MANAGEMENT OF CLEFT LIP AND
PALATE-II

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INDIAN DENTAL ACADEMY
Leader in continuing dental education
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• Primary Repair of Cleft Lip
• Primary Repair of Cleft Palate
• Comprehensive orthodontic treatment of the cleft
lip and ...
Primary repair of unilateral cleft lip:
Anatomic Considerations:
• The superficial muscles of the face are arranged
schema...
www.indiandentalacademy.com
• The nasal septum is pulled by muscles on the non
cleft side, displacing it with the anterior nasal
spine in that directi...
•
•
•
•

Some characteristic muco-cutaneous
abnormalities are also seen associated with
the cleft lip.
Malposition of nost...
The goal of primary closure is not
only to re-establish normal
insertions of all the naso-labial
muscles but also to resto...
Timing of repair
• There is still some controversy about ideal
time for cleft lip repair.
• Most surgeons abide by the rul...
Lip Adhesion:
• Some surgeons prefer to perform a
preliminary lip adhesion before definitive
lip repair.
• Particularly do...
• Technique involves paring of cleft margins
and a 3 layer repair including mucosa,
muscle and skin.
• This converts the c...
• According to Salyer et al (Clinics in Plastic Surgery,
April 2004):
• Lip adhesion may contribute to additional scarring...
Techniques of lip repair
• Early lip repairs involved paring the lip margins
and repair of skin and mucosa without muscle
...
1. Straight line technique
(Rose-Thompson)
• Used in case of an
incomplete cleft lip that
requires minimal
lengthening.
• ...
2. Triangular Flap technique
(Tennison-Randall)
• Used in situations where
maximal lengthening of the
lip is required.
• P...
3. Millard’s Rotation
Advancement Technique:
• One of the most popular cleft
lip repair techniques in the
USA.
• Described...
4. Modified Rotation Advancement Flap
(Mohler, 1986):
• Produces a scar line that more closely
mimics the normal philtral ...
www.indiandentalacademy.com
5.

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Primary Repair of Cleft Palate:
• Primary cleft palate repair is indicated in nearly all
affected children to facilitate s...
Advantages of early repair of cleft palate:
1. Encourages normal speech patterns.
2. Permit normal swallowing patterns.
3....
Contra-indications to early repair:
1. Children with upper airway obstruction
2. Severe retrognathia
3. Persistent glossop...
Goal of cleft palate repair:
To create normal function in the hard palate
and soft palate.
Simple obturation of the cleft ...
Pathologic anatomy of the cleft palate:
• Four muscles with various degrees of fusion
compose the soft palate and produce ...
www.indiandentalacademy.com
In cleft palate patients, the attachments of these
muscles in the soft palate are defective
The muscles that normally join...
Surgical repair of cleft palate
• The French dentist LeMonnier performed the first
surgical repair of a congenital cleft p...
Surgical preparation of patient:
• General anesthesia.
• Head of table lowered.
• Use of mouth prop, cheek retractor, thro...
Techniques of surgical repair:
Incomplete clefts of soft palate:
1. Side-to side veloplasty:
Veau, in the early 20th centu...
2. Kriens Intravelar Veloplasty:
• Proposed by Kriens in 1969
• Restores the levator sling and the palatal
musculature at ...
3. Furlow double opposing Z-plasty
• Has become the veloplasty of choice for
many surgeons, over the past decade.
• Uses t...
www.indiandentalacademy.com
Incomplete clefts of hard and soft palate
1. Von Langenbeck’s technique (1859)
• This technique depends on paring the edge...
www.indiandentalacademy.com
2. Veau-Wardill-Kilner
(VWK) palatoplasty
• Modification of von
Langenbeck technique
• Involves medial and
posterior movem...
Concerns with the VWK palatoplasty:
Denudation of palatal bone anteriorly, which may
adversely affect midfacial growth in ...
www.indiandentalacademy.com
Complete bilateral cleft palate:
• Presents a unique challenge because of cleft width and
continuity of the palatal cleft ...
Post-operative care:
• Average blood loss for the procedure is 50-60 ml
and the length of procedure is 12 hours.
• Post-op...
Comprehensive orthodontic treatment:
Aims :
1. To prevent gross deformity of dental arches.
2. Restore normal overall cont...
6. To create more room for tongue, facilitating
articulation.
7. Prepare the dentition for secondary bone
grafting, prosth...
Timing and sequence of treatment
(4 periods)
I. Neonate and infant (Birth to Two Years)
Presurgical orthodontics, maxillar...
II. Primary Dentition (2-6 years of age)
• Establishment of primary dentition permits
classification of the type of develo...
• According to Vig and Mercado, contemporary
opinion recognizes a need for orthodontic
treatment in the early mixed and pe...
III. Mixed dentition Stage (7-12 years of age)
Goals of treatment at this stage include:
1. Lateral expansion of the poste...
• The maxillary arch should not be over-expanded ,
or else the alveolar defect would be widened. It
should be sufficient t...
4. Growth modification:
Children treated for cleft lip and palate often
develop midfacial retrusion.
In order to avoid the...
• Lisa So (AJODO 1996) evaluated 10 consecutive
Southern Chinese girls born with unilateral
complete cleft lip and cleft p...
Skeletal and dental effects of reverse headgear

www.indiandentalacademy.com
Use of implants for maxillary protraction
• Use of conventional face mask therapy using the
maxillary dentition as anchora...
• The implants were left to integrate for 6 months
followed by placement of customized abutments that
projected into the b...
The secondary dental change frequently seen in
www.indiandentalacademy.com
standard facemask therapy was avoided.
• In the future, new protraction devices may
use short-duration dynamic forces rather
than continuous forces as currently
...
Alveolar bone grafting

•
•
•
•

Purpose: Not simply to close a hole in the
alveolus but also to accomplish certain
esthet...
• Augmentation of piriform region.
• Establish good soft tissue contours with
adequate keratinized gingiva for periodontal...
Historical aspects:
• The first reports of maxillary alveolar bone
grafting appeared in the German literature in the
early...
Timing of repair:
• Timing of repair has been controversial.
• From a chronologic viewpoint it may be primary
or secondary...
•
•

•
•

Early secondary repair is done if the patient
appears to have a functional lateral incisor that can
erupt into t...
• This age is believed to be appropriate because
sagittal and transverse growth of the maxilla is
essentially complete by ...
Role of the orthodontist in alveolar cleft
grafting:
• Orthodontist plays an essential role.
• In infancy, maxillary ortho...
This includes:
• Placement of fixed appliance on the maxillary
arch.
• Expansion of the anterior and posterior maxilla to
...
• Bone grafting of the alveolar cleft without
proper orthodontic preparation will lead to
poor results with malposition of...
Bone graft donor sites:
• The gold standard site in alveolar cleft repair is he
iliac crest, typically harvested as a a pa...
• Bergland et al of the Oslo study group reported
high rates (85%) of spontaneous eruption of the
canine following bone gr...
www.indiandentalacademy.com
• Other sites which have been investigated are the
tibia, the calvarial bone and mandibular
symphysis.
• Tibial bone provi...
Procedures involved in alveolar bone
grafting:
• Layered closure of the oro-nasal fistula is
achieved.
• The oro-nasal fis...
www.indiandentalacademy.com
Innovations in repair of cleft sites:
• Platelet rich plasma is an autologous source of
growth factors that has been shown...
Composite intramenbranous bone grafts:
• In an effort to augment the healing of
autogenous EC bone, Rabie and Lie (Int J O...
• Rabie and Chay (AJODO 2000) reported a
case of cleft lip and palate with a large
alveolar defect in which bone harvested...
• Distraction osteogenesis has also been used
by Liu et al (Plastic Reconstr Surg 2000) to
close large alveolar clefts tha...
3. Permanent dentition stage treatment
• The permanent dentition is associated with the
adolescent growth spurt and onset ...
This requires full face and profile assessment as well
as cephalometric analysis and prediction tracings.
If the skeletal ...
• In case orthognathic surgery is required, the
orthodontist must perform necessary presurgical
orthodontics to decompensa...
Orthognathic surgery for the cleft patient
Timing of orthognathic surgery
• Orthognathic surgery should be delayed till sk...
• Two jaw surgery i.e combination of maxillary
advancement and mandibular setback is indicated
when there is a true mandib...
•
•
•
•

Some co-existing conditions which may need
repair at the time of osteotomy include:
Palatal fistulae
Soft tissue ...
Relapse following LeFort I maxillary
advancement
• Relapse is more likely in cleft patients with
maxillary hypoplasia.
• T...
Dental anomalies associated with cleft
lip and palate
• Congenital developmental dental anomalies have
frequently been rep...
• In addition, the extent or “penetration” of the
anomalies in the dentition depends on the severity
of the cleft.
• The t...
• Hypodontia outside the cleft region was also much
higher in cleft-affected children than in others.
(Ranta AJO 1986) fou...
• In addition, supernumerary teeth may be seen
adjacent to the cleft site.
• Lateral incisors with peg shape, crown-root
m...
The Goslon Yardstick (Mars et al
Cleft Pal J 1987)
• Mars et al have devised a method of categorizing
malocclusions in pat...
Prosthetic Management of Cleft Lip and
Palate Patients.
• When a lateral incisor is present and is viable,
every effort sh...
1. Canine on cleft side in ideal Class I relation with
lower canine.
2. Distal/ posterior eruption of the canine
3. Lack o...
Thank you
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Management of cleft lip and palate 2. /certified fixed orthodontic courses by Indian dental academy

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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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  • The orthodontist’s knowledge of craniofacial growth and cephalometry qualifies him/her to monitor closely the craniofacial growth, dental development of the patient, as well as treatment results.
  • The secondary dental change frequently seen in standard facemask therapy was avoided.
  • Management of cleft lip and palate 2. /certified fixed orthodontic courses by Indian dental academy

    1. 1. MANAGEMENT OF CLEFT LIP AND PALATE-II www.indiandentalacademy.com
    2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    3. 3. • Primary Repair of Cleft Lip • Primary Repair of Cleft Palate • Comprehensive orthodontic treatment of the cleft lip and palate patient (including secondary alveolar bone grafting) • Orthognathic surgery for the cleft patient. • Dental anomalies associated with cleft lip and palate • The GOSLON Yardstick www.indiandentalacademy.com
    4. 4. Primary repair of unilateral cleft lip: Anatomic Considerations: • The superficial muscles of the face are arranged schematically in 3 interdependent rings. • These muscles include the transverse nasal muscle, levator labii superioris alaeque nasi, levator labii superioris, depressor septi, orbicularis oris. • In patients with clefts, these muscles do not insert on their corresponding elements on the medial side of the cleft. • As a result they are prolapsed laterally, and cannot solicit stimulation and normal growth. www.indiandentalacademy.com
    5. 5. www.indiandentalacademy.com
    6. 6. • The nasal septum is pulled by muscles on the non cleft side, displacing it with the anterior nasal spine in that direction. • On the cleft side the labial commisure is deviated latero-inferiorly, which in turn favors lateral deviation of the chin to the cleft side. • This accentuates the nasal asymmetry and the entire anterior part of the face is distorted and malformed. www.indiandentalacademy.com
    7. 7. • • • • Some characteristic muco-cutaneous abnormalities are also seen associated with the cleft lip. Malposition of nostril skin on upper part of lip. Retraction of labial skin Alteration of white roll of lip Presence of a special mucosa neighboring the muco-cutaneous junction on the sides of the cleft. www.indiandentalacademy.com
    8. 8. The goal of primary closure is not only to re-establish normal insertions of all the naso-labial muscles but also to restore the normal position of all the other soft tissues, including the mucocutaneous elements. www.indiandentalacademy.com
    9. 9. Timing of repair • There is still some controversy about ideal time for cleft lip repair. • Most surgeons abide by the rule of 10s. • General anesthesia is usually necessary for surgery and is safe when the infant is 10 weeks of age, 10 lbs in weight and has a Hb level of 10g. • Recently there has been discussion of early repair in the first 1-2 weeks of life: not common yet. www.indiandentalacademy.com
    10. 10. Lip Adhesion: • Some surgeons prefer to perform a preliminary lip adhesion before definitive lip repair. • Particularly done in extremely wide complete clefts with marked maxillary and nasal distortion. • Reduces the actual deformity by helping to mold the maxillary segments closer together • May make formal lip repair less difficult. www.indiandentalacademy.com
    11. 11. • Technique involves paring of cleft margins and a 3 layer repair including mucosa, muscle and skin. • This converts the complete cleft into an incomplete one. • Non-surgical lip adhesion with tape has also been reported to be of benefit. • However, current opinion among some authors is that lip adhesion is an unnecesary procedure. www.indiandentalacademy.com
    12. 12. • According to Salyer et al (Clinics in Plastic Surgery, April 2004): • Lip adhesion may contribute to additional scarring or abnormal tethering of the lip or nasal elements. • Using a lip adhesion treats the abnormal skeletal base, making it easier for the surgeon to close the lip at the expense of overall esthetics of nose and lip. • May cause fixation or scarring of the alar base or associated adjacent structures in an abnormal position, making definitive normal contour of nose more difficult. • The utility of naso-alveolar molding in early treatment of unilateral cleft lip and palate has also been challenged www.indiandentalacademy.com recently.
    13. 13. Techniques of lip repair • Early lip repairs involved paring the lip margins and repair of skin and mucosa without muscle realignment. • The orbicularis oris muscle therefore maintained its abnormal attachments resulting in an orbicularis bulge in the lateral lip segment. • Nowadays it is standard practice to detach the muscle from its abnormal skin and mucosal attachments and reorient it in a proper fashion. www.indiandentalacademy.com
    14. 14. 1. Straight line technique (Rose-Thompson) • Used in case of an incomplete cleft lip that requires minimal lengthening. • Slightly curved or angled incisions of equal length are made on either side of the cleft , which, after suturing, create a philtral scar line symmetric with normal philtral column. • Formal muscle repair is also done. www.indiandentalacademy.com
    15. 15. 2. Triangular Flap technique (Tennison-Randall) • Used in situations where maximal lengthening of the lip is required. • Precise reproducible mathematical markings as described by Randall are used, allowing excellent results even by relatively inexperienced surgeons. • Scar line crosses the philtrum in lower portion of lip, which may be unesthetic. www.indiandentalacademy.com
    16. 16. 3. Millard’s Rotation Advancement Technique: • One of the most popular cleft lip repair techniques in the USA. • Described by Millard as a cut as you go technique and is not easy to master. • Rotation and advancement flaps are marked and adjusted during the procedure to provide adequate lip length. • Scar line crosses upper philtrum column. www.indiandentalacademy.com
    17. 17. 4. Modified Rotation Advancement Flap (Mohler, 1986): • Produces a scar line that more closely mimics the normal philtral column, than original Millards technique. • Achieved by extending the rotation incision into the columella and making a back-cut. • Muscle repair is also performed. • Lengthening of columella occurs. • Scar line is more vertical and lateral in the upper lip, which appears more natural. www.indiandentalacademy.com
    18. 18. www.indiandentalacademy.com
    19. 19. 5. www.indiandentalacademy.com
    20. 20. Primary Repair of Cleft Palate: • Primary cleft palate repair is indicated in nearly all affected children to facilitate speech and swallowing. • Earlier, primary repair was performed at 18-24 months of age, but recent advances in anesthesia and surgery allow early cleft palate repair at 9-12 months of age. • An infant is generally ready for repair when able to drink from a capped cup without a nipple. www.indiandentalacademy.com
    21. 21. Advantages of early repair of cleft palate: 1. Encourages normal speech patterns. 2. Permit normal swallowing patterns. 3. Allow eustachian tube to function against a repaired palate. 4. Trauma of surgery completed early before patient is a toddler. 5. Help parents lead the child through tasks of development with less difficulty. www.indiandentalacademy.com
    22. 22. Contra-indications to early repair: 1. Children with upper airway obstruction 2. Severe retrognathia 3. Persistent glossoptosis as occurs in Robin sequence. 4. Children at risk of excessive blood loss, delayed wound healing 5. Increased anesthetic risk. www.indiandentalacademy.com
    23. 23. Goal of cleft palate repair: To create normal function in the hard palate and soft palate. Simple obturation of the cleft never permits normal function. It requires realignment of all the associated tissues (mucosa, submucosa, muscle, nerve, vessel, and bone) to create a functional structural unit. www.indiandentalacademy.com
    24. 24. Pathologic anatomy of the cleft palate: • Four muscles with various degrees of fusion compose the soft palate and produce its primary functions of elevation, obturation of the nasal pharyngeal opening, and traction on the eustachian tube during swallowing. • These are the tensor veli palatini, the levator veli palatini, the uvulus, and the palatopharyngeus. www.indiandentalacademy.com
    25. 25. www.indiandentalacademy.com
    26. 26. In cleft palate patients, the attachments of these muscles in the soft palate are defective The muscles that normally join at the midline of the soft palate, course anteriorly and insert on or near the posterior edge of the hard palate. Result in defective function of the soft palate. Lead to compromised sphincter function, velopharyngeal insufficiency, problems in speech, chronic otitis media, risk of permanent hearing loss. www.indiandentalacademy.com
    27. 27. Surgical repair of cleft palate • The French dentist LeMonnier performed the first surgical repair of a congenital cleft palate in the 1760’s. • The 3 stage operation consisted of passing sutures through the cleft borders, cauterizing the cleft edges, and realigning the fresh edges. • By the early 20th century, goals included lengthening of the palate to improve speech in the cleft patient. • In the past few decades, attention has shifted to achieving optimal speech development and avoiding abnormal growth after repair. www.indiandentalacademy.com
    28. 28. Surgical preparation of patient: • General anesthesia. • Head of table lowered. • Use of mouth prop, cheek retractor, throat pack • Occlusal mouth mirror for indirect visualization of the hard palate, nasal mucosa. • Magnification, headlights. www.indiandentalacademy.com
    29. 29. Techniques of surgical repair: Incomplete clefts of soft palate: 1. Side-to side veloplasty: Veau, in the early 20th century repaired clefts of soft palate by bringing together the cleft edges,without suturing together the muscle bundles. www.indiandentalacademy.com
    30. 30. 2. Kriens Intravelar Veloplasty: • Proposed by Kriens in 1969 • Restores the levator sling and the palatal musculature at the midline where they normally meet. • Accomplished by dissecting anteriorly malpositioned bundles from posterior edge of hard palate and repositioning them in the midline. • The effectiveness of Krien’s technique over conventional veloplasty has not yet been demonstrated in randomized, prospective, controlled studies. www.indiandentalacademy.com
    31. 31. 3. Furlow double opposing Z-plasty • Has become the veloplasty of choice for many surgeons, over the past decade. • Uses two reversed Z plasties based upon the cleft midline, both of which draw in soft palate tissue from the sides to close the cleft defect and restore the musculature to its anatomic position. www.indiandentalacademy.com
    32. 32. www.indiandentalacademy.com
    33. 33. Incomplete clefts of hard and soft palate 1. Von Langenbeck’s technique (1859) • This technique depends on paring the edges of the cleft and separating the oral and nasal mucosa. • Releasing incisions are made, hard palate is elevated bilaterally to allow mucosal closure. • The nasal mucosa and oral mucosa are sutured side to side to form a 2 layered closure. • Generally used for cases of incomplete clefts of hard and soft palate. www.indiandentalacademy.com
    34. 34. www.indiandentalacademy.com
    35. 35. 2. Veau-Wardill-Kilner (VWK) palatoplasty • Modification of von Langenbeck technique • Involves medial and posterior movement of left and right palate. • Purpose is to increase palatal length to improve velopharyngeal function. • Accomplished via a VY lengthening done at the anterior hard palate. www.indiandentalacademy.com
    36. 36. Concerns with the VWK palatoplasty: Denudation of palatal bone anteriorly, which may adversely affect midfacial growth in cleft palate patients. (La Rossa D. Cleft Palate Craniofac J 2000) A recent retrospective study (Pigott et al. Cleft Pal Craniofac J 2002) comparing the von Langenbeck and VWK techniques, found that over a 5 year period, maxillary growth was less affected with the von Langenbeck Technique with releasing incisions. www.indiandentalacademy.com
    37. 37. www.indiandentalacademy.com
    38. 38. Complete bilateral cleft palate: • Presents a unique challenge because of cleft width and continuity of the palatal cleft with clefts of the lip and alveolus. • Technique for repair: two flap palatoplasty,which is similar to the VWK repair but involves more extensive dissection anteriorly to encompass the cleft edges at the alveolus. • May be combined with a vomer flap, for closure of nasal mucosa: four flap palatoplasty. • In addition, buccal flaps can been used to cover denuded areas of the palate. • Mann and Fisher (Plast Reconstr Surg 1997) have documented the use of bilateral buccal flaps in conjunction with a modified Furlow repair to cover denuded areas on www.indiandentalacademy.com palate. the posterior hard
    39. 39. Post-operative care: • Average blood loss for the procedure is 50-60 ml and the length of procedure is 12 hours. • Post-op. monitoring with pulse oximetry; observation for hemostasis and respiratory distress. • Adhesive arm restraints for 10 days to prevent patient from placing objects in the mouth. • Diet of clear fluids initiated on 1st post-operative morning. • A patient who has adequate oral intake, is in no distress and meets usual discharge criteria may be sent home on the 1st post-operative afternoon. www.indiandentalacademy.com
    40. 40. Comprehensive orthodontic treatment: Aims : 1. To prevent gross deformity of dental arches. 2. Restore normal overall contour of upper arch 3. Relate the upper and lower dental arches, by expanding the upper arch as required, and extracting in the lower arch if necessary. 4. To encourage proper functional exchange between the arches. www.indiandentalacademy.com
    41. 41. 6. To create more room for tongue, facilitating articulation. 7. Prepare the dentition for secondary bone grafting, prosthetic rehabilitation, orthognathic surgery. 8. To improve the appearance of the profile and facial contours. The orthodontist’s knowledge of craniofacial growth and cephalometry qualifies him/her to monitor closely the craniofacial growth, dental development of the patient, as well as treatment results. www.indiandentalacademy.com
    42. 42. Timing and sequence of treatment (4 periods) I. Neonate and infant (Birth to Two Years) Presurgical orthodontics, maxillary orthopedics. Feeding plates, Passive molding plates, Elastic straps. Nasal Stents. www.indiandentalacademy.com
    43. 43. II. Primary Dentition (2-6 years of age) • Establishment of primary dentition permits classification of the type of developing malocclusion, which is an important part of diagnostic regimen. • Anterior crossbite may be seen unilateral/ bilateral, with or without mandibular shift. • Orthodontic treatment may be required to remove interfering contacts in order to eliminate mandibular shift. • If the dental crossbite relationship is a continuing problem, it may reflect an underlying skeletal discrepancy. This may require growth modification with face mask. www.indiandentalacademy.com
    44. 44. • According to Vig and Mercado, contemporary opinion recognizes a need for orthodontic treatment in the early mixed and permanent dentitions. • No strong evidence supports a benefit from routinely treating dental malocclusions in the primary dentition. • Treatment may be deferred till it can be combined with other treatment goals. www.indiandentalacademy.com
    45. 45. III. Mixed dentition Stage (7-12 years of age) Goals of treatment at this stage include: 1. Lateral expansion of the posterior segments if required, using palatal expanders incorporating screw, or quad helix. Puneet Batra, Ritu Duggal and Hari Parkash (JIOS 2003) reported on the use of a Nickel Titanium Palatal Expander which is temperature activated and produces light continuous pressure (230-300 gms) on the mid palatal suture. They documented three cases of CL/P which were treated with this modality to correct crossbite and molar relation. www.indiandentalacademy.com
    46. 46. • The maxillary arch should not be over-expanded , or else the alveolar defect would be widened. It should be sufficient to improve arch form and correlate it with lower arch. (Note: If grafting is done prior to expansion of the maxilla, a 3 month period must elapse before attempting expansion.) 2. Correction of incisor malalignment and displaced teeth. 3. Resolution of anterior crossbite. www.indiandentalacademy.com
    47. 47. 4. Growth modification: Children treated for cleft lip and palate often develop midfacial retrusion. In order to avoid the need for later surgery, growth modification by protraction of the maxilla and restraint of mandibular growth may be attempted. Facemask and reverse headgear have been used to achieve correction of skeletal discreopancy. Buschang et al (Angle 1994) evaluated 20 children with UCLP, treated at 7.3 years of age, with a combination of maxillary expansion and facemask therapy. Their results showed that although skeletal changes are limited, they do produce marked improvements in the soft tissue profile. www.indiandentalacademy.com
    48. 48. • Lisa So (AJODO 1996) evaluated 10 consecutive Southern Chinese girls born with unilateral complete cleft lip and cleft palate who were treated with the reverse headgear for a period of 9.7 + 1.6 months with a standard deviation of months. • The pretreatment age ranged from 9 to 12 years and none of the subjects had reached maximal pubertal growth. • 10 patients with UCLP who were matched for age and sex and were not treated, served as controls. www.indiandentalacademy.com
    49. 49. Skeletal and dental effects of reverse headgear www.indiandentalacademy.com
    50. 50. Use of implants for maxillary protraction • Use of conventional face mask therapy using the maxillary dentition as anchorage may be associated with anchorage loss in the form of maxillary dental protrusion. • Osseointegrated implants can be used to provide unlimited anchorage for protraction. • Singer et al (Angle Orthod 2000) reported a case in which Branemark Implants were placed in the zygomatic buttresses of the maxilla in a 12-year old female patient with a Class III malocclusion associated with unilateral cleft lip and palate defect. www.indiandentalacademy.com
    51. 51. • The implants were left to integrate for 6 months followed by placement of customized abutments that projected into the buccal sulcus • Elastic traction (400 g per side) was applied from a facemask to the implants at 30 degrees to the occlusal plane for 14 hours / day for 8 months. The maxilla moved downward and forward 4 mm rotating anteriorly as it was displaced. • Clinically, this resulted in an increase in fullness of the infraorbital region and correction of the pretreatment mandibular prognathism. • There was an increase in nasal prominence as the maxilla advanced. This contributed to the increase in facial convexity. www.indiandentalacademy.com
    52. 52. The secondary dental change frequently seen in www.indiandentalacademy.com standard facemask therapy was avoided.
    53. 53. • In the future, new protraction devices may use short-duration dynamic forces rather than continuous forces as currently delivered. • Current research on the mechanobiology of the sutures is exploring the response of cells to oscillating mechanical signals. ( Mao, J Dent Res 2002) www.indiandentalacademy.com
    54. 54. Alveolar bone grafting • • • • Purpose: Not simply to close a hole in the alveolus but also to accomplish certain esthetic and functional goals. These goals are: Closure of oronasal fistula Stabilization of the lesser segment Adequate bone support for teeth adjacent to the cleft. Allow for eruption of teeth in the cleft area (lateral incisor or canine) with good bony support. www.indiandentalacademy.com
    55. 55. • Augmentation of piriform region. • Establish good soft tissue contours with adequate keratinized gingiva for periodontal health. • Minimize growth disturbances www.indiandentalacademy.com
    56. 56. Historical aspects: • The first reports of maxillary alveolar bone grafting appeared in the German literature in the early 20th century with reports by Lexer and Drachter. • Boyne and Sands in 1972, desribed a successful protocol for secondary alveolar bone grafting, using the ilium as the donor site, which has become the standard technique, the world over. www.indiandentalacademy.com
    57. 57. Timing of repair: • Timing of repair has been controversial. • From a chronologic viewpoint it may be primary or secondary. • Primary repair occurs between birth and the age of 2 years, and is typically performed at the same time as lip repair, or as a later operation before palate repair. • Long term studies in the 1970s and 1980s showed it to be associated with higher incidence of detrimental growth effects such as midface retrusion and anterior crossbite. www.indiandentalacademy.com
    58. 58. • • • • Early secondary repair is done if the patient appears to have a functional lateral incisor that can erupt into the grafted cleft site. This is performed when the lateral incisor root is 2/3rds – 3/4th formed.(age 6-7 years) Morphology of the lateral incisor is an important consideration. Conventional secondary repair as described by Boyne and Sands is performed generally at the age of 9-11 years just before the eruption of the canine tooth. Done in cases where early repair is not warranted. Vast majority of patients fall into this category. www.indiandentalacademy.com
    59. 59. • This age is believed to be appropriate because sagittal and transverse growth of the maxilla is essentially complete by the age of 8 years, and remaining vertical growth is from eruption of permanent teeth. Tertiary repair: Done after the eruption of the permanent dentition (usually the 2nd permanent molars) • Shown to have a lower success rate compared to conventional secondary grafting. • Gradual loss of bone along the distal surface of central incisor root and mesial surface of canine root limits the bone graft “take”. www.indiandentalacademy.com
    60. 60. Role of the orthodontist in alveolar cleft grafting: • Orthodontist plays an essential role. • In infancy, maxillary orthopedics is carried out to expand the collapsed lesser segment, mold the anterior maxillary arch and reduce the alveolar gap. • Prior to secondary bone grafting, further orthodontic treatment is required. www.indiandentalacademy.com
    61. 61. This includes: • Placement of fixed appliance on the maxillary arch. • Expansion of the anterior and posterior maxilla to develop favorable arch form, partially or completely eliminate crossbites. • Alignment or derotation of malpositioned incisors. • Improvement of dental function and esthetics. Approximately 4-6 months of orthodontic treatment should be anticipated in preparation for alveolar bone grafting. www.indiandentalacademy.com
    62. 62. • Bone grafting of the alveolar cleft without proper orthodontic preparation will lead to poor results with malposition of the lesser segment, a stabilized maxillary arch constriction, and posterior crossbite. • Correction of these will necessitate additional surgical procedures. www.indiandentalacademy.com
    63. 63. Bone graft donor sites: • The gold standard site in alveolar cleft repair is he iliac crest, typically harvested as a a particulate cancellous bone and marrow (PCBM) graft. • Provides the greatest volume of cancellous bone available among commonly used sites. • Success rates using cancellous iliac bone have been reported to be usually greater than 80%. • Limited dissection of muscle and periosteum, along with use of percutaneous trephine method have reduced postoperative pain substantially. www.indiandentalacademy.com
    64. 64. • Bergland et al of the Oslo study group reported high rates (85%) of spontaneous eruption of the canine following bone grafting. Another 15% required forced eruption. • Da Silva Finho et al (Angle Orthod 2000) reviewed the literature pertaining to successful eruption of permanent canine following secondary alveolar bone grafting and found it to vary from 27% to 95%. • In their own sample of 50 patients treated with secondary alveolar bone grafting, the authors reported spontaneous eruption of the canine through the graft in 72% of cases, while in another 6%, orthodontic traction succeeeded in erupting them. www.indiandentalacademy.com
    65. 65. www.indiandentalacademy.com
    66. 66. • Other sites which have been investigated are the tibia, the calvarial bone and mandibular symphysis. • Tibial bone provides sufficient cancellous bone, but disadvantages are a visible scar and possibility of damage to epiphyseal growth plate. • Calvarial bone and mandibular symphysis bone have the advantage of being located in the facial skeleton and arise from membranous bone. This gives the theoretical advantage of less overall resorption. • Disadvantage: Provide much smaller quantity of cancellous bone, making them inappropriate for larger clefts. www.indiandentalacademy.com
    67. 67. Procedures involved in alveolar bone grafting: • Layered closure of the oro-nasal fistula is achieved. • The oro-nasal fistula is incised and two sets of flaps are created: nasal and oral mucosal layer. • Nasal closure is performed before placing the bone graft and the oral closure. • Buccal and palatal flaps need to be raised for proper closure of the alveolar cleft. • After closure of the nasal and palatal flaps, the bone graft is placed over the inferolateral pyriform rim, to augment the alar base. • Following this, the buccal flaps are closed. www.indiandentalacademy.com
    68. 68. www.indiandentalacademy.com
    69. 69. Innovations in repair of cleft sites: • Platelet rich plasma is an autologous source of growth factors that has been shown to accelerate the rate and degree of bone formation in a bone graft. • Obtained by centrifuging autologous blood into its basic components. • Rich source of growth factors such as PDGF, TGF, which have been shown to play important roles in bone regeneration and repair. • Approximately 60-100 cc of whole blood is recommended to provide an adequate amount of PRP. www.indiandentalacademy.com
    70. 70. Composite intramenbranous bone grafts: • In an effort to augment the healing of autogenous EC bone, Rabie and Lie (Int J Oral and Maxillofac Surg 1996) mixed the autogenous EC bone with demineralized endochondral bone matrix (DBMEC). This composite endochondral bone graft (ECDBMEC) produced 47% more bone than autogenous EC bone alone. • Similar results were obtained when autogenous IM bone mixed with DBM, prepared from IM bone in origin, produced 204% more bone than the IM bone alone. www.indiandentalacademy.com
    71. 71. • Rabie and Chay (AJODO 2000) reported a case of cleft lip and palate with a large alveolar defect in which bone harvested from the chin mixed with DBM was used successfully. www.indiandentalacademy.com
    72. 72. • Distraction osteogenesis has also been used by Liu et al (Plastic Reconstr Surg 2000) to close large alveolar clefts that would otherwise have been difficult to close using conventional methods. • Yen et al (JOMS 2001) have also reported the use of a modified distraction device for closure of cleft spaces. www.indiandentalacademy.com
    73. 73. 3. Permanent dentition stage treatment • The permanent dentition is associated with the adolescent growth spurt and onset of puberty, during which time the skeletal discrepancy becomes more accentuated and occlusal relationships deteriorate. • Sagittal maxillary deficiency coupled with vertical maxillary deficiency may result in overclosure of mandible accentuating the Class III tendency. • Transverse discrepancies may be accentuated by the Class III sagittal relation and lead to posterior crossbites. • As the patient matures, a decision has to be made whether the patient can be treated by orthodontics www.indiandentalacademy.com alone or in combination with orthonathic surgery.
    74. 74. This requires full face and profile assessment as well as cephalometric analysis and prediction tracings. If the skeletal discrepancy is mild and esthetic concerns are minimal, dental compensation by orthodontic treatment alone may be recommended. This would involve full banded/ bonded appliances with use facemask therapy upto the beginning of adolescent growth spurt. Extractions may be required for corection of crowding. Use of Class III elastics in patients with vertical and sagittal discrepancies. • Caution must be exercised, as the patient may outgrow the dental correction, ultimately requiring surgery. www.indiandentalacademy.com
    75. 75. • In case orthognathic surgery is required, the orthodontist must perform necessary presurgical orthodontics to decompensate the dentition, for maximal skeletal correction. • 12-18 months of pre-surgical orthodontics are usually necessary to align the teeth, correct axial inclinations, dental midline discrepancy, coordinate arches and localize space for prosthetic replacement of teeth. • Placement of full-size archwires with lugs provides a means for rigid intermaxillary fixation at time of surgery. • After surgery, post-surgical orthodontic detailing www.indiandentalacademy.com of occlusion is achieved in 4-6 months.
    76. 76. Orthognathic surgery for the cleft patient Timing of orthognathic surgery • Orthognathic surgery should be delayed till skeletal maturity has been achieved as documented by hand wrist radiographs or sequential cephalometric radiographs taken at 6 month intervals. • Usually at 17 years for girls and 18-20 years for boys. • Velopharyngeal function must be evaluated prior to surgery as it may be disturbed by Le Fort I advancement of maxilla leading to velopharyngeal incompetence. • The LeFort I osteotomy is the most favored technique by authors for correction of sagittal www.indiandentalacademy.com maxillary deficiency.
    77. 77. • Two jaw surgery i.e combination of maxillary advancement and mandibular setback is indicated when there is a true mandibular prognathism, or if there is maxillary retrognathia of more than 10-12 mm. • Segmental osteotomy: Is done if the greater maxillary segment is in a good position, but the lesser segment is medially and posteriorly displaced. • LeFort II osteotomy: Indicated in patients with severe paranasal hypoplasia extending to the infraorbital rims. • Premaxillary osteotomy: Done in patients with repaired BCLP who have protruded and rotated premaxilla. Generally done in children above 11 www.indiandentalacademy.com years of age.
    78. 78. • • • • Some co-existing conditions which may need repair at the time of osteotomy include: Palatal fistulae Soft tissue abnormalities Bone asymmetry Soft tissue scars of palate and lip, nose. • Some authors are of the opinion that esthetic and functional correction of the lip, nose or both is best performed at a separate procedure, when the soft-tissue and skeletal changes from osteotomies have stabilized. www.indiandentalacademy.com
    79. 79. Relapse following LeFort I maxillary advancement • Relapse is more likely in cleft patients with maxillary hypoplasia. • This relapse is related to the factors that originally contributed to the deformity: • Scarring, muscle pull, tension in the soft tissues, instability of bone segments.(Hochban et al 1993) • Functional harmony, good occlusal adjustment, rigid fixation with plates and bone grafting are recommended to promote stability. www.indiandentalacademy.com
    80. 80. Dental anomalies associated with cleft lip and palate • Congenital developmental dental anomalies have frequently been reported to occur in individuals born with cleft lip, cleft palate, or both. • These include anomalies in number of teeth (missing or supernumerary), their shape, size, time of formation and/or eruption, as well as the formation and mineralization of their enamel. • Both the deciduous and permanent dentitions are affected, but the occurrence of these anomalies appears in a considerably higher rate in the permanent dentition. • The maxillary arch has been reported to have a higher incidence of tooth abnormalities than the mandibular www.indiandentalacademy.com arch.
    81. 81. • In addition, the extent or “penetration” of the anomalies in the dentition depends on the severity of the cleft. • The teeth that are most frequently missing, excluding the third molars, are the maxillary permanent lateral incisor in the cleft area and the second premolars outside the cleft region. • Shapira (AJODO 1999) found an incidence of 74% for missing maxillary lateral incisors and 18% for missing second premolars in children with cleft lip, cleft palate, or both. • Hypodontia was found to occur approximately three times as frequently on the cleft side as on the non-cleft side in the maxilla (Ranta 1972) www.indiandentalacademy.com
    82. 82. • Hypodontia outside the cleft region was also much higher in cleft-affected children than in others. (Ranta AJO 1986) found the frequency of missing teeth outside the cleft site for children with cleft lip and palate, as follows: 7.5% to 32.3% for the maxillary 2nd premolars, 3.1% to 10.4% for the maxillary lateral incisors, and 0.4 to 10.8% for the mandibular second premolars. • Shapira et al (Angle Orthod 2000) in a study of 278 patients with cleft lip, cleft palate, or both age 5 to 18 years found an overall hypodontia prevalence of 77% (excluding third molars) for the www.indiandentalacademy.com sample.
    83. 83. • In addition, supernumerary teeth may be seen adjacent to the cleft site. • Lateral incisors with peg shape, crown-root malformations and enamel hypoplasia are also seen. • The teeth adjacent to the cleft site may be rotated, palatally erupted, poorly inclined, or periodontally compromised. • These dental anomalies are thought to be caused by a combination of genetic and exogenous factors. www.indiandentalacademy.com
    84. 84. The Goslon Yardstick (Mars et al Cleft Pal J 1987) • Mars et al have devised a method of categorizing malocclusions in patients with unilateral clefts of lip and palate in such a way as to represent the severity of the malocclusion and the difficulty of correcting it. • This is known as the Goslon Yardstick and is based on the assessment of Antero-posterior arch relationships. Vertical labial segment relationships Transverse relationships. This method has been successfully used to compare treatment results in multi center studies. www.indiandentalacademy.com
    85. 85. Prosthetic Management of Cleft Lip and Palate Patients. • When a lateral incisor is present and is viable, every effort should be made to preserve it. • If it is missing, orthodontic space closure may be carried ou or space may be preserved for a future prosthesis. • According to Figueroa et al (Clins in Plast Surg 1993) there are certain specific indications for prosthetic replacement of the lateral incisor. www.indiandentalacademy.com
    86. 86. 1. Canine on cleft side in ideal Class I relation with lower canine. 2. Distal/ posterior eruption of the canine 3. Lack of suitable bone for tooth movement.(Give FPD) 4. Long span of movement for canine. 5. Need for excessive palatal contouring of canine. 6. Abnormal shape of maxillary central incisors 7. Unfavorable shape/size/ color of canine. 8. When there is sufficient bone for a single osseointegrated implant prosthesis. www.indiandentalacademy.com
    87. 87. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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