BDS [Orthodontics] course

1. CLEFT LIPAND PALATE
PROF (Dr.) SAIBEL FARISHTA

2. CLEFTS OF LIP AND PALATE CAN OCCUR INDIVIDUALLY OR TOGETHER IN
VARIOUS COMBINATIONS. THEY CAN ALSO OFFER ALONG WITH
CONGENITAL DEFECTS THAT AFFECT OTHER PARTS OF THE BODY.
INCIDENCE -
THE INCIDENCE OF CLEFT LIP AND PALATE IS FOUND TO BE DIFFERENT
AMONG DIFFERENT RACES.
IN INDIA, 1 IN EVERY 600 – 1000 BIRTHS.
THE NEGROID RACE HAS THE LEAST INCIDENCE (1 IN EVERY 2000
BIRTHS)
CLEFT LIP IS COMMON AMONG MALES, WHILE CLEFT PALATE IS MORE
COMMON AMONG FEMALES.
UNILATERAL CLEFTS ACCOUNT FOR 80% OF CASES, AMONG THIS 70% ARE
SEEN ON THE LEFT SIDE.
REASON -
THE FACE IS FORMED BY THE FUSION OF A NUMBER OF EMBRYONIC
PROCESSES THAT FORM AROUND THE PRIMITIVE ORAL CAVITY OR
STOMADEUM.
DEFECTIVE/INCOMPLETE FUSION BETWEEN THE VARIOUS PROCESSES
LEADS TO DIFFERENT TYPES OF CLEFTING.

3. ETIOLOGY OF CLEFT LIPAND PALATE
HEREDITY -
CLEFTS OF THE LIPAND PALATE CAN BE TRANSMITTED AS A
DOMINANT OR RECESSIVE TRAIT. 1 IN 3 CHILDREN WITH CLEFTS
HAVE SOME RELATIVES WITH SIMILAR CONGENITAL DEFECTS.
ENVIRONMENT -
CERTAIN TERATOGENS – LIKE VIRUS AND DRUGS LIKE CORTISONE,
VALIUM, DILANTIN ETC.
MULTIFACTORIAL ETIOLOGY -
THE ETIOLOGY CANNOT BE ATTRIBUTED TO ANY SINGLE FACTOR,
GENETIC OR ENVIRONMENTAL.
PREDISPOSING FACTORS
INCREASED MATERNAL AGE
RACIAL
BLOOD SUPPLY
(MONGLOIDS)
(DECREASED BLOOD
SUPPLY TO NASO-
MAXILLARY REGION
DURING EMBRYONIC
DEVELOPMENT)

4. EMBRYOLOGY
THE FIRST PHARYNGEAL ARCH (MANDIBULAR ARCH)
DEVELOPS TWO PROMINENCES –
1) THE MAXILLARY PROMINENCE
2) THE MANDIBULAR PROMINENCE

9. AS THE MEDIAL NASAL PROMINENCES MERGE WITH THE MAXILLARY
PROMINENCE, THEY FORM AN INTERMAXILLARY SEGMENT.

10. THE INTERMAXILLARY SEGMENT GIVES RISE TO -
1) PHILTRUM OF THE UPPER LIP
2) THE PREMAXILLARY PART OF THE MAXILLA
3) THE PRIMARY PALATE

12. MECHANISM OF PALATAL SHELF ELEVATION
- INTRINSIC FORCE WITHIN SHELF
- ACCUMULATION OF GLYCOSAMINOGLYCANS
- ACCUMULATION AND HYDRATION OF HYALURONIC
ACID
- INCREASE IN VASCULARITY
- CONTRACTION OF ELASTIC FIBRES OR MUSCLE FIBRES
- UNEQUAL DIVISION IN THE PALATALAND THE ORAL
EPITHELIUM
- NEUROTRANSMITTERS LIKE SEROTONIN
- INCREASE IN VIMENTIN EXPRESSION
- MASTER CONTROLLING GENE IS FSP-1, SSH

15. LOCAL FACTORS
1) FAILURE OF THE HEAD TO ELEVATE & BECOME ERECT AT 7-9TH WEEK
2) FAILURE OF TONGUE TO DESCEND DOWNWARDS & THEREBY CAUSING A
MECHANICAL INTERFERENCE TO FUSION OF THE PALATINE SHELVES
3) DEFICIENCY OF OXYGEN
4) SHIFT OF BLOOD SUPPLY OF FACE - DURING THE 6TH WEEK, MOST OF THE
MID-FACE IS SUPPLIED BY THE STAPEDIAL ARTERY, WHICH IS A BRANCH
OF THE INTERNAL CAROTID ARTERY
5) AT AROUND THE 7TH WEEK, STAPEDIAL ARTERY SEVERS FROM THE
INTERNAL CAROTID ARTERY & IT’S TERMINAL BRANCHES JOINS THE
EXTERNAL CAROTID ARTERY. DELAY IN THIS STEP CAN LEAD TO CLEFT

16. - CLASSIFICATIONS -
DAVIS AND RITCHIE’S CLASSIFICATION
GROUP I – PRE ALVEOLAR CLEFTS (INVOLVING ONLY THE LIP)
SUBCLASSIFIED AS – UNILATERAL
BILATERAL
MEDIAN
THIS IS A MORPHOLOGICAL CLASSIFICATION BASED UPON THE
LOCATION OF THE CLEFT RELATIVE TO THE ALVEOLAR PROCESS.
GROUP II – POST ALVEOLAR CLEFTS (IT INVOLVES DIFFERENT
DEGREES OF HARD AND SOFT PALATE CLEFTS, THAT
EXTEND UPTO THE ALVEOLAR RIDGE)
GROUP III – ALVEOLAR CLEFTS (THESE ARE COMPLETE CLEFTS
INVOLVING THE PALATE, ALVEOLAR RIDGE & THE LIP)
SUBCLASSIFIED AS – UNILATERAL
BILATERAL
MEDIAN

17. VEAU’S CLASSIFICATION
GROUP I – CLEFTS INVOLVING ONLY THE SOFT PALATE
GROUP II – CLEFTS INVOLVING THE SOFT AND HARD PALATE,
EXTENDING UPTO THE INCISIVE FORAMEN
GROUP III – THESE ARE COMPLETE UNILATERAL CLEFTS
INVOLVNG SOFT PALATE, HARD PALATE, LIP AND THE
ALVEOLAR RIDGE
GROUP IV – THESE ARE COMPLETE BILATERAL CLEFTS
INVOLVNG SOFT PALATE, HARD PALATE, LIP AND THE
ALVEOLAR RIDGE

18. KERNAHAN’S STRIPPED ‘Y’ CLASSIFICATION
IT USES A STRIPPED ‘Y’ HAVING NUMBERED
BLOCKS. EACH BLOCK REPRESENTS A SPECIFIC
AREA OF THE ORAL CAVITY.
BLOCK 1 & 4 - LIP
BLOCK 2 & 5 - ALVEOLUS
BLOCK 3 & 6 - HARD PALATE ANTERIOR TO
INCISIVE FORAMEN
BLOCK 7 & 8 - HARD PALATE POSTERIOR TO
INCISIVE FORAMEN
BLOCK 9 - SOFT PALATE
1 4
5
63
2
7
8
9
R L
KERNAHAN’S
CLASSIFICATION

19. MILLARD’S CLASSIFICATION
A MODIFICATION OF
KERNAHAN’S STRIPED ‘Y’
CLASSIFICATION
THE INVERTED TRIANGLES
REPRESENT THE NASAL ARCH
AND THE UPRIGHT TRIANGLES
REPRESENT THE NASAL FLOOR

20. L - A - H - S - H - A - L CLASSIFICATION
IT REPRESENTS THE ANATOMIC AREAS AFFECTED BY THE CLEFT
L - LIP
A - ALVEOLUS
H - HARD PALATE
S - SOFT PALATE
H - HARD PALATE
A - ALVEOLUS
L - LIP

21. C
L
E
F
T
L
I
P

22. CLEFT PALATE
CLEFT PALATE

23. CLEFT PALATE
CLEFT PALATE

24. CLEFT LIP

25. CLEFT PALATE

26. CLEFT PATIENT

27. PROBLEMS ASSOCIATED WITH CLEFTS
3. SPEECH AND HEARING PROBLEMS – CLEFT LIPAND PALATE IS
SOMETIMES ASSOCIATED WITH DISORDERS OF THE MIDDLE EAR.
1. DENTAL PROBLEMS – THE PRESENCE OF CLEFT IS ASSOCIATED
WITH DIVISION, DISPLACEMENT AND DEFICIENCY OF ORAL TISSUE.
ONE OR MORE OF THE FOLLOWING FEATURES MAY BE VISIBLE –
CONGENITALLY MISSING TEETH, PRESENCE OF NEONATAL TEETH,
SUPERNUMERARY TEETH, ECTOPICALLY ERUPTING TEETH,
MICRODONTIA, FUSED TEETH ETC.
2. ESTHETIC PROBLEMS – MILD TO MODERATE FACIAL
DISFIGUREMENT. THE OROFACIAL STRUCTURES MAY BE MALFORMED
OR MISSING. NOSE DEFORMITY MIGHT ALSO OCCUR.
4. PSYCHOLOGICAL PROBLEMS – CLEFT LIPAND PALATE PATIENTS
ARE PRONE FOR PSYCHOLOGICAL STRESS.

28.  WHEN A CLEFT LIP IS PRESENT, IT MAY BE DIFFICULT FOR THE
BABY TO MAKE A GOOD SEAL AROUND THE NIPPLE
 BABIES WITH CLEFT PALATE USUALLY NEED SPECIAL BOTTLES
AND TECHNIQUES TO FEED PROPERLY
THERE ARE 3 TYPES OF BOTTLES FOR FEEDING CLEFT BABIES -
1) THE MEAD-JOHNSON CLEFT PALATE NURSER
2) THE HABERMAN FEEDER, AND
3) THE PIGEON NIPPLE
FEEDING TECHNIQUES

29. MANAGEMENT
‘A MULTIDISCIPLINARY CLEFT PALATE TEAM’ IS REQUIRED TO TREAT
CLEFT PALATE PATIENTS.
IT INCLUDES A PEDEATRICIAN, PEDODONTIST, ORTHODONTIST, ORAL
SURGEON, PROSTHODONTIST, SOCIAL WORKER, GENETIC SCIENTIST,
ENT SURGEON, PLASTIC SURGEON, PSYCHIATRIST AND A SPEECH
THERAPIST.
STAGE I - TREATMENT DONE FROM BIRTH – 18 MONTHS
STAGE II - TREATMENT DONE FROM 18 MONTHS – 5 YEARS
(PRIMARY DENTITION)
STAGE III - TREATMENT DONE FROM 6 – 11 YEARS
(MIXED DENTITION)
STAGE IV - TREATMENT DONE FROM 12 – 18 YEARS
(PERMANENT DENTITION)
TREATMENT INVOLVES 4 DISTINCT STAGES

30. STAGE I TREATMENT
(Birth – 18 months)
IT INCLUDES -
1. FABRICATION OF A PASSIVE OBTURATOR
2. PRESURGICAL ORTHOPAEDICS
3. SURGICAL MANAGEMENT OF CLEFT LIP
4. SURGICAL MANAGEMENT OF CLEFT PALATE
1. FABRICATION OF A PASSIVE OBTURATOR -
THE MAXILLARY OBTURATOR IS AN INTRA-ORAL PROSTHETIC
DEVICE THAT FILLS THE PALATAL CLEFT AND PROVIDES A FALSE
ROOFING AGAINST WHICH THE CHILD CAN SUCKLE, THUS
REDUCING FEEDING DIFFICULTIES.
AFTER SELECTIVE BLOCKING THE UNDERCUTS, THE OBTURATOR
IS FABRICATED USING COLD CURE ACRYLIC.
CLASPS CAN AID IN RETENTION.

31. 2. PRESURGICAL ORTHOPAEDICS -
THE AIM OF PRE SURGICAL ORTHOPAEDICS IS TO ACHIEVE AN
UPPER ARCH FORM THAT CONFORMS TO THE LOWER ARCH.
DUE TO THE ABSENCE OF LIP TISSUE AND THE DIVISION PRESENT
BETWEEN ALVEOLUS AND PALATE, AN OUTWARD DISPLACEMENT
OF THE PRE MAXILLA OCCURS. THIS DISPLACEMENTS CAN BE
CORRECTED BY EXTRA-ORAL STRAPPING ACROSS THE
PREMAXILLA. A MICROPORE ADHESIVE TAPE CAN ALSO BE
STRAPPED.
IN CASE OFA NARROW, COLLAPSED MAXILLARYARCH, THE
EXPANSION CAN BE ACHIEVED BY A SUITABLE APPLIANCE
INCORPORATING EXPANSION SCREWS.
ADVANTAGES OF PRESURGICAL ORTHOPAEDICS
1. IT REDUCES THE SIZE OF CLEFTS, AIDING IN SURGERY
2. PARTIAL OBTURATION OF CLEFT ASSISTS IN FEEDING
3. SPEECH IS IMPROVED AS THE SIZE OF DEFECT IS REDUCED
4. REASSURES THE PARENTS AT A CRUCIAL TIME

32. OBTURATOR
EXTRA-ORAL STRAPPING

33. 3. SURGICAL LIP CLOSURE -
SOME PREFER EARLY SURGERY SOON AFTER BIRTH, WHILE OTHERS
RECOMMEND A DELAYED LIP SURGERY.
THE EARLY SCHOOL SUGGESTS THAT SURGERY SHOULD BE
PERFORMED WITHIN 45 DAYS OF BIRTH, AS DURING THIS TIME, THE
CHILD HAS A MARKED IMMUNITY TO SURGICAL SHOCK .
WHEREAS, THE LATE SCHOOL SUGGESTS THAT SURGERY SHOULD BE
POSTPONED TILL THE COMPLETION OF DENTITION, SO THAT THE
TISSUES CAN GROW AND MATURE, THEREBY GIVING THE SURGEON
MORE MUSCLE MASS TO WORK ON DURING SURGERY.
‘MILLARD’ HAS SUGGESTED - THE RULE OF TEN. ACCORDING TO THIS,
SURGERY SHOULD NOT BE PERFORMED LESS THAN 10 WEEKS OF AGE,
WHEN THE BODY WEIGHT IS NOT LESS THAN 10 POUNDS AND THE
BLOOD HAEMOGLOBIN NOT LESS THAN 10% GRAMS.
4. SURGICAL PALATE CLOSURE -
IT IS CARRIED OUT BETWEEN 1 – 2 YEARS OF AGE. THIS FACILITATES
NORMAL SPEECH, HEARING AND IMPROVES SWALLOWING. BONE
TRANSPLANT FROM RIBS, ILIAC CREST ETC. CAN BE USED.

34. STAGE II TREATMENT
(18 months – 5 years)
THIS STAGE COMPRISES OF TREATMENT CARRIED OUT DURING
PRIMARY DENTITION. VARIOUS PROCEDURES CARRIED OUT
DURING THIS PHASE ARE –
1. ADJUSTMENTS IN THE INTRA-ORAL OBTURATOR TO
ACCOMMODATE THE ERUPTING DECIDUOUS TEETH
2. IT MAINTAINS A CHECK ON ERUPTING PATTERN AND TIMING
3. ORAL HYGIENE INSTRUCTIONS CAN BE GIVEN TO THE PATIENT
4. RESTORATION OF DECAYED TEETH CAN BE DONE
NO ORTHODONTIC TREATMENT IS USUALLY INITIATED DURING
THIS PHASE, AS THE DESIRED BENEFITS ARE LOST, AS SOON AS
THE DECIDUOUS TEETH ARE SHED.
STAGE III TREATMENT
(From 6 – 11 years)
THIS STAGE COMPRISES OF TREATMENT CARRIED OUT DURING
MIXED DENTITION. VARIOUS PROCEDURES CARRIED OUT
DURING THIS PHASE ARE –
1. CORRECTION OFANTERIOR CROSSBITES
2. BUCCAL SEGMENT CROSSBITES (WITH QUAD-HELIX, SCREWS)

35. STAGE IV TREATMENT
(From 12 – 18 years)
THIS STAGE COMPRISES OF TREATMENT CARRIED OUT DURING
PERMANENT DENTITION PHASE.
A FIXED ORTHODONTIC APPLIANCE IS USED TO CORRECT
CROWDING, SPACING, CROSSBITE PROBLEMS.
A MAXILLARY DEFICIENCY CAN BE TREATED USING A FACE
MASK.
PROSTHESIS CAN BE GIVEN IN CASE OF MISSING TEETH AFTER
COMPLETION OF ORTHODONTIC THERAPY.
AFTER ORTHODONTIC THERAPY, THE PATIENT IS PLACED ON A
RETENTION PHASE. MOST CLEFT PALATE PATIENTS REQUIRE
LONG TERM RETENTION DUE TO INADEQUATE BONE SUPPORT,
THE ABSENCE OF TEETH AND PRESENCE OF STRETCHED SCAR
TISSUE.
THE SUCCESSFUL REHABILITATION OF THE PATIENT NEEDS A
MULTIDISCIPLINARYAPPROACH.

36. FACEMASK

37. EXTERNAL DISTRACTOR
INTERNAL DISTRACTOR
INTERNAL DISTRACTOR

38. TREATMENT OF CLEFT – A BRIEF OVERVIEW