CLEFT LIP AND PALATE

1. NAVODAYA DENTAL COLLEGE
DEPARTMENT OF PEDODONTICS
STAFF NAME – Dr K M PARVEEN REDDY
Associate Professor
TOPIC NAME – CLEFT LIP AND PALATE

2. DAVIS & RITCHIE (1922)
They classified congenital clefts
based on the position of the cleft
in relation to the alveolar process
GP I : PRE ALVEOLAR –(LIP
ONLY)
GP II : POST
ALVEOLAR(HARD AND
SOFT PALATE)
GP III :COMPLETE
ALVEOLAR (LIP
ALVEOLUS, PALATE)
CLASSIFICATION

3. VEAU’S CLASSIFICATION (1931):
Group I - Cleft of
soft palate only
Group II - Cleft of hard and
soft palate, extending no
further than the incisive
foramen thus involving the
secondary palate alone.

4. Group III - Complete
unilateral cleft of soft and
hard palate, lip and
alveolar ridge
Group IV - Complete
bilateral cleft of soft and
hard palate, lip and alveolar
ridge on both sides.

5. Kernahans classification
• In this classification the
incisive foramen is taken as
the reference point
• 1,4 – LIP
• 2,5 – ALVEOLUS
• 3,6 – PALATE ANT TO
INCISIVE FORAMEN
• 7,8 – PALATE POST. TO
INCISIVE FORAMEN
• 9 – SOFT PALATE

6. V MILLARD’S CLASSIFICATION (1977):
• A modification of
Kernahan’s striped “Y”
classification.
• The inverted triangles
represent the nasal arch the
upright triangles represent the
nasal floor.
L- lip
A- Alveolus
H- hard palate
S– soft palate

7. • LAHSHAL - OKREINS (1987)
• L – LIP
• A – ALVEOLUS
• H – HARD PLALTE
• S – SOFT PALATE

8. SCHUCHARDT & PFEIFERS

9. age orthodontics surgery
After birth external elastics
over protruding premaxilla –
no obturator
3–4 weeks
6 months
Lip adhesion
Millard Forked Flap
von Langenbecka (simultaneous
closure
of the hard and soft palate
18–30 months
4–5 years Correction of buccal crossbite
only using a fixed quad
helix palatal expander
5–7 years Fixed palatal retention
7–8 years Align anterior teeth prior to secondary
alveolar cranial bone graft (SABG)
Secondary bone graft using iliac crest
bone
9–13 years Full banded treatment with or without
maxillary protraction (Delaire faciai
mask)
Nasal tip revision
13–17 years Full orthodontics. Evaluate need for
surgicaiorthodontics (Distraction
osteogenesis or Lefort I)
Maxillo-mandibular surgery
Nasal-lip revision
17–18 years
Postsurgical orthodontics followed by
prosthetics
Nasal-lip revsions

10. • Obturator construction
• Dental problems associated with CLP
• Maintaining good oral hygiene
• Application of topical fluorides
• Recall appointments
• Observation and review for developmental changes in dentition
• Motivates parent and child to cooperate with the treatment
Role of Pedodontist

11. Feeding
• Three types of bottles:
– Mead-Johnson cleft Palate
Nurser
– Haberman feeder
– Pigeon nipple

12. • Mead – Johnson cleft palate nurser:
– Soft squeezable
– Short nipple
• Practice squeezing
• Stop when child stops breathing
• Haberman feeder:
– For premature infants with only cleft palate
– One-way valve – keeps milk in nipple
– Milk expressed – when placed against palate
– Sucking not required
– Less tiring for mother

13. • Obturator for palate + bottle
feeding:
• Pigeon nipple:
– Can be used with any bottle
– Works well for slightly older
infants
– Firm side – towards palate
– Soft side – towards tongue
– Small notch – at base of
nipple: for airflow – should be
present below the nose
– Tightening the nipple:
• Decreases flow of milk
– Loosening the nipple:
• Increases flow of milk

14. • Cross-cut nipples: used with
compressible bottles, offer the
advantage of controlling the
flow of liquid when feeding.
• Slight thickening of liquid
should be done

15. ISOLATED CLEFT PALATE:
Feeding techniques:
a) breast feeding
b) bottle feeding using soft nipple with
enlarged outlet.
c) commercially used cross cut (juice)
nipples.
CLEFT OF THE SOFT PALATE
Feeding techniques:
Correctly shaped, regular nipple.
CLEFT LIP ONLY
Feeding technique:
a) breast feeding
b )large nipple size.

16. • Breast feeding should be encouraged
• Feeding by bottle rather than spoon
Nostrils – cleaned.
Lips- well lubricated
with Vaseline
If orthopedic splint worn – remove before feeding, clean
it , place it , then feed
Tapes – checked for dry, cleaned firmly attached to elasto
plast base on cheeks
Basic Instruction

17. POSITION FOR FEEDING :
Regular breast feeding or bottle feeding do
not work well
Unable to seal their lips, velvopharynx
Cannot develop sufficient suction on
bottle nipple.
• A semi-upright position.
• Feeding the baby in a reclining
position - contamination of the
middle ear and ear infections.
• Always the baby’s head – higher
than his stomach.

18. CLEFT LIP PALATE:
Feeding techniques:
Deliver the milk
directly into the mouth.
A soft bottle is useful.
LACT-AIDE DEVICE
Used after lip closure.
Delivers the milk
through a small
tube while the infant is
placed at
mothers breast

19. Feeding obturator
 The feeding obturator is a prosthetic aid that is designed to
obturate the cleft and restore the separation between the oral
and nasal cavities.
 The obturator also prevents the tongue from entering the
defect and interfering with spontaneous growth of the
palatal shelves.
 reduces nasal regurgitation,
 reduces the incidence of choking,
 also helps in the development of the
jaws and contributes to speech

20. MULTIDISCIPLINARY SEQUENCE OF TREATMENT
• STAGE I - Maxillary Orthopedic stage
( birth- 18 months)
• STAGE II - Primary Dentition stage
( 18 months- 5 years)
• STAGE III - Late primary/ mixed dentition
( 6 -10 11 years)
• STAGE IV - Permanent dentition stage
(12 - 18 years)

21. Management of CLP- immediate
attention of new born.
Feeding problems- difficult to maintain
adequate nutrition .
Numerous prosthetic devices.
Mc Neil (1950) devised , Intra oral
maxillary obturator.
STAGE I – MAXILLARY
ORTHOPEDIC STAGE
( BIRTH- 18 MONTHS)

22. Clinical presentation
Anteriorly positioned
premaxilla
Laterally positioned
premaxilla
STAGE I

23. INTRA ORAL MAXILLARY OBTURATOR :
Advantages:
1) Provides a false palate, reducing incidence of feeding
difficulties in infants
2) Maxillary cross arch stability preventing arch collapse
after definitive cheiloplasty .
3) Molding the cleft segments into approximation before
primary alveolar bone grafting.
4) Facilitate infants ability to create sufficient –ve
pressure, which allow adequate sucking of milk

24. Block out excessive undercuts – wax
Apply tinfoil substitute over entire surface of maxillary model – let it dry
Pour resin in cleft till the level of palate
Place in warm moist environment – cure for 20 min
Add resin – on the palate and mucobuccal area
Trim and polish
PROCEDURES PERFORMED BY - PEDODONTIST
STAGE I

25. Management of initial obturator
therapy:birth – 3months
• Appliance positioned in mouth
• Areas of excessive pressure – reduced
• Parents instructed:
– How to wear
– Cleanliness
• Initial adjustment: 2 days
• Follow-up – monthly
• Serves till lip closure – 3 months
• Advantage: Enhances nourishment
STAGE I

26. PREMAXILLARY ORTHOPEDICS
(BIRTH-4/5 MONTHS)
In some cases BCLP ,premaxillary segment is
anteriorly placed or displaced laterally to one
side .
• Hofman (1686):
Head cap & premaxillary
strap to reposition premaxilla.
Useful in antero posterior &
vertical repositioning.
• Soft elastic tape:(micro foam tape)

27. • FACE MASK THERAPY
• Used in mild maxillary deficient cleft patient
• Orthopaedic forces for maxillary protraction
• Orthopaedic force 350-500 gm per side over
10-12 hr / day for an average of 12-15
months.
 Stability…….(Questionable)
 Because of two reasons
 Counter pressure of a tight lip on the maxilla. Which
inhibits its growth
 Scarring in pterygo maxillary region after extensive tissue
mobilization for palatal closure
Correction of jaw relationship- Face
mask Therapy

28. RULE OF TEN
10 weeks
age
10 pounds
of body
weight.
10 g Hb dl
of blood
Lip correction – as early as possible
Soft palate correction –18-24 mons
Hard palate correction – 4-5 years of age