cleft management


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cleft management

  1. 1. WEL- COME
  3. 3. CONTENTS <ul><li>Prenatal Diagnosis. </li></ul><ul><li>Protocol For Dental Care. </li></ul><ul><li>A Multi- Disciplinary Team. </li></ul><ul><li>Management </li></ul><ul><li>Dentofacial Orthopedics </li></ul><ul><li>Management of cleft Lip & Nasal Deformity. </li></ul><ul><li>Cleft Palate Repair. </li></ul><ul><li>Orthodontic Treatment. </li></ul><ul><li>Role of E.N.T. Specialist, Speech Pathologist. </li></ul><ul><li>Correction of Maxillary Hypoplasia </li></ul><ul><li>Correction of Enamel Hypoplasia. </li></ul><ul><li>Role of Prosthodontics </li></ul><ul><li>Role of Psychologist </li></ul>
  4. 4. PRENATAL DIAGNOSIS AND COUNSELING <ul><li>Intrauterine diagnosis of orofacial clefts is possible by ultrasonography. </li></ul><ul><li>Complete clefts are seen easily at 16 weeks gestation. </li></ul><ul><li>Incomplete clefts are seen more readily at 27 weeks. </li></ul><ul><li>Palatal clefts are difficult to visualize by prenatal ultra sonography. </li></ul><ul><li>The family or obstetrician may request prenatal consultation with a surgeon. </li></ul>
  5. 5. <ul><li>At Birth </li></ul><ul><ul><li>Predental treatment is provided which comprises feeding plate, pre surgical orthopedics and helps surgeon in repair by stimulating palatal bone growth and preventing collapse of dental arches. </li></ul></ul><ul><li>3-5 Month. </li></ul><ul><ul><li>Alignment of the primary teeth and palatal expansion to be started using a simple fixed appliance like warch & Arnold expander plastic surgeon to repair the lip. </li></ul></ul><ul><ul><li>Suction myringotomy for “Glue ear” </li></ul></ul><ul><li>12 Months. </li></ul><ul><ul><li>Pedodontic review palatal pro sthetic speech. Appliance may by required to correct velo pharygeal incompetence. </li></ul></ul><ul><ul><li>Plastic surgeon to repair the cleft palate. </li></ul></ul>Protocol For Dental Care of Cleft Lip and Palate in Children
  6. 6. <ul><li>2-6 Years. </li></ul><ul><ul><li>Pedodontic showed review facial growth and development with regular monitoring one year interval. </li></ul></ul><ul><ul><li>Preventive measures for caries like fissure, sealing, fluoride. </li></ul></ul><ul><ul><li>Restorative </li></ul></ul><ul><li>6-7 years. </li></ul><ul><ul><li>Removal of super numerary teeth, correction of cross bite. </li></ul></ul><ul><ul><li>Orthodontic consultation. </li></ul></ul><ul><li>8-9 years. </li></ul><ul><ul><li>Suitability about bone grafting. </li></ul></ul><ul><ul><li>Dental bone assessment (OPG, wrist, lateral cephalogram,. </li></ul></ul><ul><ul><li>Review by the plastic surgeon, speech pathologist & ENT surgeon. </li></ul></ul><ul><ul><li>If needed to relieve crowding and retroclination of the anterior teeth. </li></ul></ul>
  7. 7. <ul><li>9 years. </li></ul><ul><ul><li>Combined orthodontist and pedodontist coalescence. </li></ul></ul><ul><ul><li>Bone graft alveolar cleft at half to 1/3 root development of permanent cuspid. </li></ul></ul><ul><li>10-12 years. </li></ul><ul><ul><li>Orthodontic consultation </li></ul></ul><ul><ul><li>Monitoring changing dentition and growth. </li></ul></ul><ul><li>12-15 years. </li></ul><ul><ul><li>Orthodontic treatment. </li></ul></ul><ul><ul><li>Speech pathologist to review changing of the pitch of voice in boys. </li></ul></ul>
  8. 8. A Multi-Disciplinary Team for Cleft Lip and Palate Patients. <ul><li>Obstetrician = Refers the child to plastic surgeon and pediatrician for expert opinion counseling the parents. </li></ul><ul><li>Pediatrician or Neonatology's = Provide medical care refers the case to the plastic surgeon. </li></ul><ul><li>Plastic Surgeon:- Carries out initial lip repair and palate surgery – performs pharyngoplasty or reversionary lip & nose surgery. </li></ul><ul><li>Oromaxillofacial Surgeon = Usually comes in the picture of bone grafting – if any final orthopedic surgery is performed at later stage. </li></ul><ul><li>Neurosurgeon = any craniofacial syndrome is associated. </li></ul>
  9. 9. <ul><li>Pedodontist= </li></ul><ul><li>A key member who sees the baby and the parent at the time of repair of the lip. </li></ul><ul><li>Provides pre surgical orthopedic treatment for the baby. </li></ul><ul><li>Pedodontist monitor the growth and development. </li></ul><ul><li>To maintain perfect oral health. </li></ul><ul><li>To guide the occlusion and facial growth. </li></ul><ul><li>Motivates the parent & the child to cooperate with the treatment. </li></ul><ul><li>Orthodontist: Carries out definitive orthodontic treatment once the full permanent dentition is erupted. </li></ul>
  10. 11. <ul><li>Speech pathologist: = </li></ul><ul><ul><li>Monitors the speech development to normal. </li></ul></ul><ul><ul><li>Test for an adequate palato pharyngeal closure and guiding the surgeon as to whether a pharyngeal flap may be necessary. </li></ul></ul><ul><li>Audiologist:- To test hearing in the baby infants & the young child providing essential information in hearing loss for both speech patholigist and otolarynologist. </li></ul><ul><li>Otolarynologist : Concerns with the health of nasopharyngeal tissues including tonsils, adenoids and middle ear structures. </li></ul><ul><li>Blockage of the auditory canal and gluteneous secretion (glue ear) is very common in these disease. </li></ul><ul><li>Psychologist: Plays on important role when the child’s family is under stress. </li></ul>
  11. 12. <ul><li>MANAGEMENT: </li></ul><ul><li>Infancy: </li></ul><ul><li>General Consideration :- Patients with C.L.P. requires, interdisciplinary care from a team of provides including a geneticist, plastic surgeon, oral and maxillofacial surgeon, otolaryngologist, dentist, orthodontist, speech therapic audiologist, psychologist, social worker & nurse. The role of each specialist depends on the age of the patient. </li></ul><ul><li>During the first days of the infant’s life:- </li></ul><ul><li>The infants with a cleft palate cannot generate the negative intraoral pressure needed to suck from a bottle. </li></ul><ul><li>The Nurse on the team or another feeding specialist must instruct the parents in the use of special feeding device for the infant eg:- Haberman nipple, catheter & syringe, spoon feeding. </li></ul><ul><li>Infants with cleft palate have difficulty ventilating the eustachian tube. This result in the accumulation of fluid in the must be treated promptly with antibiotics. </li></ul>
  12. 13. DENTOFACIAL ORTHOPEDICS <ul><li>In unilateral complete cleft lip and palate (UCCLP) or bilateral complete cleft lip and palate (BCCLP) with a protruding premaxilla, labial repair is often completed with tension on the closure. </li></ul><ul><li>Orthopedic appliances bring the dentoalveloar segments together facilitating a tension free labial repair that requires undermining of tissues. </li></ul><ul><li>In addition, alveolar approximate forms the skeletal plateform for correction of the nasal deformity and permits gingivoperiosteoplasty. Alveolar closure eliminates an around fistula. </li></ul><ul><li>The appliance is removed at the time of labial repair and replaced with a passive appliance to maintain the alveolar position. </li></ul>
  13. 14. Management of Cleft Lip And Nasal Deformity <ul><li>Single stage: repair the unilateral complete cleft lip and nasal deformity in a single stage. </li></ul><ul><li>Two stage repair : First repair unilateral cleft lip & than lip nasal adhesion. </li></ul><ul><li>Reasons For Two Stage Repair </li></ul><ul><li>Minimize tension. </li></ul><ul><li>Increase the bulk of the orbicularis oris muscle to construct the filtral ridge. </li></ul><ul><li>Increase the vertical dimension of labial elements. Particularly on the medical side and </li></ul><ul><li>Gives the surgeon two chances to correct the position of the lower lateral cartilage. </li></ul>
  14. 16. TIMING OF NASOLABIAL REPAIR <ul><li>Labial repair is traditionally carried out when the child is approximately 10 weeks of age, weight 10 pounds, and has a serum hemoglobin value of 10mg 1 ml & total leukocyte count less than 10,000/C.C. it is important to wait until the period of postnatal anemia is corrected. The child should be gaining weight and growing before under going nasolabila repair. </li></ul><ul><li>TECHNIQUES OF NAGOLABIAL REPAIR. </li></ul><ul><ul><li>Type of cleft lip surgery:- </li></ul></ul><ul><ul><li>Millard’s rotation advancement flap and tennison randall triangular flap methods. </li></ul></ul><ul><ul><li>Rose Thompson straight line repair, the skoog’s procedure are less frequently used. </li></ul></ul><ul><ul><li>Rectangular flap method of triangular hagedorn le mesurier are rarely used. </li></ul></ul><ul><ul><li>For bilateral cleft lip can be repaired in two stage by in a single stage by veau -III procedure, millards single stage procedure or black procedure. </li></ul></ul><ul><ul><li>Basic steps in cleft lip repair. </li></ul></ul><ul><ul><li>The lip is closed in three layers – mucosa, muscle, skin. </li></ul></ul>
  15. 18. AIM OF REPAIR <ul><li>To achieve equal length of filtral ridges an either side. </li></ul><ul><li>Horizontal cupid’s bow. </li></ul><ul><li>Accurate repair of muscle, skin, mucosa without vermilion deformity. </li></ul><ul><li>Proper alignment of white line. </li></ul><ul><li>Symmetrical nostril floor, and finally an esthetically acceptable scar. </li></ul><ul><li>1. Straight Line Lip Repair. </li></ul><ul><li>Indication :- of incomplete and narrow clefts. </li></ul><ul><li>Advantage :- Easy repair </li></ul><ul><li>Disadvantage :- Limited Indications. </li></ul>
  16. 19. Tennison Randall Repair <ul><li>A triangular flap is created on the lateral side of the cleft to fit into the triangular. </li></ul><ul><li>This procedure can be planned exactly after initial measurements the results can not be modified once the lip is cut. </li></ul><ul><li>The scar is more prominent than in other procedures. </li></ul><ul><ul><li>Advantage :- Measured techniques </li></ul></ul><ul><ul><li> More easily taught. </li></ul></ul><ul><ul><li> Can be used for wide dept. </li></ul></ul><ul><ul><li>Disadvantage : Scar interrupts the philtrum </li></ul></ul><ul><ul><li> line difficult to modify during </li></ul></ul><ul><ul><li> procedure. </li></ul></ul>
  17. 20. VEAU REPAIR <ul><li>There is only a displacement, deformation and under development of the muscles and the skeletal tissue. </li></ul><ul><li>The surgical procedure should thus aim at returning there structures to their correct positions. </li></ul><ul><li>The naso labial muscles are reconstructed accurately and within a few weeks, without any form of flap closure. </li></ul><ul><li>This method gives satisfactory results in bilateral cleft lip. </li></ul><ul><li>MILLARD’S Techniques (Rotation advancement technique) principles of closing bilateral cleft lip. </li></ul><ul><ul><li>Maintain symmetry </li></ul></ul><ul><ul><li>design the prolabium of proper size & shape. </li></ul></ul><ul><ul><li>Ensure primary muscular continuity. </li></ul></ul>
  18. 21. <ul><ul><li>Construct the median tubercle from lateral labial elements. </li></ul></ul><ul><ul><li>Peeform primary construction of the columella & nasal tip. </li></ul></ul><ul><li>Procedure :- rotation flap and columella flap are planned on the medial side of the cleft. after full thickness of the lip is cut along the marking rotation gap is produced on the medial side which is filled by an advancement flap planned on the lateral side of cleft. </li></ul><ul><li>Advantage :- Minimal tissue is discarded </li></ul><ul><li>Allows modification during repair </li></ul><ul><li>Disadvantage : Difficult for use in wide cleft. </li></ul><ul><li>May narrow the nostrial. </li></ul>
  19. 22. <ul><li>Basic goals of palate repair </li></ul><ul><li>Separation of oral and nasal cavities. </li></ul><ul><li>Construction of watertight and airtight velopharyngeal valve. </li></ul><ul><li>Preservation of facial growth. </li></ul><ul><li>Development of esthetic dentition. </li></ul><ul><li>Development of functional occlusion. </li></ul><ul><li>TIMING OF SURGERY </li></ul><ul><li>Early repair leads to a better speech development but severe mid facial growth retardation and dental malocclussion. </li></ul><ul><li>Palate repair after full growth of maxilla midfacial growth retardation & dental malocclusion problem is less but speech problem become more severe. </li></ul><ul><li>Palate repair should be done 1-1½ years age give the best balanced result. </li></ul><ul><li>Only soft palate are closed by 6-18 months. </li></ul>CLEFT PALATE REPAIR
  20. 23. <ul><li>TECHNIQUES OF PALATE REPAIR </li></ul><ul><li>Single stare technique. </li></ul><ul><li>eg:- von langenbeck repair </li></ul><ul><li>Ven wardill kilner v-y push back palatoplasty at are 1½ years. </li></ul><ul><li>Two stare technique:- </li></ul><ul><ul><li>First stage : soft palate repair before 18 month. </li></ul></ul><ul><ul><li>Second stage hard palate repair at 4-5 years. </li></ul></ul><ul><ul><li>eg. Schweckendiek technique. </li></ul></ul><ul><li>1) Primary Veloplasty By Schweekendiek . </li></ul><ul><ul><li>First soft palate is closed at an early age 16-12 months) </li></ul></ul><ul><ul><li>Hard palate closed after few years. </li></ul></ul><ul><ul><li>Principle of this techniques is that the soft palate aids in the speech and is essential to be closed early for velopharyngeal mechanism. </li></ul></ul><ul><ul><li>Disadvantage : - Speech problem (Severe) </li></ul></ul><ul><ul><li>Additional surgical procedure. </li></ul></ul>
  21. 25. <ul><li>2) VON LANGENBECK’S PALATO PLASTY. </li></ul><ul><ul><li>Use bipedicled mucoperiosteal flaps of the hard and soft palate for repair of the defect. </li></ul></ul><ul><ul><li>There interiorly and posteriorly based flaps are advanced medially closed the palatal defect. </li></ul></ul><ul><ul><li>Advantage :- Easy to perform, requires less dissection. results in decreased denuded palate. </li></ul></ul><ul><ul><li>Disadvantage :- Failure to provide additional </li></ul></ul><ul><ul><li> palatal length. </li></ul></ul><ul><ul><li> - Poor results in large clefts. </li></ul></ul><ul><ul><li> - Currently not commonly used. </li></ul></ul>
  22. 27. <ul><li>Veau-Wardill-Kilnar-v-y- Pushback palatoplasty. </li></ul><ul><li>Two mucoperiosteal flaps are raised from a hard palate and nasal layers are mobilized abnormal attachment of palatal muscles are divided from the posterior border of the hard palate to be sutured in midline to the opposite side the palatal muscle. </li></ul><ul><li>Suturing done anterior of the nasal layer and progressed toward Uvula. </li></ul><ul><li>ORTHODONTICS AND MAXILLARY ORTHOPAEDICS. </li></ul><ul><li>Different stages of dentition methods. </li></ul><ul><ul><li>predental treatment. </li></ul></ul><ul><ul><li>Deciduous dentition ( 3 to 6 years) </li></ul></ul><ul><ul><li>Early mixed dentition ( 7 to 9 years) </li></ul></ul><ul><ul><li>Late mixed and early permanent dentition. </li></ul></ul><ul><ul><li>Permanent dentition. </li></ul></ul>
  23. 28. <ul><li>A) PRE DENTAL TREATMENT </li></ul><ul><li>I Feeding palate proper feeding advise pre-surgical feeding plate. </li></ul><ul><li>II.To help the surgeon in the repair of the cleft by pushing. </li></ul><ul><li>III. To stimulate palatal bone growth and to restore orofacial functional matrix. </li></ul><ul><li>IV. To expand or prevent the collapse of maxillary segment. </li></ul><ul><li>B) PRIMARY DENTITION TREATMENT </li></ul><ul><li>Simple form of fixed maxillary lingual appliance (i.e warch or an Arnold expander) are preferred over the removable palatal expansion for improving speech. </li></ul><ul><li> </li></ul>
  24. 29. <ul><li>C) MIXED DENTITION TREATMENT </li></ul><ul><li>Minor crossbites may be neglected but severe crossbites one corrected by expansion by usual method. </li></ul><ul><li>Retroclination of permanent incision and anterior cross bite to correct this usually partial banded approach is needed . </li></ul><ul><li>Crowded dentition: This may require serial extraction primary cupids are removed to treat incisior crowding & the primary molars. </li></ul><ul><li>After alveolor bone grafting. </li></ul><ul><li>To movement carriage enough space is created in the arch to allow the cuspids to erupt. </li></ul>
  25. 32. PERMANENT DENTITION TREATMENT <ul><li>The problem at this stage are posterior cross bite and malposed permanent incisors. </li></ul><ul><li>If orthognathic surgery is done to correct the underlying skeletal imbalance pre operative and post operative orthodontic treatment is needed to achieve proper alignment, position and indication of the teeth on their respective arches. </li></ul><ul><li>ROLE OF ENT SPECIALIST, SPEECH PATHOLOGISTS AND SPEECH THERAPY </li></ul><ul><li>ENT specialist, Audiologist and speech specialist work together to note the middle ear problems and progress in speech. </li></ul><ul><li>Detect abnormalities in articulation and resonance which is develops due to velopharyngeal in competence after palatoplasty. </li></ul><ul><li>The abnormalities detected by video fluoroscopy or nasopharyngoscopy. </li></ul>
  26. 33. <ul><li>PROCEDURE FOR CORRECTION OF VELOPHARYNGEAL INSUFFICIENCY </li></ul><ul><li>Pharyngeal flap 2) Sphincter pharyngoplasty. </li></ul><ul><li>- Pharyngeal flap designed on the basis of location and extent of lateral pharyngeal wall motion. The raw under surface of the flap is lined with tissue from the nasal side of the soft tissue palate to prevent contracture and narrowing of the flap the donor site on the posterior pharyngeal is closed. </li></ul><ul><li>ALVEOLAR BONE GRAFTING TIME 8-11 years. </li></ul><ul><li>Cancellous bone is used for alveolar grafting. </li></ul><ul><li>It promotes more rapid vascularization due to presence of living osteoblasts. </li></ul><ul><li>DONAR SITE OF BONE </li></ul><ul><li>Ilium, calvaria, tibia mandible or ribs. </li></ul><ul><li>The bone should be placed within the cleft from the piriform aperture to the level of the alveolar crest. </li></ul><ul><li>Gingival mucoperiosteal flaps are used for oral closure over an alveolar bone graft because they are well vascularized. </li></ul>
  27. 34. ADVANTAGE <ul><li>Bony support to teeth. </li></ul><ul><li>Helps stabilize the maxillary segments. </li></ul><ul><li>Aesthetic appearance of the alveolus. </li></ul><ul><li>Closure of oro nasal fistula. </li></ul><ul><li>Gives supports to the alar bone of the nose. </li></ul><ul><li>Provides bone for a titanium implants. </li></ul><ul><li>OPERATIVE CORRECTION OF MAXILLARY HYPOPLASIA </li></ul><ul><li>Maxillary hypoplasia is three dimensional deficiency </li></ul><ul><li>Class III malocclusion ( Sagittal plane) </li></ul><ul><li>Narrowed arch (horizontal plane) </li></ul><ul><li>Over closure the mandible (vertical plane) </li></ul>
  28. 36. TREATMENT <ul><li>Destruction osteogenesis. </li></ul><ul><li>Pre surgical orthodontics & Lefort – I osteotomy. </li></ul><ul><li>Fabrication of an over lay denture may be necessary for improved occlusion and appearance. </li></ul><ul><li>DENTAL ENAMEL HYPOPLASIA: </li></ul><ul><li>Defect occurs in central & lateral incisors. </li></ul><ul><li>Treatment </li></ul><ul><li>Restoration </li></ul><ul><li>Placement of stainless steel crown. </li></ul><ul><li>Fluoride application. </li></ul><ul><li>Dietary advice. </li></ul><ul><li>Preventive oral health care </li></ul>
  29. 37. ROLE OF PROSTHODONTIST <ul><li>Replacement of absent maxillary lateral incisor. </li></ul><ul><li>Replacement by fixed partial denture and implantation method. </li></ul><ul><li>ROLE OF PSYCHOLOGIST </li></ul><ul><li>The psychiatrist and psychologist evaluate the patient for strength and weakness in cognitive interpersonal, emotional, behavioural and social development: emphasis is placed on the patient’s ability to cope with the emotional and psycheal stress created by the cleft defect. Consultation with the parents and schools regarding educational or behavioural management if carried out when indicated. </li></ul>
  30. 38. CONCLUSION <ul><li>The management of cleft lip & palate is necessary at correct time. If delayed in the treatment there may be possibility to developed abnormalities. </li></ul><ul><li>So to prevent some problems like speech problem facial asymmetry, feeding problem & infection to nasal cavity & unasthetic appearance. The treatment is necessary. </li></ul>
  31. 39. REFERENCES <ul><li>Pediatric Oral & Maxillofacial Surgery by Leonard B. Kaban , Maria T. Troulis. </li></ul><ul><li>Facial cleft and cranio synostosis By Timothy A. Turvey, Kathorine W L VIG , Raymond J. Fansecu. </li></ul><ul><li>Clinical Pedodontics By Sidney B. Finn. </li></ul><ul><li>Oral & Maxillofacial Surgery by Chitra Chakravarthy </li></ul><ul><li>Clinical Pedodontics By Shobha Tandon. </li></ul>
  32. 40. Thank you