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Cleft lip & Palate /certified fixed orthodontic courses by Indian dental academy
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Cleft lip & Palate /certified fixed orthodontic courses by Indian dental academy


The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call

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  • 1. CLEFT LIP & PALATE INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. Overview Introduction Basic Science Timetable of Events • • • • neonatal toddler gradeschool teenage Surgical Procedures Conclusion/Future Directions www.indiandentalacademy.com
  • 3. Introduction A TEAM APPROACH IS REQUIRED • • • • • • • • pediatrician surgeon OMFS dentist ENT psychiatrist speech nurse coordinator www.indiandentalacademy.com
  • 4. Introduction Most common congenital malformation of H and N (1:1000 in US; 1:600 in UK) Second most common overall (behind club foot) www.indiandentalacademy.com
  • 5. Epidemiology Syndromic CLAP associated with more than 300 malformations Pierre Robin Sequence; Treacher-Collins, Trisomies 13,18,21, Apert’s, Stickler’s, Waardenburg’s Nonsyndromic CLAP diagnosis of exclusion www.indiandentalacademy.com
  • 6. Syndromic CLAP Single Gene Transmission trisomies 21, 13, 18 Teratogenesis fetal alcohol syndrome Thalidomide Environmental factors materal diabetes amniotic band syndrome www.indiandentalacademy.com
  • 7. Epidemiology: continued Isolated cleft palate genetically distinct from isolated cleft lip or CLAP same among all ethnic groups (1:2000, M:F 1:2) Isolated CL or CLAP different among ethnic groups American Indians: 3.6:1000 (m:f 2:1) Asians 3:1000 (m:f 2:1) African American 0.3:1000 (m:f 2:1) www.indiandentalacademy.com
  • 8. Embryology Primary versus secondary palate divided by incisive foramen primary palate develops 4-5 wks secondary palate develops 8-9 wks Primary palate mesodermal proliferation of frontonasal and maxillary processes never a cleft in normal development www.indiandentalacademy.com
  • 9. Embryology: continued Secondary palate medial ingrowth of lateral maxillae with midline fusion always a cleft in normal development macroglossia, micrognathia may provide anatomical barriers to fusion www.indiandentalacademy.com
  • 10. Classification Veau Classification - 1931 Veau Class I: isolated soft palate cleft Veau Class II: isolated hard and soft palate Veau Class III: unilateral CLAP Veau Class IV: bilateral CLAP Iowa Classification - a variation of Veau Classification www.indiandentalacademy.com
  • 11. Classification; continued Complete Clefts absence of any connection with extension into nose vomer exposed Incomplete Clefts midline attachment (may be only mucosal) ex: submucous cleft (midline diasthasis, hard palatal notch, bifid uvula) www.indiandentalacademy.com
  • 12. Anatomy - Normal Lip: “Cupid’s Bow” Maxilla primary/secondary palates soft palate alveolus maxillary tuberosity hamulus www.indiandentalacademy.com
  • 13. Anatomy: palatal muscles Superior constrictor – primary sphincter Tensor veli palatini – tenses palate Levator Veli palatini – elevates palate – dilates ET Salpingopharyngeus, palatopharyngeous, palatoglossus: minor contribution www.indiandentalacademy.com
  • 14. Cleft Anatomy Unilateral Cleft Lip and alveolus lack of mesodermal proliferation • cleft of orbicularis – medial portion to columella – lateral portion to nasal ala • cleft of alveolus – alveolar bone graft www.indiandentalacademy.com
  • 15. Cleft Anatomy - The Nose Ipsilateral LLC flattened rotated downward Short columella Bifid tip www.indiandentalacademy.com
  • 16. Cleft Antatomy: continued Bilateral Cleft Lip/Alveolus/nose duplication of unilateral defect premaxilla orbicularis to alar cartilages bilaterally bifid tip extremely short columella www.indiandentalacademy.com
  • 17. Cleft Anatomy: continued Clefts of the primary hard palate/alveolus cleft alveolus always associated with cleft lip cleft lip not necessarily associated with cleft alveolus by definition there is opening into nose www.indiandentalacademy.com
  • 18. Cleft Anatomy: continued Clefts of secondary palate Failure of medial growth maxillae • fusion at incisive foramen • macroglossia Submucous vs. complete Vomer www.indiandentalacademy.com
  • 19. Multidisciplinary Approach These are not merely surgical problems Requires team approach throughout life neonatal period toddler grade school adolescence young adulthood www.indiandentalacademy.com
  • 20. The Neonatal Period Pediatrician: directs care establishes feeding complete clefts preclude feeding • breast feeding not possible • a soft, large bottle with large hole is required • a palatal prosthesis may be required www.indiandentalacademy.com
  • 21. The Neonatal Period Presurgical Orthodontics (Baby Plates) • Molds palate into more anatomically correct position • decreases tension • may improve facial growth • Grayson, presurgical nasal alveolar molding (PSNAM) www.indiandentalacademy.com
  • 22. The Neonatal Period Surgical Repair Cleft Lip In US - “the rule of tens” - 10 wks, 10 lbs, Hgb 10 Lip adhesion vs baby plates Cleft Palate Varies from 6-18 months - most around 10 mo Early repair may lead to midface retrusion Early repair improves speech www.indiandentalacademy.com
  • 23. The Toddler Years Priority: Speech “Cleft errors of speech” in 30% primary defects - due to VPI (hypernasality) • consonants are most difficult sounds (plosives) secondary defects - due to attempted correction • glottic stops, nasal grimace Velopharyngeal insufficiency diagnosed by fiberoptic laryngoscopy or BaSw surgical repair after failed speech therapy - usually around age 4 www.indiandentalacademy.com
  • 24. The Toddler Years Growth hormone deficiency 40 times more common in CLAP suspects when below 5% on growth chart www.indiandentalacademy.com
  • 25. The Grade School Years Three primary issues Orthodontics poor occlusion congenitally absent teeth alveolar bone grafting fills alveolar defect - around age 12 psychological growth considered standard of care www.indiandentalacademy.com
  • 26. The Teenage Years Midface retrusion etiology - ?early palatal repair surgical correction around age 18 Psychological development counseling standard of care Rhinoplasty usually last procedure performed, around age 20 www.indiandentalacademy.com
  • 27. Surgical Techniques Cleft Lip Repair unilateral rotation-advancement flap developed by Millard complications • dehiscence – infection • thin white roll – excess tension www.indiandentalacademy.com
  • 28. Surgical Techniques Cleft Lip Repair bilateral bilateral rotation advancement with attachment to premaxilla mucosa complications • dehiscence • thin white roll www.indiandentalacademy.com
  • 29. Surgical Techniques Velopharyngeal Incompetnece superior based pharyngeal flap sphincter pharyngoplasty • palatopharyngeus complications • continued VPI • stenotic side ports www.indiandentalacademy.com
  • 30. Surgical Techniques Alveolar Bone Grafting iliac crest bone graft complications infected donor site • hematoma failed graft • dehiscence • palatal prosthesis www.indiandentalacademy.com
  • 31. Surgical Techniques Midfacial Advancement LeForte osteotomies leave vascular pedicle attached in back of maxilla - prevents necrosis complications • malocclusion • infection • necrosis www.indiandentalacademy.com
  • 32. Surgical Techniques Rhinoplasty standard techniques tip projection alar rotation columellar length complications alar stenosis www.indiandentalacademy.com
  • 33. Controversies: Otologic Disease >90% have COME Robinson, et al • prospective, 150 patients - 92% Muntz, et al. • retrospective, 96% Pathology: ETD (controversial) abnormal muscular attachment Huang, et al. - Cadaveric study • palatal repair restores ET function. ?Midface growth? www.indiandentalacademy.com
  • 34. Controversies: Timing of Repair Early repair Advantage: improved speech • Rohrich, et. al; retrospective study. The earlier the repair, the better speech. Disadvantage: worsening midface retrusion • Rohrich, et. al; people with unrepaired palates have less midface retrusion www.indiandentalacademy.com
  • 35. Controversies: VPI Surgical Repair Reserved for failure of speech pathology Pharyngeal Flap - superiorly based Advantage: time tested, severe cases Disadvantage: passive obturator Sphincter Pharyngoplasty (palatopharyngeus rotation flap) Advantage: active sphincter Disadvantage: new technique www.indiandentalacademy.com
  • 36. Controversies Presurgical Nasal Alveolar Molding molds palate, alveolus and nose Advantage: excellent early results Disadvantage: no long term results Grayson, et al. www.indiandentalacademy.com
  • 37. Conclusion and Future Directions Multidisciplinary approach Not merely a “surgical problem” Alveolar bone grafting PSNAM Pharyngoplasty vs. pharyngeal flap www.indiandentalacademy.com
  • 38. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com