Ortho management of clp /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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Ortho management of clp /certified fixed orthodontic courses by Indian dental academy

  1. 1. 1 Orthodontic management of cleft lip and palate. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. 2 CONTENTS Introduction Prevalence & incidence. Embryology Etiology Classification Management:- 1] Neonatal 2] Mixed dentition 3] Permanent dentition Recent trends in management Conclusion www.indiandentalacademy.com
  3. 3. 3 INTRODUCTION  It can be defined as “a furrow in the palatal vault” (clp). / A breach in the continuity of palate.  Cleft lip or harelip is most common congenital deformities seen at the time of birth.  No group of patients is more profoundly handicapped in a personal sense than those who are facially disfigured. Whatever the cause, the high visibility of facial deformity creates special difficulties related to social identity and interaction. Initially reaction towards this person are universally negative even the health professionals initially have negative response as well. www.indiandentalacademy.com
  4. 4. 4  To tell simply face is the part of body with which a person faces the world. So for the health professionals and us. www.indiandentalacademy.com
  5. 5. 5  The management of cleft lip and palate presents a great challenge not only because it involves face that is the most exposed organ of the human body but also because of associated various anatomical and functional problems, which continue to show up with age. WHY? www.indiandentalacademy.com
  6. 6. 6  Facial esthetics  Feeding difficulties( poor oral seal and nasal reflux)  Speech problems poor pharyngeal seal and oronasal communication  Chronic middle ear problems( poor Eustachian tube function)  Management team:- Paediatrician Orthodontist Surgeon Otolaryngologist Audiologist Speech pathologist Social worker Psychiatrist Geneticist Prosthodontist Paediatric dentist Radiologist Neurologist Neurosurgeonwww.indiandentalacademy.com
  7. 7. 7 AIMS OF TREATMENT.  Regardless of the type of oral cleft, an inter-disciplinary team of specialists should provide the care  There should be a team leader or co-coordinator that facilitates the function and efficiency of the team and ensures co- ordinate care to the patient.  Treatment plan at any stage should be discussed and implemented based on team recommendations. www.indiandentalacademy.com
  8. 8. 8  The principal role of the inter- disciplinary team should be to provide integrated case management to assure quality and continuity of patient care and long term follow ups.  Parents should be provided with written materials on feeding and all aspects of care and management of the child with craniofacial deformity such an inter-disciplinary co-ordinate team approach with defined treatment protocols have shown better treatment outcome and has reduced the overall burden of care of the child and parents. www.indiandentalacademy.com
  9. 9. 9 HISTORY  Harelip has been reported as back as 1000AD.  Parea, a French surgeon (in 1561) first used the Obturator.  Le monnier French dentist [1764] –surgical repair of cleft palate.  In 1826, DIFFENBACH suggested separation of soft tissue of the palate from the underlying bone, also recommended use of lateral relaxation incisions in the soft tissue of the hard palate region to close clefts of velum & hard palate.  Fergusson in 1844 & von lagenback in 1862 –laid emphasis on creating mucoperiosteal flap.  During First World War Harold gilles and POMFRET KILNER in London, victor view in Paris also developed skill to repair cleft. www.indiandentalacademy.com
  10. 10. 10  “we must strive for maximum harmony and balance as near to normal as conditions will allow”- Tweed. “To strive, to seek to find, and not to yield” – Tennyson “ The essential goal of cleft care is restoration of the patient to a ‘normal’ life unhindered by handicap or disability” – Shaw et al. www.indiandentalacademy.com
  11. 11. 11 PREVALENCE & INCIDENCE  The incidence of cleft lip and/or palate has been reported in early studies to be as low as 1 in 3000 in Negroids to as high as 4.9/1000 live births in Afghans.  Studies done in India among such communities reveal an incidence of 1 in every 600-1000 births.  The incidence of CLP is highest among the Mongoloids. Cleft lip is common among males while cleft palate is more common among females. Unilateral clefts account for 80% of the incidence while bilateral clefts account for the remaining 20%. Among the unilateral clefts involving the left side are seen in 70% of the cases. www.indiandentalacademy.com
  12. 12. 12 EMBRYOLOGY www.indiandentalacademy.com
  14. 14. 14  Formation of the Palate The palate develops in 2 parts . viz; 1.The primary palate 2.The secondary palate  Palate is formed by the contribution of the maxillary processes and frontonasal process. The medial nasal process forms the small triangular, median part of the palate called the primary palate. www.indiandentalacademy.com
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  16. 16. 17 PROBABLE REASONS  Complete tongue obstruction over a time specific period (Poswillo and Roy and Humphrey).  Alteration in the shelf force:-  Due to alterations in mucopolysaccharide synthesis ( Ferguson)  Administration of certain drugs like phenobarbitone and vit A. (Smiley and R.Nanda)  Alteration in the cranial flexure ( Harris)  Disturbance in the epithelial fusion ( Smiley)  Alteration in the vascularity of the region ( Cooper) www.indiandentalacademy.com
  17. 17. 18 CLASSIFICATION  Davis and Ritchie classifications (1922). This is a morphological classification based on the location of the cleft relative to the alveolar process. Group I – Pre alveolar cleft:-They are clefts involving only the lip and are sub classified as: Unilateral Bilateral Median Group II - Post alveolar clefts:- This group comprises of different degrees of hard and soft palate clefts that extend up to the alveolar ridge Group III - Alveolar clefts:- They are complete clefts involving palate, alveolar ridge and the lip. They can be subdivided in to ; Unilateral Bilateral Medianwww.indiandentalacademy.com
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  19. 19. 20 Veau’s Classification (1931).  Group –1: They are clefts involving the soft palate only  Group –2: They are clefts of the hard and soft palate extending up to the Incisive- foramen.  Group-3: They are complete unilateral clefts involving the soft palate, the palate, lip and the alveolar ridge.  Group -4: They are complete bilateral clefts affecting the soft palate, the hard palate, lip and alveolar ridge. www.indiandentalacademy.com
  20. 20. 21 Fogh Anderson (1942)  Group -1:-They are clefts of the lip. It can be subdivided in to :- Single - unilateral or median clefts. Double – Bilateral cleft  Group-2: They are clefts of the lip and the palate. They are once again sub- classified into: Single – Unilateral clefts Double – Bilateral clefts  Group –3:They are cleft of the palate extending up to the incisive foramen. www.indiandentalacademy.com
  21. 21. 22 Schuchard and Pfeifer’s symbolic classification:  This classification makes use of a chart made up of a vertical block of three pairs of rectangles with an inverted triangle at the bottom.  The inverted triangle represents the soft palate while the rectangles represent the lip, alveolus and hard palate as we go down.  The advantage of this classification is its simplicity while the disadvantages include difficulty in writing, typing and communication. www.indiandentalacademy.com
  22. 22. 23 Kernahan’s Stripped ‘Y’ classification:  This classification uses a stripped ‘Y’ having numbered blocks. Each block represents a specific area of the oral cavity. Put forward by kernahan and stark.  Block 1 and 4 Lip  Block 2 and 5 Alveolus  Block 3 and 6 Hard palate anterior to the incisive foramen  Block 7 and 8 Hard palate posterior to incisive foramen  Block 9 Soft palate. www.indiandentalacademy.com
  23. 23. 24 Lahshal classification:  Presented by Okriens in 1987  LAHSHAL is a paraphrase of the anatomic affected by the cleft. L lip A alveolus H hard palate S soft palate H hard palate A alveolus L lipwww.indiandentalacademy.com
  24. 24. 25 Iowa system classification:  Group –I These are defined as clefts of the lip only.  Group-II These are defined as clefts of the palate only i.e. secondary palatal clefts.  Group-III These are defined as clefts of the lip , alveolus and palate i.e. complete cleft lip and palate.  Group-IV These are defined as clefts of the lip and alveolus i.e. primary cleft palate and lip  Group –V This classification is defined as miscellaneous and includes clefts which do not fit into any of the above categories. www.indiandentalacademy.com
  25. 25. 26 INDIAN CLASSIFICATION  Proposed by Dr. C. Balakrishnan in1975  Cleft lip only (GP.I)  Cleft lip and alveolus (gp. 1-a)  Cleft palate only (gp.2)  Cleft lip and palate (gp.3) www.indiandentalacademy.com
  26. 26. 27 ETIOLOGY.  Hereditary: - Acc. To fogh and Anderson less than 40%, cases are genetic in origin. Acc. To Drilien 1 in 3 children with clefts had some relatives with similar congenital defects.  20% of isolated cleft are genetic in origin. Acc. to Bhatia main modes of transmission is either by single mutant gene producing a large effect or by no. of genes [polygenic inheritance] each producing a small effect together?  Two types of cleft [recent research] 1] Hereditary-probably polygenic Acc.to this each and every individual caries some genetic liability for clefting but since that is less than threshold level it doesn’t not occur when the liability reaches the threshold level cleft occurs 2] Monogenic or syndromic- associated with various congenital anomalies-they are high-risk type. Frazer realizing The impact of the problem wrote “ No single factor causes all the clinically observed cases of cleft lip and palate. Even in the individual cases the etiology is for most part of the result of multiple factors ”. www.indiandentalacademy.com
  27. 27. 28  Multifactorial threshold hypothesis: - It suggests that many contributory risk genes interact with one another and the environment and they collectively determine that threshold of abnormality is breached resulting in defect. It clearly explains the etiology of isolated cleft lip or palate.  Congenital: - Congenital anomaly is which is already present at birth. It can be hereditary or genetically determined or induced by environment or teratogens.  Hereditary anomalies might or may not present at birth and may appear in due course of time.  Infections: - Like rubella, influenza, toxoplasmosis etc.to the mother during pregnancy may cause the defect. www.indiandentalacademy.com
  28. 28. 29  Drugs: -  Aminoptrein [an antifolic drug] is an abortifacient. A foetus survived of such abortion drugs can become malformed.  All cytotoxic anticancer drugs such as alkylating agents can cause the defect.  Cortisone is suspect teratogens.  Alcoholic mother may give birth to a child with foetal alcoholic syndrome, which may be associated with cleft palate.  Thalidomide also has a similar effect.www.indiandentalacademy.com
  29. 29. 30  Radiation: - Such as x rays, gamma rays etc. these are ionizing radiations and are capable of producing either somatic or genetic effects. Somatic effects are seen in the exposed individual and the genetic effects are expressed in the individual descedents like cleft lip, palate, microcephaly and neonatal death. These are due to irradiation of the fetus during the pregnancy  Diets: Deficiency of riboflavin folic acid and hypervitaminosis an act as environmental teratogens. www.indiandentalacademy.com
  30. 30. 31 GENETIC INFLUENCE  Monogenic or single gene disorder: Autosomal dominant inheritance:-  Clefting-ankyloblepharon filiform  Adentum syndrome  Ectrodactyly  Clefting syndrome  Vander woude syndrome(asociation of lower lip pits or clp) www.indiandentalacademy.com
  31. 31. 32 Autosomal recessive syndrome:- Appert ayndrome Bixer syndrome Bowen-armstrong syndrome Juberg-harward syndrome Robert syndrome www.indiandentalacademy.com
  32. 32. 33 Environmental:- Fetal hydantoin syndrome Fetal trimethadione syndrome Clefting ectropion syndrome Unknown genesis:- Pilloto syndrome Yong syndrome II. Polygeneic or Multifactorial syndrome:- Here many genes with relatively small effect act in concert withpoorly defined environmental triggering mechanisms leading to expression of the abnormalitiy www.indiandentalacademy.com
  33. 33. 34 CHROMOSOMAL ABBERATIONS  Cleft lip and palate occurs as a feature of several syndromes resulting from chromosomal aberrations. Notable among them being trisomy D and E syndrome. www.indiandentalacademy.com
  34. 34. 35 PREDISPOSING FACTORS  Increased maternal age: Women who conceive late have an increased risk of having an off spring with some form of clefting. The cause remains unknown.  Racial Some races are more susceptible to clefts than the, Mongoloids show the greatest percentage of incidence.  Blood supply:- Any factor that reduces the blodd supply to the nasomaxillary complex during the embryological dev. predisposes to cleft. www.indiandentalacademy.com
  35. 35. 36 Problems associated with clp  They can be broadly classification as: - Dental Esthetic Speech and hearing Psychologic www.indiandentalacademy.com
  36. 36. 37 Dental problems  The presence of the cleft is associated with division, displacement and deficiency of oral tissue. Congenitally mussing teeth (most commonly the upper laterals ) Presence of natal or neonatal teeth Presence of supernumerary teeth Ectopically erupting teeth Anomalies of tooth morphology Enamel hyperplasia Microdontia www.indiandentalacademy.com
  37. 37. 38  Fused teeth  Aberrations in crown shape  Macrodontia  Mobile and early shedding teeth due to poor periodontal support.  Posterior and anterior crossbite  Protruding premaxilla  Deep bite  Spacing /crowding.  Difficulty in mastication and swallowing. www.indiandentalacademy.com
  38. 38. 39 Esthetic problems  The clefts involving the lip can result in facial disfigurement varying from mild to severe. The oro- facial structures may be malformed and congenitally missing.  Deformities of nose can also occur. Thus esthetics is greatly affected. www.indiandentalacademy.com
  39. 39. 40 Hearing and speech: -  The first two years of the child are very crucial from the point of speech development and it is the same time when the 1ry surgeries are done. Physiological integrity of the structure involved in speech and adequate neuro – sensory – motor functions are essential for development of the normal speech.  Receptive language problem may arise in children with cleft plate because of the fluid in the middle ear.  Hearing loss may also occur is these patients due to ossicular malformations and /or improper aeration of the Eustachian tube. www.indiandentalacademy.com
  40. 40. 41  Clinically an operated cleft palate child usually presents with short palate or decreased mobility of soft palate due to Scarring and oro- nasal fistula,  Thus causing velo- pharyngeal insufficiency, hypernasality, nasal escape of air, mis-articulations and poor intelligibility of speech. High nasality could be due to oronasal fistula or inadequate velo-pharyngeal seal.  Acrylic or chrome cobalt obturators, which are still very popular in India, were given to prevent nasal escape of air. The modified obturator called speech bulb appliance is useful in cases where palatal lift or soft palate closure is needed to improve velo-pharyngeal seal. www.indiandentalacademy.com
  41. 41. 42 PSYHCOLOGICAL PROBLEMS  They are under lot of psychological stress due to their abnormal facial appearance they have to put up with staring, curiosity, pity etc.  They also face problems in obtaining jobs and making friends.  Studies have shown that these patients are badly in academics.  This is usually as a result of hearing impairment, speech problems and frequent absence from school. www.indiandentalacademy.com
  42. 42. 43 MANAGEMENT  The cleft child has a lot of dentoalveolar and maxillo mandibular problems, which are quite different from the routine orthodontic patient  The maxilla is more often seen to be retruded, and this effect is primarily seen as a post surgical problem. Further more, there is a progressive decline of the maxillary prominence in both UCLP and BCLP patients as the child grows through adolescence  There are postural adaptations to the dentoalveolar and basilar discrepencies and a lower jaw position in over closure is a common feature. www.indiandentalacademy.com
  43. 43. 44 In addition to the sagittal discrepancies getting accumulated by the surgery, transverse relations are also severely compromised. Two common types of maxillary transverse collapse patterns mostly related to the palatal repair surgery are seen. 1)The unilateral collapse frequently seen in UCLP presents with the lesser segment caught behind under the greater segment. 2)The bilateral collapse, typically seen in BCLP has equal transverse constriction of the maxillae. The arch deficiency and dentoalveolar mutilation is further complicated by congenitally missing lateral incisors, supernumerary and fissural teeth adjoining the cleft site, ectopically erupting maxillary canines and a general hypoplasia of the maxillary incisors. Anchorage planning and management of tooth movement is thus complicated. www.indiandentalacademy.com
  44. 44. 45 NEONATAL( Birth to 18 months)  Early contact and counseling of the parents should be done to reassure them and prevent inaccurate information being provided by other professionals who are not involved in cleft treatment.  The optimum time for the first contact by the professionals with the family and evaluation of the child soon after the birth . www.indiandentalacademy.com
  45. 45. 46  Feeding a child with cleft palate is a very challenging job. Making the parents understand about the normal physiology and altered anatomy can guide towards a successful feeding.  The normal process of feeding involves two basic tasks, suckling and swallowing. In patients with cleft lip and alveolus , breast feeding is not a problem and can be achieved with slight adjustmentswww.indiandentalacademy.com
  46. 46. 47 NEONATAL  Placing the finger over the cleft assist in creating negative pressure inside the oral cavity and thus making swallowing effective.  However , in cleft palate patients breast feeding is usually not successful. The patient cannot build up pressure inside the oral cavity because the air is drawn through the nose.  For this variety of nipples and feeding devices are available. Two of them are inexpensive and readily available.  Enlarged (1/4 inch) cross cut regular nipple and the Mead Johnson cleft palate nursing bottle. www.indiandentalacademy.com
  47. 47. 48  During feeding following guide lines should be followed: 1. The infant is held upright in the lap at about 45o to 60o angle to decrease nasal regurgitation. 2. Direct the nipple to intact part of the palate. 3. Burping the infant after ½ of feed is necessary because excessive air is swallowed. 4. Adjust the flow of the milk dropping in the mouth to the ability of the child to swallow and limit the feeding to maximum ½ an hr. 5. Observe the child for choking , cyanosis or abdominal distention. During feeding , widened eyes or choking indicate too rapid flow of liquid and needs to be adjustedwww.indiandentalacademy.com
  48. 48. 49 FEEDING APPLIANCE  The feeding appliance assists in feeding by sealing the oro- nasal fistula and thus enables the child to suck by negative intra- oral pressure.  Feeding appliance should be considered to assist with feeding only if other methods of feeding are not successful in the first one or two weeks.  Infants up - to 6 months of age are require 115 to 120 cal /kg. of body weight and they are fed every 2-4 hrs.  If oral feeding is not useful, naso–gastric feeding many be used temporarily. www.indiandentalacademy.com
  49. 49. 50  The orthodontist has been involved in some centers in providing feeding plates and the use of plates to remove the influence of tongue on cleft width.  The speech and language pathologist recommends such plates during the 1st year of development until the palate closure is done. The appliance provides the cleft child with an intra-oral environment as normal as possible during the early critical and active phase of articulation development.  Burstone pioneered and introduced neonatal maxillary orthopedics in the 1950 s www.indiandentalacademy.com
  50. 50. 51 RATIONALE FOR TREATMENT  Reposition the severely displaced maxillary segments.  Reduction in width of wide clefts.  Improved symmetry of nose and cleft maxilla. www.indiandentalacademy.com
  51. 51. 52 Passive maxillary obturator  It is an intra oral prosthetic device that fills the palatal cleft.  Provides a false roofing against which chid can suckle.  Reduces feeding difficulties viz; insufficient sucking,excessive air intake,choking.  Provides maxillary cross arch stability preventing the arch from collapse. www.indiandentalacademy.com
  52. 52. 53 DECIDUOUS DENTITION(18months to 5 years)  No orthodontic intervention is done in the early deciduous dentition.  Treatment at this stage can produce only ephemeral results and such results would be poor temporary compensations for deeper skeletal abnormalities which become increasingly manifest later.  Patient are seen regularly at six month intervals for review, keeping the motivation of the family, generating early rapport with the child, constant monitoring of the caries and oral hygiene status, and diet consulting.  In certain cases, equilibration of deciduous canine is done to avoid encouraging lateral shifts of the mandible.  Towards the end of the deciduous dentition, the 5 year old child becomes a candidate for early dentofacial orthopedic intervention by face mask therapy if indicated. www.indiandentalacademy.com
  53. 53. 54 MIXED DENTITION(sixth year to 11nth year.)  The aim of the treatment :- 1. Symmetry within the upper dentition and related to the facial midline. 2. Normally functioning occlusion with. 3. Correct position of upper incisor teeth and 4. Favorable transverse and sagittal posterior occlusion www.indiandentalacademy.com
  54. 54. 55 Orthodontic evaluation at 6 yrs of age: - 1 Soft tissue facial appearance: full face and profile 2 Types of the face: Prognathic, orthognathic or retrognathic. 3 Basal jaw configuration: sagittal vertical or transverse 4 Dental occlusion: Frontal (overjet, overbite) or lateral (Angle classification) 5 Dental space conditions. 6 Disturbances of dental development and occlusion. 7 Orofacial dysfunction 8 Vestibular, periodontal and mucosal abnormalities.www.indiandentalacademy.com
  55. 55. 56  Retroclination or cross bite is corrected. The correction of lateral incisor cross bite, which is usually present in cleft, is postponed until the permanent dentition.  Before correcting the rotation and cross bite of teeth one should confirm the adequate bone support of the tooth on a radiograph. (IOPA OR OCCLUSAL)  If insufficient bone support is available, de rotation may result in root exposure in the cleft and devitalization.  If adequate bone support ,de rotation and cross bite correction are usually performed before the patient is considered for alveolar bone grating.  But if the adequate bone support is not there then these procedures are performed after the alveolar bonr grafting. Pre surgical orthodontics www.indiandentalacademy.com
  56. 56. 57  If the cross bite or edge to edge bite causes functional shift of the mandible, then attempts should be done to relieve it by selective grinding or orthodontic treatment .  Maxillary arch expansion is needed and this procedure if required should be performed before secondary alveolar bone grafting. The correction of maxillary arch collapse helps to prevent 1. Lateral shifts of the mandible 2. Improve sagittal mandibular position by cricumventing the adaptive mandibular prognathism 3. Provide area for the tongue 4. Promote normal maxillo mandibular developement and prepare the arch for secondary bone grafting as a part of prebone graft orthodontics. www.indiandentalacademy.com
  57. 57. 58  The Quad Helix appliance in .036 Blue Elgiloy provides controlled force application to correct severe segmental dislocation. The typical expansion period lasts for 3 months with 2 activations at 6weeks intervals. The rate of the transverse expansion is 3mm/month. The optimal force is 200gm. on each side.  Advantages are: - 1.Easy to construct at the chair- side using ordinary laboratory pliers and minimal inventory 2.It offers the unique advantages of providing four sites of activation. 3 It exerts 3-diamensional control on the molars 4 It provides controlled force 5 Relatively less patient co-operation 6 Provides powerful anchorage preservation mechanismwww.indiandentalacademy.com
  58. 58. 59 PROTRACTION FACE MASK  Used between 5 and 8 years  AIMS OF THE TREATMENT 1. Correct midface skeletal deficiency 2. Eliminate anterior and / or posterior crossbite 3. Provide optimal space for spontaneous incisor eruption 4. Improve the soft tissue profile.  The introduction of the facial mask for early protraction by heavy forces to the maxillary complex in CLP patients was reported by Delaire and Colleagues.www.indiandentalacademy.com
  59. 59. 60  The Quad –Helix appliance is used as anchorage for the facial mask.  No other fixation of the mask is needed than the two intra oral elastic bands from the hooks in the canine regoins to a bar on the mask.  The force used for facial protraction is about 350gm. on each side (Total 700gm.) .The facemask is used mainly at night for 10- 12 hrs. for 6 to 12months.  RAPID SAGGITAL CORRECTION IS ACHIEVED:- 1.Maxillary base protraction 2.Canting of the maxillary plane upward 3.Remodelling changes in the anterior maxilla 4.Backward rotation of the mandible www.indiandentalacademy.com
  60. 60. 61 RETENTION  Fixed palatal arch  A Function corrector III (FR-3 )- active retainer only when unfavourable growth pattern is seen. www.indiandentalacademy.com
  61. 61. 62 PERMANENT DENTITION  Aims of the Treatment in the Permanent Dentition: - 1. Improving the dentofacial relationship. 2. Balancing the relationship between dental and skeletal components 3. Establishing favourable maxillo mandibular balance and proportion 4. Establishing normal incisal and buccal occlusion. 5. Establishing harmonious dental arches in both jaws. 6. Correcting axial inclination of teeth. 7. Correcting midlines. 8. Avoiding prosthetic replacement of teeth when possible. 9. Establishing functional occlusion in centric relation. 10. Establishing optimal lip contour and contact www.indiandentalacademy.com
  62. 62. 63 Special precautions during orthodontic tooth movement.  Avoid overzealous tooth movement into the cleft sites  Mechanics should be gently placed.  Orthodontic treatment is a prolonged procedure in CLP patients than the routine patients.  The orthodontist should abstain from proclining the upper anteriors into the tight scarred upper lip. www.indiandentalacademy.com
  63. 63. 64  The decision of orthodontics versus orthognathic surgery should be judiciously made.  Long term retention after treatment should be advocated.  Follow up should be advised on a 6 month basis till at least 21 years of age and the original and post treatment records should be reviewed at every such visit.  Strict monitoring excellent performance of the child on personal oral hygiene and caries control efforts. www.indiandentalacademy.com
  64. 64. 66 Arndt Nickel Titanium Expander  In mixed dentition. put forward by Micheal O. Abdoney in 1995.  It is temperature activated xpander which creates tranverse xpansion, uprights and roataes the maxillay molars and allows a smooth transition to fixed retention with no patient compliance required. www.indiandentalacademy.com
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  66. 66. 68 CONCLUSION  The course of the individual CLP patients rehabilitation depends not only on the quality of the individual components of the treatment, but also on organization and co-ordination to ensure the right timing, sequence and balance during the often protracted course of treatment. For this reason, a well adapted CLP protocol, with a collectively operating interdisciplinary approach to provide integrated cleft care seems to be absolutely imperative . www.indiandentalacademy.com
  67. 67. 69  Our responsibilities go beyond orthodontics.  We can always go further, we can always work harder, we can always find newer possibilities; but for that, we must keep going and doing. www.indiandentalacademy.com
  68. 68. 70 Pierre Robin Syndrome  Has a very high recurrence risk.  The anomalad includes cleft palate, micrognathia, glossoptosis.  Primary defect lies in arrested dev. & ensuing hypoplasia of the mandible” bird facies” www.indiandentalacademy.com
  69. 69. 71 Kallmann Syndrome:  Clefts plus Endocrine Pituatary Problems, often Media www.indiandentalacademy.com
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