CLEFT LIP & PALATE INDIAN DENTAL ACADEMYwww.indiandentalacademy.com   www.indiandentalacademy.com
CONTENTS:1. INTRODUCTION2. EPIDEMIOLOGY3. ETIOLOGY4. EMBRYOLOGY5. CLASIFICATION OF CLEFTS6. TRRREATMENT OF CLEFT LIP AND P...
INTRODUCTION:        Orofacial clefts are among the most common congenitalanomalies requiring multidisciplinary care. Such...
EPIDEMIOLOGY:Cleft lip and palate is a global problem.(0.28-3.74/1000 live birthsglobally)Least incidence in negroids(0.4%...
ETIOLOGY:1.) Heredity:   Transmitted through a male as sex linked recessive gene.   Predisposition for cleft lip is 40% wh...
SYNDROMES ASSOCIATED WITH CLEFT LIP AND PALATEVan der woude SyndromeTreacher Collins Syndrome              Autosomal Domin...
2.) Environmental Factors:        Usually occurs due to various influences during Ist trimester.• Environmental terratogen...
MALNUTRITION:Hypervitaminosis A: acute maternal exposure to 13-cis retinoicacid during first trimester causes cell death i...
FIND OUT THE WORDS     www.indiandentalacademy.com
www.indiandentalacademy.com
EMBRYOLOGY   The first pharyngeal arch (mandibular    arch), develops two prominences:    The maxillary prominence   Th...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
   As the medial nasal prominences merge with the    maxillary prominence, they form an intermaxillary    segment.       ...
The intermaxillary segment gives rise to :-1. philtrum of the upper lip.2. The premaxillary part of the maxilla3. The prim...
www.indiandentalacademy.com
Mechanism of palatal shelf elevation*Intrinsic Force within the shelf*Accumulation of Glycosaminoglycans*Accumalation and ...
www.indiandentalacademy.com
www.indiandentalacademy.com
Local Factors:•Failure of the head to elevate and become erect at around the7-9th week•Failure of the tongue to descend do...
Leave applications- -          jokes1. Infosys, Bangalore : An employee applied    for leave as follows: Since I have to g...
www.indiandentalacademy.com
DAVIS AND RITCHIE CLASSIFICATION(1922): They classified congenital clefts based on the position of the cleft in relation t...
II VEAU’SCLASSIFICATION (1931):       Group I -     Cleft of        soft palate onlyGroup II - Cleft of hard and soft pal...
   Group III - Complete    unilateral cleft of soft    and hard palate, lip    and alveolar ridgeGroup IV - Complete bila...
III KERNAHAN’S STRIPED “Y”CLASSIFICATION (1971):       In this classification the    incisive foramen is taken as    the ...
V   MILLARD’S CLASSIFICATION(1977):      A modification of   Kernahan’s striped “Y”   classification. . The inverted tri...
Treatment of CLCP: A brief Overview               www.indiandentalacademy.com
FEEDING TECHNIQUESWhen a cleft lip is present, it may be difficult for the baby to make agood seal around the nipple.Babie...
Feeding obturatorThe feeding obturator is a prosthetic aid that is designed to obturate thecleft and restore the separatio...
INFANT ORTHOPEDICSInfant orthopedics was pioneered by Burstone at Liverpool in 1950s.Two movements were carried out- expan...
   Displacement of segment    make lip repair more difficult   Orthopaedic appliances are    used to resposition the    ...
Naso Alveolar Moulding-   Nasoalveolar molding is a nonsurgical method of    reshaping the gums, lip and nostrils before ...
LIP CLOSURESurgical closure of a cleft lip is done as early in infancy as iscompatible with a good long-term result. at 10...
PALATE CLOSUREObjective:Join the cleft palatal edges,Lengthen the soft palate,The timing of closure is controversial. Can ...
VelopharyngealInsufficiency   Velopharyngeal insufficiency is a disorder    resulting in the improper closing of the    v...
VPD is of 3 types:a) Velopharyngeal Mislearning: due to articulation difficultiesb) Velopharyngeal Incompetence: Due to fu...
Treatment of VPI   Speech Therapy   Some speech problems linked with VPI, such as    mispronouncing words, can be treate...
AIM OF TREATMENT IN CLCP PATIENTS:     To get optimum alignment.     Harmonize relationship of the dental arches for spe...
   MIXED DENTITION       A tentative decision on extraction of        supernumerary teeth and overretained teeth.      ...
   FACE MASK THERAPY   Used in mild maxillary deficient cleft    patient   Orthopaedic forces for maxillary    protract...
Rationale for bone graftingTo restore physiologic continuity of arch for esthetic and hygenicreplacementTo provide bone fo...
Alveolar bone grafting divided in two types:1) Primary alveolar bone grafting: done at the time of lip closure ataround 10...
CURRENT CONTROVERSIES THREE CONTEMPORARY CONTROVERSIES ARE: 1) Timing of grafting 2) The type of bone for alveolar graftin...
EXPANSION:If Expansion done before grafting, as after the graft mature andsutures fuse it is difficult to expand maxilla l...
GRAFTING MATERIAL       Autogeous                        Advantages      Iliac crest                      adequate quanti...
PERMANENT DENTITION : Clinical feature of this stage : Medial displacement of the maxillary segment giving buccal   cross...
ALIGNMENT OF INCISOR TEETH   Incisors usually rotated and in crossbite. Corrected by means    of fixed orthodontic applia...
MASSAGE POINTS IN HAND     www.indiandentalacademy.com
www.indiandentalacademy.com
Orthognathic Surgery combined      with OrthodonticsDue to severe skeletal discrepancy, there is deterioration of esthetic...
Decompensation:Usually requires 12 months.Multiple segment maxillary osteotomies requires segmental treatment.The bracket ...
Post surgical orthodontics: involves detailing of occlusion, closure of residual spaces and maintenance of transverse dime...
DISTRACTION OSTEOGENESIS1903 . Dr. Gavril of Russia-Bone lengthening of leg.      It is a procedure that moves two segment...
Maxillary surgery required in 25-60% of cases with clcp.(Ross and Subtenly)Distraction osteogenesis allows soft tissue ada...
INTERNAL DISTRACTORSAdvantage:•Esthetics•Psychological relilefDisadvantage:•Difficult to control the direction of forcePro...
CONCLUSION:Orofacial clefts have been identified to have a multifactorial etiologyand therefore require an interdisciplina...
REFERENCES:• CRANIOFACIAL DEVELOPMENT- Sperber•Surgical orthodontic treatment- Proffit and White•Grayson etal, Pre surgica...
www.indiandentalacademy.com
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Cleft lip and palate importance in orthodontics /certified fixed orthodontic courses by Indian dental academy

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Cleft lip and palate importance in orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. CLEFT LIP & PALATE INDIAN DENTAL ACADEMYwww.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. CONTENTS:1. INTRODUCTION2. EPIDEMIOLOGY3. ETIOLOGY4. EMBRYOLOGY5. CLASIFICATION OF CLEFTS6. TRRREATMENT OF CLEFT LIP AND PALATE: - INFANT ORTHOPEDICS - TREATMENT IN MIXED DENTITION - TREATMENT IN PERMANENT DENTITION - SURGICAL ORTHODONTICS - DISTRACTION OSTEOGENESIS7. CONCLUSION8. REFERENCES www.indiandentalacademy.com
  3. 3. INTRODUCTION: Orofacial clefts are among the most common congenitalanomalies requiring multidisciplinary care. Such anomalies includeseveral handicaps such as impaired suckling, defective speech,deafness, malocclusion, gross facial deformity and severepsychological problems. Cleft of lip and the palate is one such condition, that occurs atsuch a strategic place in the orofacial region and at such a crucialtime that it becomes a complex congenital deformity. Management of CLCP involves a multi disciplinary approachrequiring the services of an orthodontist, oral surgeon,prosthodontist, otolaryngologist, audiologist, speech therapist,paediatrician. www.indiandentalacademy.com
  4. 4. EPIDEMIOLOGY:Cleft lip and palate is a global problem.(0.28-3.74/1000 live birthsglobally)Least incidence in negroids(0.4%) and maximum in afghans(4.9%)Among Indians it seen maximum in Agarwal community andBrahmins(1.7%).The incidence of oral clefts is seen more in males than in females.Cleft lip alone- more in males than femaleCleft palate- more in females than males www.indiandentalacademy.com
  5. 5. ETIOLOGY:1.) Heredity: Transmitted through a male as sex linked recessive gene. Predisposition for cleft lip is 40% while only 18-20% for cleft palate.It is transferred as:a) Monogenic/ single gene disorder-conform to mendelian inheritanceb) Polygenic/ multifactorial inheritance- show familial tendency but not mendelian inheritancec) Chromosomal abnormalities: - Down’s Syndrome - Edwards Syndrome (trisomy 18) - Trisomy D and E www.indiandentalacademy.com
  6. 6. SYNDROMES ASSOCIATED WITH CLEFT LIP AND PALATEVan der woude SyndromeTreacher Collins Syndrome Autosomal DominantCleidocranial SyndromeEctodermal DysplasiaStickler’s SyndromeRoberts SyndromeAppelt StndromeChristian Syndrome Autosomal RecessiveMeckel Syndrome www.indiandentalacademy.com
  7. 7. 2.) Environmental Factors: Usually occurs due to various influences during Ist trimester.• Environmental terratogens:-Ethyl Alcohol- causes FAS (fetal alcohol Syndrome).-Cigarette smoking- 30% increase in cleft lip and palate and 20%increase in cleft palate in smoking during pregnancy. Nicotine actssynergistically with TGF.-Anti seizure drugs.eg: diphenyl hydantion and trimethadione.alsocauses growth retardation, craniofacial dysmorphism, mental deficiency www.indiandentalacademy.com
  8. 8. MALNUTRITION:Hypervitaminosis A: acute maternal exposure to 13-cis retinoicacid during first trimester causes cell death in the pharygealarch leading to facial clefting. Vit A analogue used as an anti-acne drug. Also proved by animal experiments.Folic Acid: Deficiency of folic acid affects virtually every organsystem. It affect the neural tube- neural crest cell migration anddifferentiation.Anaemia and anorexiaINFECTION DURING PREGNANCY:Rubella infection during the first 3 months associated withclefting.PARENTAL AGE:Shaw etal presented evidence that women above the age of 35had a doubled risk of having a child with CLCP.above 39- tripledrisk. www.indiandentalacademy.comConsanguineous marriages- increased risk of CLCP in child.
  9. 9. FIND OUT THE WORDS www.indiandentalacademy.com
  10. 10. www.indiandentalacademy.com
  11. 11. EMBRYOLOGY The first pharyngeal arch (mandibular arch), develops two prominences: The maxillary prominence The mandibular prominence www.indiandentalacademy.com
  12. 12. www.indiandentalacademy.com
  13. 13. www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16.  As the medial nasal prominences merge with the maxillary prominence, they form an intermaxillary segment. www.indiandentalacademy.com
  17. 17. The intermaxillary segment gives rise to :-1. philtrum of the upper lip.2. The premaxillary part of the maxilla3. The primary palate. www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19. Mechanism of palatal shelf elevation*Intrinsic Force within the shelf*Accumulation of Glycosaminoglycans*Accumalation and hydration of Hyaluronic acid.*Increase in vascularity*Contraction of elastic fibres or muscle fibres.*Unequal division in the palatal and the oral epithelium*Neurotransmitters like Serotonin*Increase in Vimentin expression*Master controlling gene is FSP-1,ssh, www.indiandentalacademy.com
  20. 20. www.indiandentalacademy.com
  21. 21. www.indiandentalacademy.com
  22. 22. Local Factors:•Failure of the head to elevate and become erect at around the7-9th week•Failure of the tongue to descend downwards, thus causing amechanical interference to fusion of the palatine shelves.•Deficiency of Oxygen•Shift of Blood Supply of Face-During the 6th week, most of themidface is supplied by the Stapedial artery which is the branchof the Internal Carotid artery.At around the 7th week, stapedial artery severs from theinternal carotid and its terminal branches join the externalcarotid artery. Delay in this vital step can lead to cleft palate. www.indiandentalacademy.com
  23. 23. Leave applications- - jokes1. Infosys, Bangalore : An employee applied for leave as follows: Since I have to go to my village to sell my land along with my wife, please sanction me one-week leave. 2. This is from Oracle Bangalore: From an employee who was performing the "mundan" ceremony of his 10 year old son: "As I want to shave my sons head, please leave me for two days.." www.indiandentalacademy.com
  24. 24. www.indiandentalacademy.com
  25. 25. DAVIS AND RITCHIE CLASSIFICATION(1922): They classified congenital clefts based on the position of the cleft in relation to the alveolar process.Group I-Pre alveolar clefts Lipclefts only with subdivisions forunilateral, median, bilateral.Group II-Post alveolar cleftsdegrees of involvement of soft andhard palate to be specified till thealveolar ridge, submucous cleftsincluded.Group III-Alveolar clefts iscomplete clefts of palate, alveolusridge and lip with subdivisions for www.indiandentalacademy.comunilateral, median, bilateral.
  26. 26. II VEAU’SCLASSIFICATION (1931):  Group I - Cleft of soft palate onlyGroup II - Cleft of hard and soft palate,extending no further than the incisive foramenthus involving the secondary palate alone. www.indiandentalacademy.com
  27. 27.  Group III - Complete unilateral cleft of soft and hard palate, lip and alveolar ridgeGroup IV - Complete bilateral cleft of softand hard palate, lip and alveolar ridge onboth sides. www.indiandentalacademy.com
  28. 28. III KERNAHAN’S STRIPED “Y”CLASSIFICATION (1971): In this classification the incisive foramen is taken as the reference point “Y” logo are each divided into three sections, representing the lip, the alveolus and the hard palate as far back as the incisive foramen. The stem of the “Y” is also divided into three parts, representing varying degrees of clefting of the hard and soft palates. www.indiandentalacademy.com
  29. 29. V MILLARD’S CLASSIFICATION(1977): A modification of Kernahan’s striped “Y” classification. . The inverted triangles represent the nasal arch the upright triangles represent the nasalLAHSHAL CLASSIFICATION: floor.L- lipA- AlveolusH- hard palateS– soft palate www.indiandentalacademy.com
  30. 30. Treatment of CLCP: A brief Overview www.indiandentalacademy.com
  31. 31. FEEDING TECHNIQUESWhen a cleft lip is present, it may be difficult for the baby to make agood seal around the nipple.Babies with cleft palate usually need special bottles and techniques tofeed properly.There are three types of bottles for feeding babies with clefts –the Mead-Johnson Cleft Palate Nurser,the Haberman Feeder andthe Pigeon Nipple: www.indiandentalacademy.com
  32. 32. Feeding obturatorThe feeding obturator is a prosthetic aid that is designed to obturate thecleft and restore the separation between the oral and nasal cavities.It creates a rigid platformThe obturator also prevents the tongue from entering the defect andinterfering with spontaneous growth of the palatal shelves.reduces nasal regurgitation,reduces the incidence of choking,also helps in the development of the jaws andcontributes to speech www.indiandentalacademy.com
  33. 33. INFANT ORTHOPEDICSInfant orthopedics was pioneered by Burstone at Liverpool in 1950s.Two movements were carried out- expansion of the collapsedsegments and pressure against premaxilla to reposition it posteriorly toits correct position.Done by placing light elastic strap across the anterior segment thatapplies a contraction force. In severe cases pin retained appliancesmay be required.Also consists of a feeder plate with steelwires bent in to hooks incorporated into theacrylic.After active treatment for 3-6weeks,it isused a retainer.Berkowitz reported the present consensus isthat these procedures offer less long termbenefit than expected. Hence now used inseverely displaced premaxilla cases. www.indiandentalacademy.com
  34. 34.  Displacement of segment make lip repair more difficult Orthopaedic appliances are used to resposition the segment in early infancy, before lip closure These appliances also act asTwo types of orthopaedic appliances “feeding plate” for infantsActive: pin retained,controlled forcesPassive: www.indiandentalacademy.com
  35. 35. Naso Alveolar Moulding- Nasoalveolar molding is a nonsurgical method of reshaping the gums, lip and nostrils before cleft lip and palate surgery, reducing the severity of the cleft. Surgery is performed after the molding is complete, approximately three to six months after birth. PRESURGICAL NASO ALVEOLAR MOLDING(Grayson etal, 1999)Actively mold and reposition the deformed nasal cartilages and alveolar processes and lengthen the deficient collumella. www.indiandentalacademy.com
  36. 36. LIP CLOSURESurgical closure of a cleft lip is done as early in infancy as iscompatible with a good long-term result. at 10 to 12 weeks of age. Therefore PNAM should be completed bythen.TechniquesRotation-advancement technique of MillardDelaire philosophy www.indiandentalacademy.com
  37. 37. PALATE CLOSUREObjective:Join the cleft palatal edges,Lengthen the soft palate,The timing of closure is controversial. Can be done early at 8-24months or at 9-12yearAt 18-24 month-Development of normal speech Tendency towards maxillary underdevelopmentAt 9-12year-Normal growth of maxilla with unrepaired cleftReduces surgical morbidity and infectionLatest suggestion-Closure of soft palate –age of 12 monthHelp in development of SpeechNo growth retardation with early soft palate closureClosure of hard palate www.indiandentalacademy.com –age of 5-6year
  38. 38. VelopharyngealInsufficiency 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 escapeDuring speech, the velopharyngeal sphincter must close off the nose to through the nose instead of the mouth.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. www.indiandentalacademy.com
  39. 39. VPD is of 3 types:a) Velopharyngeal Mislearning: due to articulation difficultiesb) Velopharyngeal Incompetence: Due to functional abnormalities. (paresis, dysarthia)c) Velopharyngeal Insufficiency: Structural problems like cleft or bifid uvula etc Diagnostic Procedures  Measurement of nasal airflow McKay-Krummer instrument Aerophonoscope Fiberoptic naso-endoscopy Videofluoroscopy  Voice resonation Evaluation Articualtion assessment Oral motor assessment www.indiandentalacademy.com
  40. 40. Treatment of VPI Speech Therapy Some speech problems linked with VPI, such as mispronouncing words, can be treated by speech therapy. Treatment focuses on teaching the child the correct manner and place of articulationSometimes an obturator is recommended to treat VPI.An obturator is like a modified dental retainer with a speech bulb orpalatal lift attached to the back. Each obturator is shaped uniquely to fitthe patient’s muscle movements.Speech Surgery: Palatoplasty Sphincter pharyngeoplasty www.indiandentalacademy.com
  41. 41. AIM OF TREATMENT IN CLCP PATIENTS:  To get optimum alignment.  Harmonize relationship of the dental arches for speech, mastication, oral health and facial appearance.PRIMARY DENTITION STAGE :Treatment priorities is to correct crossbite by using removal plates orlingual arch.To control or eliminate oral habits, functional shift or space loss afterpremature loss of primary teethAfetr the first phase, a removable retainer (atleast night time) is worn tillthe next phase is begun. www.indiandentalacademy.com
  42. 42.  MIXED DENTITION  A tentative decision on extraction of supernumerary teeth and overretained teeth.  Correction of cross bite- jack screw, RME, quad helix, Niti expanders  Maintain space for proper eruption of teeth.  Expand collapsed segment to improve surgical Traumatic occlusion is eliminated in preparation of alveolar graft. access to the graft site. (By aligning offending tooth) Correction of jaw relationship- Face mask Therapy www.indiandentalacademy.com
  43. 43.  FACE MASK THERAPY Used in mild maxillary deficient cleft patient Orthopaedic forces for maxillary protraction Orthopaedic force 350-500 gm per side over 10-12 hr / day for an average of 12-15 months.Stability…….(Questionable)Because of two reasons Counter pressure of a tight lip on the maxilla. Which inhibits its growth Scarring in pterygo maxillary region after extensive tissue mobilization for palatal closure www.indiandentalacademy.com
  44. 44. Rationale for bone graftingTo restore physiologic continuity of arch for esthetic and hygenicreplacementTo provide bone for stability of dental arch and the premaxillary segmentBone is provided into which unerupted teeth may erupt.At the time of placement of graft, patent oronasal fistulas can be closedTo allow orthodontic alignment of teethTo provide support for the lip and the alar base and the nasal tip. www.indiandentalacademy.com
  45. 45. Alveolar bone grafting divided in two types:1) Primary alveolar bone grafting: done at the time of lip closure ataround 10-12 weeks. Common in 1950s. Causes hinderance in maxillarygrowth.2) Secondary alveolar bone grafting: done after lip closure at laterstage. This is can be dived into three:Early (2-5 years): performed in primary dentition. Rationale is to alloweruption of the lateral incisor if present. Can affect growth of midface.Intermediate (6-15years): performed in late mixed dentition time toallow the eruption of the permanent canine in the graft. There isminimal interference in growth.Late secondary alveolar bone grafting (adolescence to adulthood):Aids in replacement of missing teeth with implants. www.indiandentalacademy.com
  46. 46. CURRENT CONTROVERSIES THREE CONTEMPORARY CONTROVERSIES ARE: 1) Timing of grafting 2) The type of bone for alveolar grafting and donor site 3) Sequencing of orthodontic expansion.Favor of 8-10 year of age (when canines about to erupt-one quarter totwo thirds of root complete)- Bergland etalErupting tooth is a potent stimulus for bone formation.After tooth eruption is complete, it can be very difficult to induce theformation of new bone.Prevents eruption into cleft-periodontal defectIf placed after eruption of permanent teeth then chances of damagingroots and resorption www.indiandentalacademy.com
  47. 47. EXPANSION:If Expansion done before grafting, as after the graft mature andsutures fuse it is difficult to expand maxilla later. Also Expanding thearch before grafting increases the size of cleft and thus more area forplacement of bone. But increased amount of bone required andrequires more soft tissue dissection for closure.Expansion can also be done 6wks after grafting. It has a potential of www.indiandentalacademy.comstimulating immature bone which may enhance graft survival
  48. 48. GRAFTING MATERIAL Autogeous Advantages Iliac crest adequate quantity easily condensed & placed little donor site morbidity Tibia adequate volume quality similar to iliac crest Rib for infants. Cranial bone inadequate quantity less resorption rapid vascularization predictable quality Allogenic grafts: it acts a scaffold into which new bone develops. Freeze dried bone( increased chances of immune reaction, HIV infection, longer post operative phase) www.indiandentalacademy.com REVASCULARISATION OF GRAFT IS SLOW.
  49. 49. PERMANENT DENTITION : Clinical feature of this stage : Medial displacement of the maxillary segment giving buccal cross bite Relative maxillary retrognathism, giving reversed incisal overjet. Deficiency of vertical growth of the upper jaw – REDUCED FACIAL HEIGHT rotation, malposition and hypodontia of teeth. Supernumerary teeth Accentuated curve of spee in maxilla Collapsed arch forms Poor oral hygiene and caries www.indiandentalacademy.com
  50. 50. ALIGNMENT OF INCISOR TEETH  Incisors usually rotated and in crossbite. Corrected by means of fixed orthodontic appliance. CORRECTION OF LATERAL DIMENSION  Lack of bony union between two sides of the maxilla, correction in lateral dimension is relatively straight forward.  By expansion appliance Quad Helix Rapid Maxillary Expansion (RME)Patients with clcp have class III malocclusion bcoz of maxillarydeficiency (A-P and Vertically), coupled with mandibular overclosure.In such cases use of class III elastics after leveling and aligning willresult in upper molar extrusion and favorable downward and backward www.indiandentalacademy.comrotation of mandible.
  51. 51. MASSAGE POINTS IN HAND www.indiandentalacademy.com
  52. 52. www.indiandentalacademy.com
  53. 53. Orthognathic Surgery combined with OrthodonticsDue to severe skeletal discrepancy, there is deterioration of estheticsand occlusion, psychological implications leading to low self esteem,defective speech, oronasal fistulas. Such cases require a combinedorthodontic and orthognathic approach.Size and position of maxilla is often a problem, thus maxillaryadvancement and occasional down grafting needs to be performed. Tocorrect the transverse problem multiple segment LeFort I osteotomiesmay be required. For a bilateral CLCP three-piece maxillary surgery(allows rotation of segments also) required while for unilateral CLCP atwo piece is sufficient.(Vlachos 1996) www.indiandentalacademy.com
  54. 54. Decompensation:Usually requires 12 months.Multiple segment maxillary osteotomies requires segmental treatment.The bracket positions are altered for teeth adjacent to the osteotomysite.Dental compensations in the lower arch also should be addressed iealleviation of crowding and proclination.Gaps present in the arches due to the missing teeth must be eitherclosed- stable result and prevents reopening of oronasal fistula.Proffit recommends overcorrecting the anterior crossbite in excess ofpositive overjet- compensate for post surgical relapse.In cases with an overjet of more than 8mm mandibular surgery(BSSO) also must be considered. If not then over advancement ofmaxilla – unstable and speech defects. www.indiandentalacademy.com
  55. 55. Post surgical orthodontics: involves detailing of occlusion, closure of residual spaces and maintenance of transverse dimension (overlay arches). Lasts for 4-6 months. Retention: After removal of appliance retainers should be placed immediately. Temporary vacuum filled retainers to be avoided-transverse control inadequate. Soldered lingual arch preffered.TIMING Never indicated in active facial growth Ideal time : age 18-19 www.indiandentalacademy.com
  56. 56. DISTRACTION OSTEOGENESIS1903 . Dr. Gavril of Russia-Bone lengthening of leg. It is a procedure that moves two segment of bone slowly apart in such a way that new bone fills the gap. In distraction osteogenesis, a surgeon makes an osteotomy in an bone and attaches a device known as distractor to both sides of osteotomy. The distractor is gradually adjust over a period of days or week to stretch the osteotomy so new tissue fills it. www.indiandentalacademy.com
  57. 57. Maxillary surgery required in 25-60% of cases with clcp.(Ross and Subtenly)Distraction osteogenesis allows soft tissue adaptation, including scartissue. Therefore doesn’t cause a problem with vello- pharyngealinsufficiency thus good results. Distraction Of maxilla first proposedby Molina & Oritz-Monasterio(1998)EXTERNAL DISTRACTORS Advantage: •Direction of force is well controlled Dis advantage: •Cranial surgery is required •Esthetics are compromised www.indiandentalacademy.com
  58. 58. INTERNAL DISTRACTORSAdvantage:•Esthetics•Psychological relilefDisadvantage:•Difficult to control the direction of forceProsthodontic Treatment:It may be required in cases where replacement of missing teeth isessential. Removable or fixed prosthesis may be given. It allows forimproved speech and www.indiandentalacademy.com better esthetics.
  59. 59. CONCLUSION:Orofacial clefts have been identified to have a multifactorial etiologyand therefore require an interdisciplinary treatment approach,comprising a team effort in which an orthodontist plays a vital role andworks hand in hand with various specialists to provide the best possibleline of treatment with a single minded approach , that is to minimize ifnot eliminate the physical, social and the emotional hardship that aperson with orofacial cleft presents. www.indiandentalacademy.com
  60. 60. REFERENCES:• CRANIOFACIAL DEVELOPMENT- Sperber•Surgical orthodontic treatment- Proffit and White•Grayson etal, Pre surgical naso alveolar molding, cleftliip- craniofacialjournal 1999:35•Advances in management of cleft palate: Edwards and Watson•Cleft lip and palate, Seminars in Orthodontics•Baik et al. surgical orthodontic treatment in patients with clcp:conventional surgery vs maxillary distraction, world J Orthod;2:331-40 www.indiandentalacademy.com
  61. 61. www.indiandentalacademy.com

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