Orthodontic management of cleftlip & palate /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,
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Orthodontic management of cleftlip & palate /certified fixed orthodontic courses by Indian dental academy

  1. 1. Orthodontic management of cleft lip/palate patients INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Overview Classification of cleft lip/palate  Incidence  History  Integration of services  Philosophy of orthodontic management  Diagnosis / clinical examination  Infant orthopaedics  Treatment : modes and timing  www.indiandentalacademy.com
  3. 3. Classifications  Davis and Ritchie’s : (1922) u/l 1. Group I – prealveolar clefts 2. Group II – postalveolar clefts : cleft involving hard and soft palate 1. Group III – Cleft of both primary and secondary palate www.indiandentalacademy.com b/l
  4. 4. Veau’s classification : (1931) A. Cleft lip class I : U/L notching of vermillion border, not extending into the lip. class II : cleft extending into the lip, but not including the floor of the nose. class III: extending into the floor of the nose. class IV: any b/l cleft of the lip, whether incomplete or complete. www.indiandentalacademy.com
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  6. 6. B. Cleft palate class I : soft palate class II : soft/hard palate extending no further than incisive foramen. class III: complete u/l cleft, extending from uvula to incisive foramen, then deviating to one side class IV: two clefts extending forward from the incisive foramen into the alveolus. www.indiandentalacademy.com
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  8. 8. Fogh Anderson’s Classification (1946) 1. Hare lip cleft 2. Hare lip cleft associated with cleft palate. 3. Isolated cleft palate. www.indiandentalacademy.com
  9. 9. Kernahan / Stark’s (1958) 1. Cleft of primary palate 2. Cleft of secondary palate 3. Cleft involving both primary and secondary palate. www.indiandentalacademy.com
  10. 10. Hawkins and Associates (1962) 1. Cleft of primary palate Cleft lip a. unilateral: rt/lt extent : 1/3 , 2/3 , complete b. bilateral : extent : 1/3 , 2/3 , complete c. median cleft : extent : 1/3 , 2/3 , complete www.indiandentalacademy.com
  11. 11. 2. Cleft of alveolar process a. unilateral: rt/lt extent : 1/3 , 2/3 , complete b. bilateral : extent : 1/3 , 2/3 , complete c. median cleft : extent : 1/3 , 2/3 , complete d. submucous : rt / lt / median www.indiandentalacademy.com
  12. 12. 3. Cleft of soft palate a. P-A width : extent : 1/3 , 2/3 , complete b. width : (maximum) in mm c. palatal shortness : none, short, moderate, marked. d. submucous cleft www.indiandentalacademy.com
  13. 13. 4. Cleft of hard palate a. P-A width : extent : 1/3 , 2/3 , complete b. width : (maximum) in mm c. vomer attachment : rt / lt / absent d. submucous cleft www.indiandentalacademy.com
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  18. 18. Incidence/Epidemology :  Incidence of cl/cp : 1:800 – white Americans 1:2000 – blacks  Incidence of cleft palate alone : 1:2500  cl/cp account for 50% of reported cases  Cl or cp alone account for 25% of reported cases www.indiandentalacademy.com
  19. 19.       Japan Denmark Caucasians Indians Black americans : 1.14-2.13/1000 : 1.10/1000 : 1/1000 : 1.7/1000 : 0.21-0.41/1000 In India : - cl + cp : 1.25/1000 - cp : 0.46/1000 www.indiandentalacademy.com
  20. 20.  Sex ratio : cl + cp : males > females cp alone : females > males  Laterality of lesions : In case of unilateral clefts, left side is more frequently involved than the right side.  Increase in frequency : - with increase in parents age, especially father - consanguineous marriages www.indiandentalacademy.com
  21. 21. History :  Repair of cleft lip reported as early as 255-206 BC in china  Earliest surgical repair : Jehan yipperman (1295 – 1351)  Lemonier, French dentist (1753) described in detail the repair of cl/cp  Fauchard, 1786 : Prosthodontic management of cl/cp patients.  First cleft palate repair in USA : Stevens (1827) www.indiandentalacademy.com
  22. 22.  Kingsley (1880) -- oral deformities as a branch of mechanical surgery.  Calvin case (1921) -- a practical treatise on technique and principles of dental orthopaedic and prosthetic correction of cleft palate ** Both recommended discontinuation of surgical intervention www.indiandentalacademy.com
  23. 23.  H.K.Cooper,Sr (1930’s) -- Introduced the integrated team concept and formed the Lanchester cleft palate clinic.  According to him : -- True integration starts with a meeting of the minds of the individuals who first examine the patient together and then agree on a program together. -- orthodontist’s role either primary/secondary/ancillary www.indiandentalacademy.com
  24. 24.  Wilton Krogman (1947-1971) Founder/Director “Philadelphia Centre for research in child growth” www.indiandentalacademy.com
  25. 25. Integration of services         Orthodontics Oral surgery Prosthodontics Speech therapy Pediatrics Psychology General dentistry Otolaryngology www.indiandentalacademy.com
  26. 26. www.indiandentalacademy.com
  27. 27. Philosophy of Orthodontic Management      Overview of the problem Interaction with other team specialists Evaluation of results Acquisition of new knowledge Diagnosis www.indiandentalacademy.com
  28. 28. Overview of the problem  Knowledge of aspects like : -  incidence etiology embryogenesis neonatal anatomy physiology enhances the ability of the orthodontist to interact with the team. www.indiandentalacademy.com
  29. 29.  Also necessary : - Discussions with plastic surgeons - Normal and cleft speech mechanisms - Maxillofacial prosthetic/Prosthodontic techniques - Social service problems - Anatomical deviations and the techniques of lip palate closure www.indiandentalacademy.com
  30. 30. Interaction with other team specialists  Prospective / Retrospective  Prospective : - proper diagnosis - treatment planning - prognosis Retrospective : - leads to improvement in rehabilitory techniques  www.indiandentalacademy.com
  31. 31. Evaluation of results  With regard to : - The degree to which alignment or normalizing of underlying hard tissues (dental /skeletal) enhances surgical repair of overlying soft tissues. - Facilitate speech therapy measures.  Prerequisite : - knowledge of wide variability in craniofacial features in the cleft population. - orthodontist willing to compromise www.indiandentalacademy.com
  32. 32. Acquisition of new knowledge      To alter one’s approach Determination of cost/benefit analysis Recognition of variability in cleft population Impractical to attempt to treat all cases alike Maintenance of good longitudinal records www.indiandentalacademy.com
  33. 33. Diagnosis  A complex undertaking because of the various complicating factors  Collection of records should begin at birth - every six months till the age of 2 yrs - every year after that. Data base - patient history - clinical / radiographic examination - systemic description of the occlusion and analysis of the orthodontic records.  www.indiandentalacademy.com
  34. 34. A. Patient history 1. Medical – Dental history :  Primary importance to the accurate description of the type and extent of cleft present at birth  Record of the timing and type of surgery performed to correct the defect  Well established differences in growth patterns and dimensions among various types of clefts www.indiandentalacademy.com
  35. 35.   Variations in frequency of dental anomalies depending on cleft type. ( 10-25%) Potential complicating factors - Mental retardation. - Neuromuscular anomalies. - Skeletal tissue anomalies. - Frequent upper respiratory infections - Enlarged tonsils or adenoids - Other forms of nasal obstruction. www.indiandentalacademy.com
  36. 36. 2. Social / Behavioral :      Behavioral characteristics Lead to extremely poor oral hygiene Poor prognosis for co-operation Patient “burn-out” Orthodontist should be willing to adjust. www.indiandentalacademy.com
  37. 37. 3. Somatic growth development and maturation  Includes : - Clinical evaluation - Serial ht/wt data - Dental age - Skeletal age  Infancy / “catch-up” growth www.indiandentalacademy.com
  38. 38.  Exhibit lower skeletal ages than normals, indicating delayed maturation  Aspects like delayed dental development and retarded eruption to be considered in terms of possible : - Serial extractions - Initiation of active treatment www.indiandentalacademy.com
  39. 39. 4. Genetic / Family history :   Family history is significant as cleft superimposed upon an underlying skeletal growth pattern may vary from Cl I, Cl II, Cl III i.e. In class III cases : immediate attention In class II cases : favourable 5. Habits : - Tongue thrust - Finger/Thumb sucking - Prolonged use of pacifiers www.indiandentalacademy.com
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  41. 41. B. Clinical and Radiographic examination 1. Facial esthetics :  In defects of palate only- facial esthetics are usually close to normal.  In case of an extensively scarred palate, there is a slight maxillary underdevelopment leading to a straight or mildly concave mid-face profile.  Also continued growth of the mandible and nose may worsen the profile. www.indiandentalacademy.com
  42. 42.  Clinical findings: - Forward rotation/position of pre-maxillary segment Tethered nasal tip Thin upper lip, protrusive lower lip Retrusive soft tissue profile Increased lower face height Lowered positioning of the tongue due to a constricted, scarred, obliterated palatal vault - Mouth breathing - Enlarged tonsils www.indiandentalacademy.com
  43. 43. 2. Intra-oral soft tissue :  Estimate of the extent , location and severity of palatal and alveolar scarring provides a clue to : 1. Response of a palate to expansion Degree of retention required. Impediments to tooth movement. Possible cause of altered tongue posture. 2. 3. 4. www.indiandentalacademy.com
  44. 44.  Soft tissues potentially leading to altered mandibular posture or function.  Abnormal, scarred frenal attachments may affect the configuration of any appliance.  Monitoring gingival signs of developing periodontal disease related to poor oral hygiene. www.indiandentalacademy.com
  45. 45. 3. Muscle balance and function :  The diagnosis and interception of developing functional problems, from early childhood through stabilization of the adult dentition is the most important aspect of clinical evaluation.  Functional alterations due to frequent occurrence of severely malposed teeth, dental anomalies and skeletal dysplasia’s. www.indiandentalacademy.com
  46. 46.  1. 2. 3.  1. 2. 3. Functional alterations : Mandibular closure Tongue function + posture Respiratory patterns Effects : Unilateral crossbite in centric occlusion Pseudoprognathism (mixed dentition) Problems of lip tonus + function www.indiandentalacademy.com
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  48. 48. 4. Dental structures :  1. 2. 3. 4. 5. 6.  Significant increase in incidence of dental abnormalities in the cleft population. Supernumerary teeth in the vicinity of the cleft Congenitally missing teeth Hypoplasia Hypocalcification Morphological irregularities Poor oral hygiene leading to caries + pdl disease Careful monitoring required as premature loss may lead to decrease in arch length. www.indiandentalacademy.com
  49. 49. www.indiandentalacademy.com
  50. 50. C. Description of the occlusion and analysis of the diagnostic records  Need to understand the basic D-A and craniofacial development potential in the cleft population  According to Graber (1949) - All children with clefts, if left untreated are capable of achieving reasonably normal skeletal/dental relationships. - Many of the present day orthodontic problems are the result of the treatment rather than the defect itself. - Specific examples www.indiandentalacademy.com
  51. 51.  1. 2. 3. 4. 5. Various problems encountered : Intra arch alignment and symmetry Profile / esthetics Transverse problems Ant/post sagittal problems Vertical problems www.indiandentalacademy.com
  52. 52. 1. Intra arch alignment and symmetry :  Process of lip repair results in a generalized reduction in cleft width and max. arch width dimensions.  Intra-arch malalignments appear with the eruption of the permanent dentition.  Severe rotations/lingual inclination of permanent incisors in clefts involving the alveolar ridge. www.indiandentalacademy.com
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  54. 54. 3. Transverse problems :     Infants : excessive max. width dimensions (BCLP > UCLP > CP > NORMAL) Full deciduous dentition : (BCLP < UCLP < CP = NORMAL) Subsequent skeletal growth might lead to more severe problems. Clinical significance: Re-expansion will invariably be necessary because of an incompatibility in growth direction. www.indiandentalacademy.com
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  56. 56. 4. Antero-posterior sagittal problems :  Variability and uncertainty due to gross displacement and distortions of landmarks (i.e. ANS, PNS)  In primary dentition class III molar relationship / ant.crossbite are of great concern.  Retroposition of the maxillary buccal segments as a result of scar-mediated “maxillary ankylosis” as www.indiandentalacademy.com proposed by Ross.
  57. 57. www.indiandentalacademy.com
  58. 58.  Clinical significance : 1. Lingual inclination will be more severe in those cases requiring surgical repair of clefts involving the premaxilla 2. A-P problems worsen with age 3. Problem compounded by the normal anterior expression of mandibular growth. 4. Consideration to be given to the rest position of the mandible at the time of record taking. www.indiandentalacademy.com
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  60. 60. 5. Vertical problems :  Vertical contributions to the orthodontic problem arise during the development of the mixed dentition 1. Progressively decreasing rate of max. vertical development by the time of early permanent dentition. 2. Increased severity due to downward and backward rotation of premaxilla. 3. Cant in the palatal plane www.indiandentalacademy.com
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  62. 62. 4. 5. 6. 7. 8. 9. 10. Altered mandibular posture and ass. Increase in gonial angle. Excessive freeway space Impeded vertical eruption of maxilla Excess vertical D-A development Local disturbances in the vertical eruption of teeth adjacent to the cleft. Overclosure of the mandible aggravates Cl III condition Elongation of the facial profile. www.indiandentalacademy.com
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  64. 64.  Net result of this complex interaction is that in occlusal contact the vertical deficiency tends to accentuate the A-P discrepancy b/w jaws, and then both problems serve to create a worsening transverse imbalance.  i.e. the primary dentition cannot be used to evaluate the magnitude of future problems. www.indiandentalacademy.com
  65. 65. Aim of cleft palate diagnosis :  Cleft palate orthodontic diagnosis must evaluate potential problems in all three planes of space, with both skeletal and dental components. It must take into account features both common to and unique for the various types of clefts, as all tend to get worse with further growth and development. www.indiandentalacademy.com
  66. 66. Timing of orthodontic treatment  FISHMAN 1. Pre-dental : (1-18 months ) - prior to the eruption of the primary molars. a) Pre-surgical b) Post-surgical Deciduous dentition : (3-6 yrs) - after full eruption of the primary dentition. Early mixed dentition : (7-9 yrs) - during eruption of permanent maxillary dentition. Late mixed and early permanent dentition : (9 yrs onwards) 2. 3. 4. www.indiandentalacademy.com
  67. 67.  PROFFIT 1. In infancy i.e. before the initial surgical repair of the lip During late primary and early ,mixed dentition. Late mixed and early permanent dentition. In the late teens, after completion of the facial growth in conjunction with orthognathic surgery. 2. 3. 4. www.indiandentalacademy.com
  68. 68. Predental Rx / Infant orthopedics ( Mcneil, Burston – 1950’s )    To align the distorted maxillary arch segments orthopaedically in early neonates, prior to any surgical repair. Topic of heated debate Approaches varied among different centers - Active orthopedic movement - Simple passive holding appliances - With or without primary bone grafting. - Extra-oral pinned appliances. www.indiandentalacademy.com
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  70. 70. Rationale / Objectives : 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. To facilitate feeding. To help establish normal tongue posture. Provide a psychological boost to patients/parents. Assist the surgeon in his initial repairs. Stimulate palate bone growth. To restore the oro-facial “functional matrix”. To help decrease the number of ear infections. Expand or prevent collapsed segments. To reduce the need for later orthodontic treatment. To allow soft tissue growth. To guide tooth eruption. Improve esthetics. To reestablish sutural growth patterns. www.indiandentalacademy.com
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  72. 72.  According to cooper : - Emphasis on minimizing total active orthodontic intervention, limiting it to what is required to achieve the optimum results. Against any orthodontic/orthopedic therapy. Patient’s monitored continuously. Wolff’s law Questioned the claimed advantages of presurgical orthopedics. - www.indiandentalacademy.com
  73. 73. Oslo approach ( 1948 ….)  One of the first cleft treatment teams, based at two places : Bergen / Oslo  Based on the principles given by Egil Harvold and Arne Bohn.  Wilhelm Loennecken (plastic surgeon) became a part of the oslo team (1948) and introduced a standard surgical procedure for all cleft treatment. www.indiandentalacademy.com
  74. 74. Loennecken’s operative plan (1948) 1. 2. 3. 4. 5. No pre-operative orthopedics. Closure of cleft lip in infancy. Simultaneous closure of the alveolar cleft by a one layer vomer flap during primary lip repair. Closure of the remaining cleft palate in early childhood by a von langenback palatoplasty. Secondry operations when required based on the current treatment plan and the requirements of the orthodontist, prosthodontist and the speech therapist all aiming at a final rehabilitation by the age of 20 yrs. www.indiandentalacademy.com
  75. 75. 5. Secondry operations when required based on the current treatment plan and the requirements of the orthodontist, prosthodontist and the speech therapist all aiming at a final rehabilitation by the age of 20 yrs. 6. All surgery to be done meticulously; no parts – soft or hard – to be unnecessarily harmed or removed. www.indiandentalacademy.com
  76. 76. Objectives :(Bergland) 1. Provide an aesthetically acceptable and healthy dentition for life and to contribute positively to the general facial form and appearance. 2. Using appliances as simple as possible. www.indiandentalacademy.com
  77. 77. Pre-surgical period   1. 2. 3. 4. When introduced in 1950’s not accepted in Oslo Pre-surgical orthodontics was used in Europe/USA for over 30 years but did not demonstrate any long term benefits in relation to: Facial growth Appearance Speech occlusion www.indiandentalacademy.com
  78. 78. Deciduous dentition 4. No treatment provided at oslo at this stage : Dental irregularities are usually minor No long-term benefits Does not ensure normal eruption of permanent teeth. Certain need of future orthodontic treatment.  Evaluation of super-numerary teeth.  1. 2. 3. www.indiandentalacademy.com
  79. 79. Mixed dentition ( preparation for bone graft )  The first alveolar bone graft was placed in 1977 in Oslo based on the results of cancellous bone grafts by Boyne/Sands.  Height of the inter-dental septum assessed on intraoral radiographs.  Best results achieved when grafting done prior to the eruption of the permanent canine.  Primary Vs Secondary bone grafting www.indiandentalacademy.com
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  82. 82.  Many of the orthodontic problems encountered at this stage are effects of early surgical repair.  Problems frequently encountered : - Malposed permanent incisors Posterior crossbite A-P molar discrepancies. Serial extraction Detection of dental anamolies. - www.indiandentalacademy.com
  83. 83.  Maxillary incisors : - Often erupt rotated, retroclined and possibly in anterior crossbite. - Corrected for esthetic reasons and to facilitate oral hygiene ( labial archwire – 3/4 months ) - Less severe cases can be treated with a maxillary Hawley plate or a finger spring. www.indiandentalacademy.com
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  87. 87.  Buccal crossbite attributable to segmental displacement corrected simultaneously using a palatal arch auxillary spring / Quad helix / Removable screws.  Segmental repositioning : - Done just prior to the bone grafting procedure Lingual appliance kept for 3 months postoperatively i.e. to enable the bone graft to maintain the transverse dimension of the basal bone. - www.indiandentalacademy.com
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  89. 89. - In pt’s with BCLP, the mobile premaxilla is stabilized with a heavy rectangular archwire to ensure immobility.  A-P molar discrepancies : (cooper) In Cl II cases : cervical pull headgear In Cl III cases : reverse pull headgear (Delaire face mask) + chin cup therapy. Care to be taken in relation to severe ant-post hypoplasia. - www.indiandentalacademy.com
  90. 90. Early Permanent dentition :  2 to 3 years after bone grafting usually when the cleft side canine has erupted spontaneously through the graft or has been surgically exposed  Orthodontic Vs Prosthodontic space closure.  Every effort is made to mesialize the posterior teeth and to correct maxillary hypoplasia.  Maxillary hypoplasia is a common problem encountered in almost 25% of the cleft population – Ross (87) www.indiandentalacademy.com
  91. 91. www.indiandentalacademy.com
  92. 92. Methods of correcting Maxillary hypoplasia  Reverse pull headgear  Distraction osteogenesis  Orhthognathic surgery www.indiandentalacademy.com
  93. 93. RPHG v/s Distraction  Factors to be considered 1. Age and compliance of the patient Amount of correction Biomechanics ( Force Vector ) 2. 3. www.indiandentalacademy.com
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  96. 96. Biomechanics of Conventional RPHG  Center of Resistance of Maxilla (Cres) – Postero-superior border of the Pterygomaxillary fissure. (Tanne)  Center or Resistance for maxillary dentition – Between root apices of deciduous molars / premolars www.indiandentalacademy.com
  97. 97. www.indiandentalacademy.com
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  100. 100. Can the same vector be used in every patient www.indiandentalacademy.com ??
  101. 101. www.indiandentalacademy.com
  102. 102. Modified design of RPHG www.indiandentalacademy.com
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  104. 104. Distraction osteogenesis “ Biologic process of new bone formation between the surfaces of bone segments that are gradually separated by incremental traction” www.indiandentalacademy.com
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  107. 107. Superimposition www.indiandentalacademy.com
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  111. 111. Surgical correction  Popularized by Obwegeser  Most commonly used Le-Fort I osteotomy.  Use of secondry bone grafts www.indiandentalacademy.com
  112. 112. When the maxilla is osteotomized as in a Le-Fort I osteotomy, the consideration of vector will vary . Center of mass for the maxilla – on the mesial aspect of the root of the upper permanent first molar www.indiandentalacademy.com
  113. 113. www.indiandentalacademy.com
  114. 114. Fixed appliance Therapy  Recognition of orthodontic limitations in correction of malocclusion.  “Therapeutic diagnosis”  Rigidity in the construction of the appliance is necessary  Fixed palatal expansion devices - Hyrax - Niti Palatal expander www.indiandentalacademy.com
  115. 115.  Additional necessary treatment mechanics : - Cervical pull headgear for anchorage Intermaxillary elastics Additional lingual root torque to maxillary incisors. Banding preferred to bonding. Orthodontic correction of lower arch delayed. - www.indiandentalacademy.com
  116. 116.  Maximum treatment time not to exceed 2 yrs and to be completed by the age of 18-20 yrs.  Bonded palatal retainer to extend to two teeth on either side of the cleft.  Assess need for full-time retention. www.indiandentalacademy.com
  117. 117. References     Cleft palate and cleft lip : A Team Approach to clinical Management and Rehabilitation of the Patient. -- Cooper, Harding, Krogman, Millard, Mazaheri International review of management of cleft lip and palate Contemporary Orthodontics : -- William R. Proffit, Henry W. Fields,Jr Atlas of Craniofacial and cleft surgery : Vol 2 -- Janusz, Bardach www.indiandentalacademy.com
  118. 118.     Cleft craft : Evolution and Surgery -- Millard Postgraduate notes in orthodontics : Bristol university Craniofacial Distraction Osteogenesis -- Samchukov, Cope, Cherkashin Alveolar bone grafting – David S. Precious Oral and Maxillofacial Surgery of North America August 2000 www.indiandentalacademy.com
  119. 119. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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