four teeth and contributes the philtrum of the upper lip. • 2° palate apparent at 6 weeks as inferiorly lying outgrowths from the maxillary process, lying lateral to the tongue. • At 8 weeks shelf elevation begins. Theories of palatal shelf elevation. (Ferguson 1981) • Extrinsic 1. Tongue movement downward. 2. Increased mandibular prominence. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 11
  • 3. Lifting of the head relative to the body. 4. Increased height of the oro-nasal cavity. 5. Straightening of the cranial base. • Intrinsic 1. Osmotic pressure, 2. Cellular reorganisation (increased density of epithelial/mesenchymal cells on the palatal side of the shelf causing rotation), 3. Contraction (muscle/non-muscle, both have been proposed), 4. Vascular erectile force. • Following elevation, at 9 weeks, further growth brings the medial edge of each shelf into close contact. At this stage, mesenchyme from each shelf is still separated by an epithelial seam of medial edge epithelium. • Three mechanisms have been proposed to explain medial edge epithelium breakdown, apoptosis (programmed cell death), epithelial to mesenchymal transformation, and migration of epithelium to the oral and nasal compartments. • Regardless of the mechanism, breakdown of the epithelial seam results in mesenchymal continuity and palatal fusion. As well as fusion between secondary palatal shelves, an important step during palatogenesis is fusion of the primary palate to the secondary palate. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 12
  • Abnormal palate Development • Clefts form when there is failure of process growth or fusion, this is due to: 1. Primary defects leading to cleft palate include: • Failure of shelf elevation; • Failure of shelf growth ; • Failure of shelf fusion. 2. Secondary defects leading to cleft palate include: • Growth disturbances in craniofacial structures • Mechanical obstruction of palatal elevation. Aetiology In normal development, fusions of the embryological processes that comprise the upper lip appear around 6 W.I.U life while fusion to form the secondary palate occur around 8 W.I.U life. Any disruption affecting the timing at which the fusion occurs will increase the incidence of cleft. The etiological factors are: A. Genetic: A gene coding for TGF has been implicated. These encode a variety of different proteins include (FGF), homebox gene, SHH, MSX1 and MSX2 B. Environmental • IU position Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 13
  • • Social deprivation • Smoking • Alcohol • Trauma. • Radiation. • Maternal hypoxia • Drugs like Steroids, Anticonvulsant drugs • Infection like CMV, Rubella • Endocrine like Diabetes • Deficiency of nutritional supplements such as deficiency in folic acids Bixler (1981) divided clefts into 3 aetiological domains C. Syndromic. Represent 70% of clefting D. Familial or hereditary. E. Sporadically or Isolated or non-Familial. The patient is the first person in a family with the defect. Most commonly: • IU position • Social deprivation • Smoking Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 14
  • • Alcohol • Trauma. • Radiation. • Maternal hypoxia • Drugs like Steroids, Anticonvulsant drugs • Infection like CMV, Rubella • Endocrine like Diabetes • Deficiency of vitamin supplements such as deficiency in folic acids Classifications Descriptive method by Veau This is most commonly used nowadays. A. Cleft lip • Notched lip • Incomplete cleft lip • Complete cleft lip • Unilateral or bilateral B. Cleft alveolus (primary palate) C. Cleft palate Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 15
  • • Cleft uvula • Soft palate only • Submucous cleft • Complete • Incomplete D. Combinations Symbolic method using the “stripped Y” Kernahan 1971 • LAHSHAL classification developed by Kriens 1989 • L lip • A alveolus • H hard palate • S soft palate • UPPER CASE FOR COMPLETE CLEFT • Lower case for incomplete cleft Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 16
  • • It starts from right side to left side Preventive treatment Hartridge et al 1999 in a review investigating the role of pre-conceptional folic acid supplementation concluded that 0.4 mgs of folic acid from pre- conception to the 12 week of pregnancy (4mgs for mothers with cleft children) although not proved conclusively can have significant protective effects. CSAG Report (Clinical Standards Advisory Group) by Shaw 1995 • First Mars 1987 show that UK is the worst. • Professionals in the field of cleft work expressed concern regarding the quality of treatment outcome for patients with cleft lip and palate in the UK. • In 1995 the Department of Health in the UK charged the Clinical Standards Advisory Group to investigate the quality of care within the UK. • All children in the UK with a unilateral complete cleft lip and palate aged 5 or 12 years of age in 1996-1997 were examined. Their speech, hearing, facial appearance, dental malocclusion, dental health, quality of bone graft and skeletal base relationships were examined. (457 children non syndromic with UCLP) • Cleft care was provided in 57 centres. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 17
  • • The study found that the average result in all these areas was poor. Children from the UK centres were more likely to suffer mid-face retrusion (70% of pt 12 years has class III) and poor dental relationships than three of the European centres. • Fewer than 60% of children in the UK had a successful bone graft in comparison with 97% from one of the other European centres. It was therefore clear that some patients were not receiving optimal care in the UK. The CSAG1 report 1998 made several recommendations, including: I. Centres should be limited to 8-15 in the UK. • England and Wales, 10 centres • Northern Ireland operates as a single centre • Scotland operates as one single centre known as CLEFTSiS II. Each centre should provide a full range of cleft care. III. Nationwide database. IV. Results should be regularly audited. V. Training should be provided for specialists in cleft care in high volume centres only. VI. Each clinical team consists of specialist orthodontists, surgeons, speech and language therapists, specialist nurses, geneticists, paediatricians, ENT specialists, anaesthetists and psychologists. In addition they have support staff responsible for data collection, audit documentation and photography. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 18
  • Indices and grading used in cleft cases Index of 5-year old children (Attack et al., 1997): • Index for dental relationships of 5 year old patients born with unilateral cleft lip and palate. • It divided the cases into 5 categories to be able to compare treatment outcomes earlier and before surgical procedures and orthodontic treatment. • The categories used in the grading are: 1. Overjet 2. Inclination of ULS 3. Presence of Crossbite 4. Presence of Open bite 5. Maxillary arch shape and palatal vault anatomy Grading 1. Grade I • Positive overjet • Average inclined or retroclined incisors • No crossbites • No openbites • Good maxillary arch shape and palatal vault anatomy. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 19
  • Prognosis: Excellent outcomes 2. Grade 2 • Positive overjet • Average inclined or proclined incisors • Unilateral crossbite/crossbite tendency • Open bite tendency around cleft site. Prognosis: Good outcomes 3. Grade 3 • Edge-to-edge bite average inclined or proclined incisors; • OR • Reverse overjet with retroclined incisors • Unilateral crossbite • Open bite tendency around cleft site Prognosis: Fair outcomes 4. Grade 4 • Reverse overjet • Average inclined or proclined incisors • Unilateral crossbite, bilateral crossbite tendency • Open bite tendency around cleft site . Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 20
  • Prognosis: Poor outcomes 5. Grade 5 • Reverse overjet • proclined incisors • Bilateral crossbite • Open bite • Very Poor maxillary arch form and palatal vault anatomy Prognosis: Very poor outcomes GOSLON index (Great Ormond Street, London and Oslo Net) Yardstick (Mars et al., 1987) • It is a record of 10 year old patients It measures the severity of malocclusion, the difficulty of correcting it and the outcomes of the child with a unilateral cleft lip and palate of children in the early permanent dentition This depend on I. Anteroposterior Assessment of labial segements • The overjet is examined first. If there is a reverse overjet of 3 to 5 mm, this indicates that the case might belong to group 3. • However, if there is already dentoalveolar compensation a higher category should be considered. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 21
  • • The anteroposterior relationships of the buccal segments are not of importance in determining the grouping of a case. II. Vertical Assessment It helps in modification of the provisional category in borderline cases. Deep bite is favorable and AOB is unfavorable III. Transverse Assessment It indicate a modification of the provisional category in borderline cases Ranking of GOLSON index 1. Groups 1 and 2 have occlusions that require either straightforward orthodontic treatment or none at all. 2. Group 3 require complex orthodontic treatment to correct the Class III malocclusion but a good result can be anticipated. 3. Group 4 are at the limits of orthodontic treatment, and if facial growth is unfavorable, orthognathic surgery will be required. 4. Cases in group 5 require orthognathic surgery. Bergland index for secondary ABG outcomes Take periapical x-ray and assess the bone formation at interseptal area around the ERUPTED canine to assess bone formation Bergland (1986). 1. Grade I: inter-alveolar bone at normal height 2. Grade II: inter-alveolar bone ¾ of normal height Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 22
  • 3. Grade III: inter-alveolar bone less than ¼-¾ of normal height 4. Grade IV: no bone at inter-alveolar area. Failed outcomes. Kindelan score  After 4-6 months of ABG, take anterior occlusal radiograph and assess the success using Kindelan score 1997.  It has an advantages that it can be applied even before the eruption of the canine. • The degree of bony fill in the cleft area was assessed using a 4- point scale: 1. Grade 1 > 75% bony fill; 2. Grade 2 50-75% bony fill; 3. Grade 3 < 50% bony fill; 4. Grade 4 no complete bony bridge. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 23
  • Problems Associated with Cleft Lip and Palate I. General difficulties 1. Feeding 2. Speech 3. Hearing (which in turn can effect speech development) and middle ear infections 4. Psychological problems II. Dental disturbances in both repaired and unrepaired cleft cases 1. Hypodontia , 28% of UCLP and 60% BLCP 2. Supernumeraries 3. Delayed eruption of teeth on cleft side 4. Increased incidence of impacted upper first molar in cleft side (4times than non-clefts individuals) (Bjerklin et al., 1993) 5. Dilacerations 6. Hypoplasia 7. Microdontia The above due to: • Distortions of the development of the dental lamina which produce tooth germs. In the patient with a cleft this process is disturbed and result in dental problems. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 24
  • • Msx1 genes mutation. III. Skeletal Features of unrepaired cleft lip and palate It is called Embryological defects 1. Cleft Lip only, maxillary arch development is generally normal. 2. Clefts in to the alveolus (incomplete) only with or without lip, increased incidence of cross bites (19%) 3. Complete bilateral, Premaxilla is anteriorly displaced beyond the tip of the nasal septum. The lateral segments may have collapsed medially producing bilateral crossbites. 4. Complete unilateral, Major segment is rotated outward so the incisor area appears prominent, the lesser (lateral) segment is more variable and may be rotated outwards producing a wide cleft or there may be inward displacement and segment overlap. 5. Isolated clefts of the palate, Excessive inter-tuberosity width may be observed causing a scissor bite bilaterally 6. Mandibular growth reduced genetically 7. Increase MMP angle, Possibly due to • Disrupted nasal respiration leading to oral respiration and a mouth open posture, allowing buccal segments to over-erupt. IV. Skeletal Features of repaired cleft lip and palate (Shaw 1990) Embryological defects + Iatrogenic effect of surgery Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 25
  • Iatrogenic effect of surgery Lip repair has minimal effect on facial growth. 1. AP disturbances. Palatal scar tissue around the tuberosity region hinders maxillary translation. 2. Transverse disturbances. Scar tissue in the palate leads to a tendency for buccal cross bites in the 1° and 2° dentitions. 3. Vertical disturbances. • An ⇑ in LFH is often found. Possibly due to disrupted nasal respiration, ⇑ oral respiration and a mouth open posture, allowing buccal segments to over-erupt. Ideal Cleft palate Team 1. Cleft nurse 2. Plastic surgeon 3. Orthodontist 4. Maxillofacial surgeon 5. ENT surgeon 6. Speech therapist 7. Audiologist 8. Pediatrician 9. Psychologist Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 26
  • 10.Geneticist Summary of the whole Treatment In red are the roles of the orthodontist and GDP Prenatal Ultrasound assessment, 70% of the cases are detected on ultrasound scan at 16-18 weeks At birth Parent counseling Feeding Pre-surgical orthopaedic appliance 6 months Primary surgical lip repair Primary alveolar bone grafting (old regime) Nasal repair Tympanoplasty or grommet, 1 year Palate repair. Preventive dentistry/advice 2-7 years Revision of lip repair Pharyngoplasty Tympanoplasty or grommet, Lee’s records 5 years Index Assessment Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 27
  • Interceptive orthodontic to: Correct X bite Align the maxillary dentition (usually using fixed appliances) in the growing child if the appearance causes the child distress or the irregular teeth are traumatizing soft tissues Cleft orthodontists can be asked to provide obturators to assist with speech prior to closure of any residual fistulae at the time of alveolar bone grafting 8-10 years Lee’s records GOSOLN Index Assessment Maxillary expansion prior to bone grafting, extract supernumerary teeth and retained primary teeth. Bone grafting OHI and optimal oral health 11-15 Lee’s records Definitive alignment of the maxillary and mandibular teeth using fixed appliances Reverse facial mask 17-20 Lee’s records Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 28
  • Orthognathic surgery Decompensation and alignment for orthognathic surgery using fixed appliances For patients with velo-pharyngeal dysfunction, the poorly functioning soft palate is raised with a palatal lift appliance and the velo- pharyngeal space obturators to reduce hypernasal speech, which assists the Speech and Language Therapist in cases that are otherwise untreatable by language therapy alone with/without surgery. Electropalatography is a relatively new technique where patients are provided with an upper removable orthodontic appliance incorporating numerous electrodes. When attached to a PC, the patient can visualize tongue to hard palate contact on various sounds and the Speech and Language Therapist can direct therapy sessions using this technique. Indeed portable EPG hardware is now available such that the patient can practice tongue positioning at home. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 29
  • In details: Prenatal age • 70% of the cases are detected on ultrasound scan at 16-18 weeks when looking for it. • Cleft Lip and Palate Association (CLAPA) provide support for the parents this stage. • Nurse to provide home visit for support • Psychologist to provide support At Birth 1. Parent counseling Parents are usually in a shock after birth, therefore a counseling is important to reassure them and facilitate the development of a bond between the mother and the child. The parent reaction could be depression, social avoidance, rejection and feelings of guilt 2. Feeding: • Orthodontist should give counselling and advice on feeding. • Acrylic plates are no longer used nowadays. • In isolated CL the nipple will fill the gap so using large teats bottle is enough. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 30
  • • Soft feeding bottles with modified long teats which help to direct the flow of the milk into the mouth are helpful. (Haberman feeder or bottle or soft Plas bottle) • Fortified milk • Some babies are fed by nasogastric tube. One of the most common reasons for a cleft baby being fed this way is due to Pierre Robin sequence. Many of these babies have severe airway problems and due to the smallness of the lower jaw, the tongue remains in a very posterior position, making oral feeding impossible for weeks or even months. 3. Pre-surgical orthopaedics: A. NASOALVEOLAR MOULDING: NAM inserted in the nostrile B. NASODENTAL MOULDING OR OBTURATORS: • Pioneered by McNeil. • It is usually carried out immediately after birth. • The types and their aims are: i. In unilateral clefts reduces displacement of the greater segment and maintain the position of the lesser segment. ii. In bilateral clefts to move the lateral segments outwards while the prolabium is moved palatally and rotated downwards. Reduction of premaxillary protrusion in bilateral clefts. Treatment comprises an intra oral appliance carrying an active component (screws) to separate the lateral segments. Elastic strapping across the prolabium (upper lip) is used to restrain the premaxillary growth. i. Passive obturating plates that assist feeding Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 31
  • ii. Active obturating plates C. EXTRA ORAL STRAPPING aid in positioning of the segments to help surgical closure of the lip specially in severe arch distortion (Latham lip strapping) Recent evidences by Shaw et al in 1992 showed that: • Low outcome if presurgical orthopaedic is used • In centres with low volume of cases and Dutch-cleft study by Anderson suggest that these devices offer no benefit to outcome either in terms of the surgery or feeding during this period. SIX Months of age A. Lip Repair • Millard technique (gives best scar) • Tennison technique or Randall technique (grives Fuller lip) Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 32
  • B. Nose Repair: alar cartilages may be repositioned at this time to increase symmetry and improve the appearance C. Alveolar Repair, primary alveolar bone grafting not recommended. However it depend on the use of vomerian flap to close the cleft D. Dental roles: • Continued advise on feeding E. ENT: tympanoplasty, aspiration and grommets • A cleft involving the posterior part of the palate and the soft palate will also involve the tensor palate muscles, which act on the Eustachian tube. • This predispose to problems in the middle ear ventilation (glue ear). • Therefore, it is important that the cleft patient’s ears should be examined at the time of lip surgery to ensure adequate middle ear drainage. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 33
  • • About 98% of the cleft patients will have otitis media (Grant et al., 1988) and will need tympanoplasty, aspiration and grommets (ventilation tubes inserted through the tympanic membrane under general anaesthetic.) 6-12 Months of age A. Palatal Repair Soft palate repair 1. Z-plasty 2. Intra-velar veolplasty: radical dissection and reorientation Hard Palate repair 1. V-Y closure technique 2. Von Langenbeck technique 3. Delair technique 4. Primary tongue flab technique Some claim that it is better to delay the closure to 5-6 years to avoid scar occurrence and subsequent growth retardation. But in this case the defect should be closed with obturators; otherwise the speech would be dramatically influenced. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 34
  • B. Sometime Lip and soft palate repair undertaken at 6 months at one time C. Dental roles: • Continued advise on feeding, • Diet analysis • OHI • Use of fluoride • Restorative care D. Pharygoplasty: • In proportion of cases the repaired palate does not completely seal off the nasopharynx during speech and nasal escape of air may occur, resulting hypernasality. • Nasopharyngoplasty is undertaken at the same time as the primary palatal repair is performed. • However, it is preferable to carry this procedure at the age of 4-5 years. Aetiological factors pf speech problems:- 1. Velopharyngeal insufficiency, 2. Hearing problems 3. Dental and occlusal anomalies. 4. Developmental learning disability. 5. Psychosocial impact. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 35
  • 1-5 Years of age 1. Lee records at 5 years stage 2. Assessment using the 5-year-old index introduced by Attack 1997 3. Interceptive Orthodontic treatment • Elimination of anterior crossbites • Identify potential problems such as supernumaries. • If second premolars are missing plan early loss of maxillary E’s to allow spontaneous closure by the molars. • In deep bite case consider a bite plane to allow posterior tooth eruption. • Plan loss of deciduous teeth around the cleft early to improve quality of mucosa prior to grafting 4. Dentist roles • Diet analysis • OHI • Use of fluoride • Restorative care 5. Speech and hearing assessment. Consideration for pharygoplasty and grommets. 6. Primary bone grafting is carried out within the first 2 years of life and is less popular than secondary bone grafting. Primary bone grafting is Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 36
  • considered unfavorable and usually results in crossbite, malocclusion and mal-union of the maxilla. 7-10 years of age 1. Lee’s records 2. GOSLON Yardstick (Mars 1987). 3. Secondary alveolar bone grafting: Types of ABG 1. Primary bone grafting (at the time of lip repair at age of 3 months) 2. Early secondary bone grafting (between the ages of 2 and 5 years) 3. Secondary alveolar bone grafting (ABG) for patients with orofacial clefts is usually carried out between the ages of 9 and 11 years; 4. Tertiary bone grafting in late adolescence (Rosenstein et al., 1982; eppley and sadove, 2000) • Alveolar bone grafting Introduced by Axhausen (1952). • Technique popularised by Boyne and Sands (1972, 1976). • Pre graft records. Occlusal, Study models and photos • Orthodontic preparation for graft at approximately 8-11 years before the eruption of the maxillary canine (Bergland 1986), ideally when the canine root is ¼ to ½ formed. One exception is, if the lateral incisor tooth is present, then earlier grafting may be considered. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 37
  • • At this age, anteroposterior and transverse maxillary growth is practically complete apart from the alveolar development of the erupting permanent teeth. Hence grafting at this time does not affect mid face growth but provides the all-important bone support for the erupting canine. • The viability of the result depend in the presence of unerupted teeth otherwise the bone will resorbe again. • Orthodontist might extract deciduous and supernumerary teeth to provide sufficient attached gingiva. • Treat caries and pathology • The orthodontist is often required to expand the maxillary arch prior to alveolar bone grafting, usually with a fixed expander such as a tri- or quad-helix. This expansion help in: 1. Maximizes the size of the bony defect and creates access for the surgeon to place the graft during surgery. 2. improves the maxillary arch form • Then the expander should be replaced with a stabilising transpalatal arch with finger horizontal palatal extensions prior to surgery to facilitate surgical access. Bilateral cleft cases require a stabilising arch wire to secure the pre-maxilla, at least 19*25 SS. • Transpalatal arches should remain for up to 3 months after surgery for stabilisation. • Care should be taken when aligning the incisors, as often the bone covering the roots of the teeth is very thin. Often the aim then is to accept Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 38
  • the mesio-distal tip and rotations present in the upper incisors. Therefore when placing the brackets it is wise to accept the inclination of these teeth rather than try to upright them and moves the roots of the teeth out of the bone and into the cleft space. After the bone graft the brackets can be replaced and the roots moved into the correct position. The main aims secondary ABG 1. Improve bony support for the alar base. 2. Improve nasal symmetry. 3. Eliminate any mucosal recesses liable to cause food retention. 4. Elimination of oro-antral communication. 5. Aims to stabilize maxillary segments 6. Allow spontaneous eruption of teeth into the cleft area 7. Enable orthodontic tooth movement through the cleft site, 8. Facilitate any prosthetic restoration Surgical technique of ABG 1. Incision 2. After closure of the nasal surface 3. Cancelous bone is harvested from donor sites, The best source of bone for grafting for the alveolar cleft defect is the iliac crest, The rib, the cranium, tibia and the mandible or artificial bone graft have also been used. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 39
  • 4. Cortical bone is not preferred because of the reduce vascularity and high risk of necrosis. 5. Additional bone is placed under the ala and the nose on the cleft side to provide nasal symmetry. 6. The covering flaps are then closed. 7. A protective palatal splint or orthodontic arch wire is sometimes used for further stabilization, 8. Modified flaps may be needed to close residual palatal fistulae defects. 9. Success rate when graft placed prior to eruption of canine 90%. But drop to 72% after or during eruption of canine. 10. Success of UCLP=BCLP if adequate stabilisation of premaxilla. 11.Then it is usually possible to proceed with orthodontic movement of teeth in the grafted Postoperative instruction 1. Preoperative intravenous antibiotics should be administered and then postoperative prophylactic antibiotics given orally for 5 days. 2. Maintain scrupulous oral hygiene. 3. The patient is given a semi- solid diet by mouth and chlorhexidine gluconate mouthwashes. 4. Adequate analgesia for both oral and donor sites. Postoperative assessment 1. General assessment After 6 weeks to check infection Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 40
  • 2. After 4-6 months Kindealn score 3. Rarely, one year after ABG, Bergland index, Chelsea Index (Witherow et al., 2002) comprises the Chelsea grade (position of bone) and Chelsea scale (quality of bony bridge); whereas, the index proposed by Long et al. (1995) assesses the percentage of bone covering the roots of the teeth adjacent to the graft site. The complications 1. Postsurgical problem at donor area 2. Granuloma formation. 3. Failure • A unilateral alveolar defect. • Anterior oronasal fistula. • Alar-base asymmetry 4. Around 15% of the canines will require exposure. 5. External root resorption. Influencing success 1. Dental development – best results when carried out before canine eruption (Bergland et al, 1986; Lee et al, 1995; Kalaaji et al, 1996; Enemark et al, 1997) 2. Donor site: Iliac crest best (LaRossa et al, 1995) although not statistically significant in CSAG study (Williams and Sandy, 2003). Chin is the best but morbidity is high and the bone might be insufficient. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 41
  • 3. Pre-operative health of graft site 4. Post-operative care 5. Socioeconomic status and ethnic group 6. Surgical procedure + more experience = better results 7. Extraction of teeth at surgery (not statistically significant in CSAG (Williams and Sandy, 2003) 8. Surgeon specialty (OMFS better than Plastic surgeon) not statistically significant (Williams and Sandy, 2003) 9. Bone volume – weigh alveolar bone (Kamakura et al, 2003) 10.Complete closure of fistulae Segmental Surgery at the same time of the secondary alveolar bone grafting, Harris 2008 Segmental surgery is now rarely required at the time of alveolar bone grafting, as orthodontic preparation or distraction osteogenesis will usually align the segments. It should be avoided because: a) Fixation is problematic b) Bone grafts do not unite with mobile segments. However, the local dentoalveolar relationship may be improved by combining the alveolar bone graft with an osteotomy to the lesser segment or premaxilla. The lesser segment osteotomy is carried out at the LeFort I level. The most common indications are: Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 42
  • 1. Vertical deficiency of the lesser segment. 2. The fistula is too large to close for bone grafting 3. Orthodontic expansion of the arch has not been possible as the lesser segment may be trapped palatally. 4. Distraction osteogenesis is not available. Lesser Segment Alveolar Distraction • Segmental alveolar distraction may overcome the technical difficulties of dividing and fixing small osteotomy segments. • By slowly moving the lesser segment at one millimetre per day towards the cleft, the size of the alveolar and dental gap is reduced. • This decreases the size of both the graft and the flaps raised to close the fistula. It may even eliminate the need for an autogenous bone graft. Segmental distraction is only possible in Young patients with erupted teeth on which brackets and tubes can be applied to fit a rigid wire to guide the distraction forward and around the arch form. 11-15 Years of age Pharyngoplasty • Pharygoplasty may be undertaken at 11-15 years to improve velo- pharyngeal competence, if not already undertaken at an earlier age. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 43
  • • VPI may become a greater problem in the adolescent as lymphoid tissue shrinks effectively increasing the distance the scarred soft palate needs to breach to create a seal. Orthodontics Conventional orthodontic treatment if the malocclusion is simple with or without EOA 18+ Years of age 1. Lee’s Records 2. Orthognathic surgery Secondary surgical correction for CLP patient Specific Problems in Cleft Patients 1. Sever skeletal problem in all direction with malar hypoplasia. 2. Anterior open bites are common 3. Posterior cross bites are common 4. Dental development may also be delayed in both arches but is most evident in the cleft segment and may compromise the presurgical orthodontics. 5. The repaired alveolar cleft is a potential site for fracture at the time of the down-fracture. 6. If the maxillary alveolus has not been reconstructed, alignment of the alveolus can be incorporated into the orthognathic procedure. However it Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 44
  • complicates the planning of the surgery and increases the potential morbidity. Segmental osteotomies are less stable than one-piece maxillary osteotomies. 7. Previous surgery produces scarring of the labial and buccal vestibule, the palate and behind the maxillary tuberosities. This presents problems with the surgical incisions, mobilisation and postoperative closure of the surgical wound. 8. A pharyngeal flap may make advancement of the maxilla difficult and will need to be divided. The patient has to be informed well in advance about the possibility of VPI and speech problem that might developed after the surgery. Treatment Planning for CLP The basic facial and orthognathic evaluation is the same as the non-cleft case with important refinements. 1. Lip-incisor relationship. As in the non-cleft case, the lip to maxillary incisor relationship is extremely important. The major surgical moves are predominantly in the maxilla and with a tight, previously scarred upper lip, small skeletal moves have a pronounced effect on the incisor exposure. 2. Asymmetries. Both dental and skeletal asymmetries are dominant features, often with compensatory asymmetries in the mandible. This should be considered 3. Pharyngeal obstruction can be caused by hypertrophied adenoidal tissue or pharyngeal flaps. Nasal airway obstruction may arise from a deviated Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 45
  • nasal septum narrowing of the nares, hypertrophied turbinates, nasal polyps and posterior choanal constriction from sub-periosteal bone and asymmetrical vomer flaps. The management of these problems is an essential part of the orthognathic procedure. Paradoxically the adenoid mass may contribute to velopharyngeal function and its removal may precipitate velopharyngeal inadequacy. 4. Preoperative speech assessment and counselling. 5. However, infection, bone and soft tissue necrosis, delayed healing, loss of teeth and relapse all occur with greater frequency due to multiple previous surgeries. The Choice of Operation for CLP Maxillary Hypoplasia 1. LeFort I osteotomy either one piece or two pieces maxilla for transverse maxillary widening. 2. High LeFort I level osteotomy. 3. The modified LeFort II and Kufner LeFort III osteotomy 4. SARPE 5. Rhinoplasty may be necessary. 6. Mismanagement of the soft tissues during closure of the labial vestibular incision may cause shortening and thinning of the upper lip. The V-Y closure of a maxillary vestibule incision may increase the vermilion show in patients with a thin upper lip. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 46
  • 7. Maxillary advancement widens the alar base, increases the projection and elevation of the nasal tip and the width of the nares. Various surgical manoeuvres can be used to prevent these unwelcome side effects. These include an alar base cinch suture, recontouring the bony piriform aperture either by trimming and/or asymmetric bone grafting and alar base resections. Mid Face Distraction Osteogenesis Indications: • With gross maxillary hypoplasia and a severe degree of scarring, the degree of advancement may be beyond the expected limits of stability of a conventional osteotomy. Distraction of the maxilla is preferable to a surgical compromise such as a mandibular setback. • If the deformity is complex particularly in the upper mid face then a higher level osteotomy with distraction often gives a better result than a modified LeFort I with masking onlay bone grafts or modified LeFort II and LeFort III osteotomies that are difficult to perform and can give unsightly steps particularly over the radix of the nose. • There is usually a need for pre-surgical orthodontics. • due to risk of worsening VPI and due to previous surgical scarring, the Large jaw discrepancies of 10mms and above may also require a mandibular setback Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 47
  • • a modified maxillary Le fort 1 advancement or Converse Wake Procedure (that move the maxilla without influencing the position of the palate) is used with careful attention paid to the mobilisation of the maxilla. • Use Distraction osteogenesis as alternative • Use Horseshoe osteotomy as alternative • Severe maxillary restriction may require Surgically assisted RME and 2 or 3 piece Le fort 1 osteotomies • Any expansion gained should be permanently retained. (Proffit and White 1990) Mandibular setback (BSSO, VSO) Mandibular set back indicated in case of: 1. Mandibular prognathisism 2. When there is a maxillary surgical limitations such as severe palatal scarring, borderline velopharyngeal insufficiency or a tight inferiorly based pharyngoplasty flap. 3. During maxillary advancement and inferior positioning, the anterior maxilla is differentially positioned more inferiorly. This will produce a posterior open bite deformity unless a mandibular ramus procedure is undertaken simultaneously. Differential down grafting of the anterior maxilla also results in a counter clockwise rotation of the mandible which may make the chin retrogenic. This can be corrected by a simultaneous augmentation genioplasty. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 48
  • Airway Considerations for CLP during surgery 1. The surgeon can do the following whilst the maxilla is down fractured • Contouring of the inner aspects of the nose • Asymmetries in the piriform region • The mucosa of the nostril floor can be repaired • Septoplasty may be indicated • Partial or complete inferior turbinectomies • Antral and nasal polyps can be removed 2. Pharyngeal flaps raise additional concerns for the anaesthetist and surgeon which may make intubation difficult and restrict the nasal airway, so submental intubation might be indicated Postoperative considerations for CLP 1. Speech therapy: The soft palate mechanism in non-cleft patients has considerable reserve capacity and can adapt to an increase in length. The repaired cleft soft palate does not have this capacity to adapt especially after major advances. The patient with borderline velopharyngeal incompetence preoperatively is likely to develop worsening of their speech postoperatively. 2. Relapse: As a prophylactic measure, extraoral elastic traction using a face mask can be used in patients who are considered particularly at risk of Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 49
  • relapse either due to scarring or who have had large surgical moves anteriorly and inferiorly. 3. Stability: The factors that increase stability include: • High quality orthodontic preparation. • Avoiding segmental procedures • Overcorrection where possible. • Compromise position must be planned and if necessary with incorporatation of a mandibular setback. • Alveolar bone grafting. • Bone grafting for inferior repositioning of the maxilla. • Internal rigid fixation for all moves. 3. Secondary plastic procedures Such as nose and lip revision. These are best undertaken after growth, since growth can detrimentally affect earlier revisions. Terminology Velopharyngeal impairment is a generic term indicating that the patient is unable to induce sufficient contact between the velum and the posterior and lateral pharyngeal walls Velopharyngeal insufficiency is a form of velopharyngeal impairment caused by a soft palate whose functional length is insufficient. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 50
  • Velopharyngeal incompetenceis a form of velopharyngeal impairment caused by neuromuscular impairment . Hypernasality is a resonance phenomenon that occurs when sound is inappropriately generated in the nasal cavity. (SIGN 1993 section 47) caries management 1. Clinicians should be aware of individuals with a medical or physical disability for whom the consequences of dental caries could be detrimental to their general health. These patients should receive intensive preventive dental care. Caries risk factors A. ◦clinical evidence of previous disease B. ◦dietary habits, especially frequency of sugary food and drink consumption C. ◦social history, especially socio-economic status D. ◦use of fluoride E. ◦plaque control F. ◦saliva G. ◦medical history Risk categ ory Caries risk factors Clinical evide nce Dietary hab its Social hist ory Use of fluori de Plaque con trol Saliva Medical histor y High risk New lesions Premature extractions Frequent sugar intake Social deprivation High caries Drinking water not fluoridated Infrequent, ineffective cleaning Low flow rate Low Medically compromised Physical Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 51
  • Anterior caries or restorations Multiple restorations No fissure sealants Fixed appliance orthodontics Partial dentures in siblings Low knowledge of dental disease Irregular attendance Ready availability of snacks Low dental aspirations No fluoride supplements No fluoride toothpaste Poor manual control buffering capacity High S mutans & lactobacillus counts disability Xerostomia Long term cariogenic medicin 2. The dental and allied professions should carry out dental health education. Consistent preventive messages should be reinforced. 3. The need to restrict sugary food and drink consumption to meal times only should be emphasised. 4. Dietary advice to patients should encourage the use of non-sugar sweeteners, in particular xylitol, in food and drink. 5. Patients should be encouraged to use sugar-free chewing gum, particularly containing xylitol, when this is acceptable. 6. Clinicians should prescribe sugar-free medicines whenever possible and should recommend the use of sugar-free forms of non-prescription medicines. 7. Sealants should be applied and maintained in the tooth pits / fissures of high caries-risk children. 8. Children should brush their teeth twice a day using toothpaste containing at least 1000 ppm fluoride, they should spit the toothpaste out and should not rinse out with water. 9. Fluoride tablets (1 mg F daily) for daily sucking should be considered for children at high risk of decay. 10. A fluoride varnish (e.g. Duraphat) may be applied every four to six months to the teeth of high caries risk children. 11. Chlorhexidine varnish should be considered as an option for preventing caries. Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 52