The most common congenital craniofacial anomaly is cleft lip and palate. It is a separation that occurs in the lip or palate or both. Cleft occurs when the lip and/or the palate do not completely fuse during fetal development between the 6th and 9th week of pregnancy. While many factors have been associated with clefts, the cause of this condition seems complex and most cases of cleft lip and palate are thought to occur by an interaction of genetic and environmental factors or as a part of a genetic syndrome. Children with cleft lip and palate often have problems with feeding, speech, dentition, hearing, and aesthetics.

1. Cleft Lip and Palate
Dr Sudeep Madhusudan Chaudhari
Dept. of Pedodontics & Preventive Dentistry

2. Contents
 Introduction
 Definitions
 Prevalence
 Embryology
 Mechanism of cleft formation
 Etiology
 Classification
 Clinical features
 Problems associated with cleft lip & palate
 Syndromes associated with cleft lip & palate
 Diagnosis

3.  Prevention
 Parental attitude
 Multidisciplinary cleft lip and palate team
 Multidisciplinary sequencing of treatment in clefts
1. Stage I (Infant appliance stage: birth to 18 months of age)
2. Stage II (Primary dentition stage: 18 months to 5 years of age)
3. Stage III (Late primary or early mixed dentition stage: 6 to 10 or 11 years of age)
4. Stage IV (Permanent dentition stage: 12 to 18 years of age)
 Role of Pediatric dentist
 Conclusion
 References

4. Introduction
 Craniofacial anomalies are a diverse group of deformities in the
growth of the head and facial bones. These abnormalities are
congenital and have numerous variations : some are mild, other are
severe and require surgery.
 The most common congenital craniofacial anomaly is cleft lip and
palate. It is a separation that occurs in the lip or palate or both. Cleft
occur when the lip and/or the palate does not completely fuse during
fetal development between the 6th and 9th week of pregnancy.

5.  While many factors have been associated with clefts, the cause of
this condition seems complex and most cases of cleft lip and palate
are thought to occur by an interaction of genetic and environmental
factors or as a part of genetic syndrome.
 Children with cleft lip and palate often have problems with feeding,
speech, dentition, hearing and aesthetics.

6. Cleft –
 A space or opening made by or as if by splitting
Cleft lip –
 A visible congenital malformation characterized by partial or
complete clefting of the upper lip.
Definitions

7. Cleft palate –
 A visible congenital malformation characterized by a closure defect
of the hard palate and/or soft palate behind the foramen incisivum
without cleft lip.
Cleft lip and palate –
 A congenital malformation characterized by partial or complete
clefting of the upper lip with clefting of the alveolar ridge and/or the
hard palate.

8. Cleft lip with or without cleft palate–
 A congenital malformation characterized by partial or complete
clefting of the upper lip, with or without clefting of the alveolar ridge
or the hard palate. Excludes midline cleft of upper or lower lip and
oblique facial fissure (going towards the eye) {International
Clearinghouse for Birth Defect Monitoring Systems (ICBDMS,
2001) }.

9. Cleft palate without cleft lip –
 A congenital malformation characterized by a closure defect of the
hard and/or soft palate behind the foramen incisivum without cleft
lip. Includes sub-mucous cleft palate. Excludes CLP, cleft uvula,
functional short palate and high narrow palate (ICBDMS, 1991).

10. Submucous cleft palate:
 A cleft of the muscle layer of the soft palate with an intact layer of
mucosa lying over the defect.

11. Prevalence
 Worldwide, oral clefts in any form (i.e., cleft lip, cleft lip and palate,
or isolated cleft palate) occur in about one in every 700 live births.
(World Health Organization WHO, 2001) Assuming 15,000 births
per hour worldwide (US Bureau of the Census, 2001), a child is
born with a cleft somewhere in the world approximately every two
minutes.
World Health Organization. (2001, December). Global registry and database on craniofacial anomalies: Report of a WHO registry
meeting on craniofacial anomalies. Bauru, Brazil: Author.

12. According to continents (/1000 births)
Asia (1.57)
North America (1.56)
Europe (1.55)
Oceania (1.33) South America (0.99)
Africa (0.57)
Panamonta V, Pradubwong S, Panamonta M, Chowchuen B. Global Birth Prevalence of Orofacial Clefts: A Systematic Review. J
Med Assoc Thai. 2015;98 Suppl 7:S11-S21.

13. According to ethnicity (/1000 births) -
Blacks (0.56)
Whites(1.55)
Chinese (1.73)
Japanese (1.73)
American Indians (2.62)
Panamonta V, Pradubwong S, Panamonta M, Chowchuen B. Global Birth Prevalence of Orofacial Clefts: A Systematic Review. J
Med Assoc Thai. 2015;98 Suppl 7:S11-S21.

14.  Cleft lip occurs more common in male than female whereas cleft
palate occurs more commonly in female than in male reason for this
is that fusion of the palatine shelves 1 week later in girls than in boys
is thought thus it could be one of factor contributing in higher
frequency of cleft palate in girls.
According to gender (/1000 births) -
Jensen BL, Kreiborg S, Dahl E and Fogh-Andersen P (1988). Cleft lip and palate in Denmark, 1976-1981: epidemiology, variability,
and early somatic development. Cleft Palate Journal 25 258.

15. India (/1000 births) -
 Cleft lip with / without cleft palate – 0.93
22785 births/year
 Isolated cleft – 0.17
4145 births/year
Peter Mossey and Julian Little. Addressing the challenges of cleft lip and palate research in India. Indian J Plast Surg. 2009 Oct;
42(Suppl): S9–S18.

16. Embryology
4th week of gestation –
 The maxillary process emerge
from 1st brachial arch on each
side.
 The nasal placodes form from
the frontal prominence. Sox2
(sex determining region Y-box
2) plays important role in
formation of nasal placodes.

17. 5th week of gestation –
 All the primordia for the lip &
palate are present.
 Medial, lateral & frontonasal
processes are formed from
nasal placodes & maxillary
processes continue to enlarge.

18. 7th week of gestation –
 Medialnasal, frontonasal &
maxillary processes fuse to
form primary palate.
Which becomes medial
portion of upper lip,
alveolus & anterior
part of hard palate upto
the incisive foramen.

19.  When primary palate is
completely formed, the
maxillary processes enlarge
intraorally to form the palatine
processes.

20. 8th week of gestation –
 Palatal shelves fill up the space
on both sides of tongue.

21. 9th & 10th week of gestation –
 Mandibular arch enlarges & the
tongue drops.
 The palatal shelves transport
horizontally & fuse with each
other & with anterior part of
palate.
 The palatal fusion occurs
anteroposteriorly & the process
is completed by the 11th & 12th
weeks IU.

23. Mechanism of cleft formation
 A cleft is formed because
- Either the epithelium beneath which the mesoderm infiltrated
failed to form or the mesoderm failed to unite the various
processes.
- Inadequate mesoderm or mesoderm that may have had insufficient
migrating potential.
- The fetus may have already grown to such a size that amount of
mesoderm was inadequate to reach the processes to facilitate their
union.

24. - From functional point of view, the tongue may have failed to
perform the complex cycle of downward, forward & lateral
movements.
- The epithelium may have broken down or contain inclusion cysts.
- There may be a lack of shelf force.
All or any of these factors can prevent the palate from uniting.

25. Etiology
 Heredity is one of the most important factor to be considered in the
etiology of these malformation.
 However, there is increasing evidence that environmental factors are
important as well.

26. Heredity :-
 According to Fogh-Andersen (1942),
- 40% of cases of cleft with or without associated cleft palate
- 20% of cases of isolated cleft palate are genetically derived.
 According to Bixler (1975), there are two forms of clefts
- Polygenic
- Monogenic/syndromic
Rajendran R. Shafer's textbook of oral pathology. Elsevier India; 2009.

27. Polygenic Monogenic/syndromic
 Determined by several different genes
acting together.
 Actually, it is presumed that every
individual carries some genetic liability
for clefting, but if this is less than the
threshold level, there is no cleft.
 When individual liabilities of two
parents are added together in their
offspring, cleft occurs.
 70% of cases of cleft lip with or without
palate and 50% of isolated cleft palate
are nonsyndromic.
 It is associated with a variety of other
congenital anomalies.
 Clefting syndromes are rare & probably
make up only 5% of all clefts.
 According to Cohen(1978), there are
now over 300 clefting syndromes
reported in literature.
Rajendran R. Shafer's textbook of oral pathology. Elsevier India; 2009.

28.  Cleft lip and palate transmembrane protein 1 (CLPTM1), Gamma-
aminobutyric acid receptor subunit beta-3 (GABRB3), T-box
transcription factor-22 (TBX22), poliovirus receptor-like-1 (PVRL1),
and interferon regulatory factor-6 (IRF6)—are responsible for
causing cleft palate, cleft lip/palate

29. Environmental factors –
 Most common risk factors reported were maternal exposure in early
pregnancy to –
- Tobacco products – cigarette smoking
- Alcohols
- Nutritional deficiencies such as riboflavin, folic acid
- Viral infections – German measles (Rubella)
- Medications – phenytoin, dilantin, valproic acid, thalidomide, aspirin, 6-
mercaptopurine
- Teratogens – herbicides such as dioxin

30.  Several environmental risk factors such as nutritional deficiency,
anemia and self-administered medications appear to play an
important role in the development of cleft lip and palate in a Central
Indian population of low socioeconomic status. (Kalaskar R et al.
2013)
Kalaskar R, Kalaskar A, Naqvi FS, Tawani GS, Walke DR. Prevalence and evaluation of environmental risk factors associated with
cleft lip and palate in a central Indian population. Pediatr Dent. 2013;35(3):279-283.

31. Classifications
 Many attempts have been made to devise one classification for cleft
lip and palate. However, today no universally accepted system has
been adopted.
 The characteristics of classifications designed by embryologists are
embryologically oriented and differ from those produced by
clinicians, which tend to be morphologically or surgically oriented.

32. A. Morphologic classifications –
a) Davis and Ritchie classification (1922) –
Group I: Pre-alveolar clefts – Unilateral
(Lip) median
Bilateral
Group II: Post-alveolar clefts – Involving the soft palate only, the
a (Soft and hard palate) soft and hard palates or a
submucous cleft
Group III: Alveolar clefts – Unilateral
(Palate, alveolus Bilateral
and lip) Median

33. b) Veau’s classification (1931) –
 Group 1: Cleft of the soft palate only
 Group 2: Cleft of the hard and soft palate to the incisive
foramen
 Group 3: Complete unilateral cleft of the soft, hard palate and
lip and alveolar ridge on one side
 Group 4: Complete bilateral cleft of the soft hard palate and
lip and alveolar ridge on both sides.

34. c)Kernahan and Stark’s Classification of Clefts (1958)
A. Clefts of primary palate
Unilateral (r/ l)
– Complete
– Incomplete.
Median
– Complete (premaxilla
absent)
– Incomplete
(premaxilla
rudimentary).
Bilateral
– Complete
– Incomplete
B. Clefts of secondary palate
only
– Complete
– Incomplete
– Submucous
C. Clefts of primary and
secondary palate
Unilateral (r/l)
– Complete
– Incomplete
Median
– Complete
– Incomplete
Bilateral
– Complete
– Incomplete

35. d) American Cleft Palate Association’s Classification
Clefts of Prepalate Clefts of Palate
 Cleft lip
- Unilateral
- Bilateral
- Median
- Prolabium
- Congenital scar
 Cleft of alveolar
- Unilateral process
- Bilateral
- Median
 Cleft of alveolar
- Unilateral process
- Bilateral
- Median
 Cleft soft palate
Extent
- Palatal shortness
- Submucous cleft
 Cleft hard palate
Extent
- Vomer attachment
- Submucous cleft
 Cleft of soft and hard palate
Clefts of Prepalate and Palate
 Any combination of clefts described under clefts
of prepalate and clefts of palate.

36. B. Embryonic classification
a) Fogh-Anderson’s classification (1942) –
 Hare lip—includes alveolus and as for back as incisive foramen
 Hare lip and cleft palate
 Isolated cleft of the palate as forward as the incisive foramen.

37. C. Symbolic classification –
a) Schuchardt and Pfeiffer’s
Classification (1966)
 This is symbolic
classification in which
different regions depicted
and then shaded according
to type of cleft depending
on whether its total or
partial.

38. b) Kernahan’s Striped ‘Y’
Classification (1973) -
 This is a symbolic
classification in which
numbering is given to each
site representing the oral
cavity. The shaded area
denotes presence of cleft in
the particular area.

39. c) Millard’s Modification of
Striped ‘Y’(1991) -
 He added another
parameter to the
Kernahan’s classification
and that was the addition
of nasal floor.

40. d) Koul’s Classification (2007) –
Koul R. Describing cleft lip and palate using a new expression system. The Cleft palate-craniofacial journal. 2007 Nov;44(6):585-9.

41. Clinical features
 Clefts can be divided in two types –
Syndromic
Cases with
additional birth
defects like lip pits
or other
malformation
Nonsyndromic
Affected individual
has no other
physical or
developmental
anomalies

42.  Cleft lip –
• can occur as –
Unilateral Bilateral

43.  The line of cleft always starts on the lateral part of the upper lip &
continues through the philtrum to the alveolus between the lateral
incisor and canine.

44.  The cleft anterior to the incisive foramen is defined as cleft of
primary palate.

45.  Cleft lip may occur with wide range of severity from a notch located
on left or right side of lip (Hare lip) to the most severe form, bilateral
cleft lip & alveolus that separates the philtrum of upper lip &
premaxilla from the rest of the maxillary arch.

46.  When cleft lip continues from the incisive foramen further through
the palatal suture in the middle of the palate, a cleft lip with palate is
present.

47.  The cleft line may be interrupted by skin or mucosal bridges, bony
bridges or both, corresponding to a diagnosis of an incomplete cleft.

48.  Isolated cleft palate –
• Is etiologically and embryologically different from cleft lip and
palate.
• Several subtypes of isolated cleft palate can be diagnosed based on
severity.

49. • The uvula is the place where the minimal form of clefting of the
palate is observed.
Fig. Bifid uvula

50. • A more severe form is a clefting of the soft palate.

51. • A complete cleft palate constitutes a cleft of the hard palate, soft
palate & uvula.

52.  A clefting posterior to the incisive foramen is defined as a clefting of
secondary palate.

53. Problems associated with cleft
 Both clinical and psychological effects of cleft lip and palate on the
patient are of considerable concern.
 A common presentation for patients with cleft lip and palate is
concurrent presence of micrognathia and glossoptosis.
- Together, this triad is referred to a Pierre Robin sequence.
- May cause respiratory & feeding difficulty.
- Obstructive sleep apnea may occur.

54.  Feeding –
- Children with cleft lip alone have little difficulty & can nurse or
bottle feed normally.
- Children with cleft palate often struggle to feed due to limited or
absent ability of the infant to create suction.

55.  Otitis media & other middle ear abnormalities –
- This is another common challenge in children with cleft lip and
palate.
- A very high percentage of children with cleft palate requires ear
tubes & often multiple ear tubes during childhood as a result of
recurrent infections
- It is important to screen these children for hearing loss & intervene
early, as delay in the correction can hinder the development of
speech.

56.  Dental anomalies –
- Individuals with cleft lip and palate have a higher incidence of
dental anomalies, particularly in permanent dentition than
individual without cleft.
- These anomalies vary in degree of severity & can include rotation,
hypodontia of enamel, microdontia or macrodontia, fused teeth,
aberrations in crown shape and supernumerary teeth.

57.  Hypodontia –
- The tooth most likely to be missing is the lateral incisor with the
prevalence being higher on the side with the cleft.
- The prevalence of missing lateral incisors increases as the extent
of clefting increases, from cleft lip alone to cleft palate alone to
cleft lip and palate. (Suzuki A et al. 2017)
Suzuki A, Nakano M, Yoshizaki K, Yasunaga A, Haruyama N, Takahashi I. A Longitudinal Study of the Presence of Dental Anomalies in the Primary
and Permanent Dentitions of Cleft Lip and/or Palate Patients. Cleft Palate Craniofac J. 2017;54(3):309-320. doi:10.1597/15-186

58.  There is a natal or neonatal tooth observed in a patient with a
complete unilateral or bilateral cleft palate & it is usually a maxillary
central incisor.
 It is common to find ectopic primary lateral incisors located
palatally, adjacent to or within the cleft site. In the permanent
dentition, canines on the side of the complete alveolar cleft may
erupt palatally into the cleft.

59.  Permanent teeth that erupt adjacent to a cleft alveolar ridge usually
have a deficiency of supporting alveolar bone about the root
surfaces. These teeth are susceptible to premature loss.

60.  Patients with a complete cleft palate and alveolus do not have a
contiguous maxillary arch. External forces applied to the maxilla
(e.g., by muscles of mastication or by the contraction of scar tissue
after surgical repair of the cleft palate) can result in medial collapse
of the posterior segments. A posterior crossbite may be observed
unilaterally or bilaterally.

61.  In an infant with a complete bilateral cleft lip and palate, the
premaxilla is often protuberant and mobile. There may be a greater
than 100% overbite, with subsequent stripping of the labially
attached gingiva overlying the mandibular incisors. Traumatic
anterior end-to-end occlusion or an anterior crossbite, is also
common.

62.  The lateral facial profile may appear noticeably convex. This may
become more perceptible as the child grows older. The appearance
may be attributed to a true mandibular or pseudo-mandibular
prognathism.

63. Common syndromes associated with cleft lip and palate -
 Van der Woude syndrome
 Pierre Robin sequence
 Velocardiofacial syndrome
 Treacher-Collins syndrome
 CHARGE syndrome
 Kabuki syndrome
 Beckwith-Wiedemann syndrome
 Klippel Feil syndrome
 Apert syndrome
 Goldenhar syndrome
 DiGeorge syndrome
 Stickler syndrome
 Fetal alcohol syndrome

64. Diagnosis
 Clefting disorders are now increasingly diagnosed prenatally as part
of routine ultrasound screening between 18 and 20 weeks in utero.
 The reported diagnostic accuracy of routine 2D ultrasonography in a
low risk population varies between 9–100% for complete clefts of lip
and palate but is much lower (0–22%) for clefts of the palate only
(Maarse et al 2010).
Maarse W, Bergé SJ, Pistorius L, et al. Diagnostic accuracy of transabdominal ultrasound in detecting prenatal cleft lip and palate: a
systematic review. Ultrasound Obstet Gynecol. 2010;35(4):495-502.

65.  Much higher accuracy is achieved using
3D ultrasound but again isolated clefts of
the palate often remain undetected.
 Prenatal screening provides knowledge of
the impending birth of a baby with a cleft,
which allows both the family and
appropriate clinicians to prepare for this
event.

66.  There are several potential advantages for informing parents of a
prenatal diagnosis of facial clefting:
1. Psychological preparation of parents and caregivers to allow for
realistic expectations at the time of delivery.
2. Education of parents on the management of the cleft.
3. Preparation for neonatal care and feeding.
4. Opportunity to investigate for other structural or chromosomal
abnormalities.

67.  Disadvantages of prenatal diagnosis of clefting –
- Parents and professionals report an emotional disturbance and high
maternal anxiety after prenatal diagnosis of cleft lip & palate is
disclosed.
- As the sensitivity of ultrasound screening in the detection of facial
clefts increases, the potential exists for an increased number of
families choosing to terminate the pregnancy even in the absence
of other malformations.
Graber LW, Vanarsdall RL, Vig KW, Huang GJ. Orthodontics: current principles and techniques. 6th edition. Elsevier ; 2017.

68. Prevention
 Prevention should be considered the ultimate objective for orofacial
clefts.
 Several epidemiological and observational reports have indicated a
protective effect of prenatal use of multivitamins and folic acid on
incidence of clefts.
 Low maternal B6 and B12 levels measured after pregnancy was
reported to increase the risk of cleft lip & palate especially in cases
associated with low serum folate. Animal studies have also
confirmed the anti-teratogenic effects of prenatal folic acid
supplementation and dietary folate.
Allam E, Windsor L, Stone C. Cleft lip and palate: etiology, epidemiology, preventive and intervention strategies. Anat Physiol. 2014
Jul;4(3):1-6.

69.  With periconceptional folic acid supplement users who had a dietary
folate intake of around 200 μg/day and more, a 75-85% risk
reduction was indicated by van Rooij et al. (2004)
van Rooij IA, Ocké MC, Straatman H, Zielhuis GA, Merkus HM, Steegers-Theunissen RP. Periconceptional folate intake by
supplement and food reduces the risk of nonsyndromic cleft lip with or without cleft palate. Prev Med 2004;39:689-94.

70. Parental attitude
 Psychological issues are a critical part of the assessment &
management of the child with cleft lip & palate and must be
addressed from the onset care.
 The parents of affected child often experience feeling of sadness,
guilt, anger & fear for child’s future social acceptance.
 The feeding difficulties experience can be threatening to new
parents, who may doubt their own ability to feed & nurture an infant
with such differences. The loss of ability to breastfeed is especially
traumatic for some mothers.

71.  As the child grows, the family will have other concerns, often related
to teasing, peer acceptance, speech difficulties, learning & behaviour
problems. For many families, securing appropriate community &
financial resources remain important issues.
 During adolescence, there are new challenges, as the child maturing
teen strives for independence and copes with being different in a
highly appearance-conscious culture.

72.  Other important circumstances that are often addressed by a
psychological professionals include child abuse & neglect, substance
abuse, domestic violence & other family dysfunction.
 The intervention in such emotional issues prior to the surgery alone
are less likely to change self image & improve quality of life.

73.  Children with CLP run twice the risk of being out of school, denied
or self ejected. Their supposedly poor academic performance maybe
attributed to their condition. Teachers may fail to appreciate what
these children are saying. The peer group may be simply curious
about the child’s facial difference, or they may be openly pejorative
(Richman et al. 2012)
Richman, L.C., McCoy, T.E., Conard, A.L., & Nopoulos, P.C. Neuropsychological, behavioral and academic Sequelae of cleft: early
developmental, school age, and adolescent/young adult outcomes. The Cleft Palate-Craniofacial Journal, 2012, 49(4): 387-396.

74.  There are reports to suggest that nearly half of the population of
children with CLP do not go beyond elementary education. The
reasons given for their nonattendance at school are shame, being
hidden by the family, rejection by teachers, bullying by peers, speech
and/or communication problems, illness and socio-economic reasons
(Reddy et al. 2010)
Reddy, S.G., Reddy, R.R., Bronkhorst, E.M., Prasad, R., Ettema, A.M., Sailer, h.f., & Berge, S.J. . Incidence of cleft lip and palate in the
state of Andhra Pradesh, South India. Indian Journal of Plastic Surgery,2010; 43(2): 184-189.

75.  On one side, there are work, livelihood, employment and/or
vocational issues of un-operated adult persons with CLP, such as,
workplace stigma, on-the-job discriminations, behind-their-back
comments or them being made the butt of jokes. (DeSouza et al.
2009)
 Women with CLP are reportedly more affected with unemployment
or under employment than men with similar problems. The end result
is their poor quality of life. (Patrick et al. 2007)
DeSouza, A., Devare, S., & Ganshani, J. Psychological issues in cleft lip and cleft palate. Journal of Indian Association of Pediatric Surgeons,
2009, 14(2): 55-58.

76.  Singh (2009) observed that parents could not afford to miss out on
their livelihood for more than a week even to avail free surgery and
treatments under the Smile Train Program.
Singh, S.K. Smile Train: The ascendancy of cleft care in India. Indian Journal of Plastic Surgery, 2009,42(Suppl.): S192-S198.

77. Multidisciplinary cleft lip and palate team
 Children born with cleft lip and palate have many problems that need
to be solved for successful habilitation. The complexity of these
problems requires that numerous health care practitioners cooperate
in providing the specialized knowledge and skills necessary to ensure
comprehensive care. The multidisciplinary cleft lip and palate team
concept has evolved from that need.

78. Cleft Lip
& Palate
TeamPlastic surgeon
Anesthesiologist
Pediatric
otolaryngologist
Oral and maxillofacial
surgeon
Pediatrician
Pediatric dentist
Orthodontist Prosthodontist
Geneticist
Audiologist
Speech pathologist
Nurse
Psychologist
Social worker

79. Role of each member -
Plastic surgeon –
 Early surgical interventions, including lip adhesion and/or primary lip repair
as well as esthetic surgical procedures throughout growth to minimize
scarring and improve facial features.
Pediatric otolaryngologist
 Early surgical interventions, including lip adhesion and/or primary lip repair,
palate repair, velopharyngeal surgery, and other possible surgical
interventions such as ear tubes

80. Oral and maxillofacial surgeon –
 Depending on training, may play a role in surgical repair of lip and palate
 Commonly involved in extractions, bone grafting procedures, as well as
distraction osteogenesis
Geneticist –
 Counsels families on the risk of having future children with CLP
 Determines if clefting is a part of a syndrome or an isolated event

81. Pediatric dentist –
 A pediatric dentist is usually the first dental specialist whom the
parents will encounter.
 Jaju and Tate (2009) reported that 92% of the programs included the
pediatric dentist in the multidisciplinary cleft palate team with the
role extending from preventive, restorative to infant orthopedics.
Jaju R, Tate AR. The role of pediatric dentistry in multidisciplinary cleft palate teams at advanced pediatric dental residency programs.
Pediatr ent 2009;31:188-92.

82.  The role of pedodontist starts from neonatal period right up to
permanent dentition phase.
 The pediatric dentist facilitates the integration of oral hygiene and
dental preventive regimens into the treatment protocol for these
children to establish desirable habits and oral health before the
provision of advanced reparative surgery and complex dental
treatment.

83. Orthodontist –
 May play a role in presurgical molding techniques (e.g., NAM or Latham)
 Early treatment for alignment and expansion of constricted dental arches and
comprehensive orthodontic treatment

84. Prosthodontist –
 Restoration of dentition to full function and esthetics in adolescence and
adulthood
Audiologist –
 Follows milestones for normal hearing and work with otolaryngologist to
determine if ear tubes are needed

85. Speech pathologist –
 Follows milestones for speech development
 Works with local speech therapists to devise a program that will maximize
speech development
 Input is important when the decision has to be made regarding
velopharyngeal surgery
Nurse –
 Provides support and counseling for families
 Coordinates many aspects of medical care
 Works with families to develop a program for feeding, particularly early in
life

86. Psychologist –
 Assesses child’s mental and emotional well-being throughout life
 Helps child adjust to stages of life and offers assistance and support when
needed
Social worker –
 Provides support and assistance to families, helping to overcome barriers,
allowing the best possible care to be delivered to the child
 Financial assistance, transportation, local arrangements, and school programs
are a few examples

87. Multidisciplinary sequencing of
treatment in clefts
1. Stage I (Infant appliance stage: birth to 18 months of age)
2. Stage II (Primary dentition stage: 18 months to 5 years of age)
3. Stage III (Late primary or early mixed dentition stage: 6 to 10 or
11 years of age)
4. Stage IV (Permanent dentition stage: 12 to 18 years of age)

88. 1. Stage I (Infant appliance stage: birth to 18 months of age) –
 Management of the patient with a cleft begins with immediate
attention to the needs of the newborn.
 Feeding problems are often associated with cleft anomalies,
particularly clefting of the palate, which make it difficult for
the infant to maintain adequate nutrition. These problems
include insufficient suction to pull milk from the nipple,
excessive air intake during feeding (requiring several
burpings), choking, nasal discharge and excessive time
required to take nourishment.

89.  Maintaining adequate nutrition for the infant –
 First goal is to prepare the neonate for surgical repair of the lip.
 Rule of ten is used to ascertain the fitness of the child.
- 10 weeks old
- 10 gm of Hb
- 10 pound weight

90.  McNeil (1954 & 1956) and other authors since then have advocated
various prosthetic appliances, both active and passive, for the
treatment of infants born with unilateral and bilateral clefts of the lip
and palate.
 One such prosthesis, an intraoral maxillary obturator, has proved
beneficial by providing an artificial palate.

91. Impression Technique and Feeding Obturator Construction
 As soon as possible (usually within 2 weeks of birth), an
impression is made of the infant’s maxillary arch.
 Before taking impression, appropriate emergency equipment,
including forced oxygen, suction, and standard airway
management equipment, should be available.

92.  An alginate impression of the
infant’s maxillary arch is made
with a modified stock tray.
 Held the infant upright during
the impression process to
prevent aspiration of excess
material.

93.  The impression should exhibit
good anatomic detail with
coverage of the entire maxillary
arch.
 A stone model is then produced.

94.  Block out excessive undercuts
with modeling dough or wax
make the appliance using
autopolymerizing acrylic resin.

95. Clinical management of initial
obturator therapy –
 The appliance is positioned in
the infant’s mouth & areas of
excessive pressure exerted by
the acrylic resin on any intraoral
tissues are identified by
observation and then reduced.
https://www.youtube.com/watch?v=UEDgh5n1r2g

96.  Parents are instructed in placement and removal of the appliance and
its daily cleaning.
 Infants are usually seen for adjustments 2 days after appliance
delivery.
 After delivery of the obturator, the infant is allowed to become
accustomed to the appliance for 1 week.
 Monthly observations are then scheduled.
 In most cases, this appliance will serve until the time of initial lip
closure at approximately 3 months of age.

97.  Advantages of this prosthetic therapy include the following:
1. Provides a false palate against which the infant can suck, reduces
the incidence of feeding difficulties in newborns and helps
maintain adequate nutrition.
2. Provides maxillary cross-arch stability and prevents arch collapse
after definitive cheiloplasty (surgical closure of the lip).
3. Provides maxillary orthopedic molding of the cleft segments into
approximation before primary alveolar cleft bone grafting.

98.  In a study by Jones (2003), maxillary obturators were constructed to
facilitate feeding for 51 infants with unilateral or bilateral cleft lip
and palate. From birth, each infant had continuously experienced
feeding difficulties before obturator therapy. After the infants had
worn the obturator for at least 8 months, parents reported that they
were more comfortable while feeding their infants and that nasal
discharge was reduced. The time required for feeding and the
difficulty experienced by the parents were also reduced.
Jones JE: The use and clinical effectiveness of the maxillary obturator appliance in cleft lip and palate infants: birth through six months of age [Doctoral
dissertation], San Jose, Costa Rica, 2003, Empresarial University.

99.  Not all clinicians who work with infants with
cleft lip and palate advocate the use of
prosthetic feeding appliances. Some believe
that such appliances are not effective in
facilitating feeding.
 Pashayan and McNab (1979) recommend
using a standard nipple that has been crosscut.
 This enlarged cut provides improved ejection
of the milk into the infant’s mouth with a
minimum of effort.
Pashayan HM, McNab M: Simplified method of feeding infants with cleft palate with or without cleft lip, Am J Dis Child 133:145–
147, 1979.

100.  There are variations in nipple
design such as long nipples
which directs milk into pharynx.
Pigeon Feeder W/Long Nipple For Cleft PalateHabermanTM feeder

101. Pigeon nipple one-way valve Feeding teats

102.  Spoon feeding is suggested as an alternative method of feeding, but
this is time consuming & can frustrate the baby as well as mother.
 Throughout the feeding the child should be in semi-upright position
to prevent choking.

103.  Presurgical orthopedics –
 In some cases of bilateral cleft lip and palate, the infant has a
premaxillary segment positioned severely anterior to the maxillary
arch segments or deviated laterally to one side of the cleft defect.
This presents a difficult clinical challenge for the surgeon before
surgical closure of the lip.
 If lip surgery is undertaken with the premaxilla in such an abnormal
position, the chances of lip dehiscence are increased.

104.  Presurgical orthopedics is the use of appliance & force in various
forms, to mold the alveolus & lessen the severity of the cleft.
 Hoffman in 1686 advocated the use of head cap and premaxillary
strap to reposition the premaxilla.
 Various methods of presurgical orthopedics include –

105. a) Elastomeric tape –
• It is simplest form to apply.
• Advantages –
- Inexpensive
- Less onerous for family when compared to other molding devices.

106. • Disadvantages –
- The applied forces are indiscriminate in nature, so palatal
constriction may result.
• Taping can be done alone or in conjunction with other molding
techniques.

107. b) Intraoral appliances –
• Are often more cumbersome to use, but they do maintain the palatal
width, since force can be applied in smaller areas and with greater
precision.

108. • The Latham appliance –
- An appliance that is surgically placed
into a young child’s mouth and
retained to the palate with a screw.
- It is adjusted regularly to reduce the
cleft size.
- The compliance is not required.
- But the disadvantage is increased
surgical interventions in a very young
child, both at the time of insertion and
at the time of removal.

109. c) Nasoalveolar molding –
• It is less invasive technique,
pioneered by Dr. Barry Grayson
& his team at New York
University.
• The removable acrylic plate is
used to mold the bony alveolus.
• The nasal stent is used to
lengthen the columella & realign
the lower lateral alar cartilage.

110. • The appliance is worn throughout
the day & held in place by tape
the cheeks.
• Changes are made to the plate
incrementally by the dental
professional.
• NAM has even been shown to
decrease the number of future
surgical interventions that are
typically performed for esthetics.
(Garfinkle JS et al. 2011)
Garfinkle JS, King TW, Grayson BH, et al. A 12-year anthropometric evaluation of the nose in bilateral cleft lip-cleft palate patients
following nasoalveolar molding and cutting bilateral cleft lip and nose reconstruction. Plast Reconstr Surg. 2011;127:1659–1667.

111. d) DynaCleft® –
• Newer method
• A premade topical
approximation device that has
been successfully used to mold
the upper lip and alveolus and to
support the developing nasal
tissues prior to cleft lip repair.
https://www.youtube.com/watch?v=TCmxgjsfzi4

112.  Airway Obstruction –
 Infants with airway obstruction
secondary to Pierre Robin
sequence may require
intervention to aid breathing.
 An obturator with a posterior
palatal extension may be used to
reposition the tongue downward
and forward out of the cleft site.

113.  Prone positioning, supplemental oxygen, nasopharyngeal tubes and
continuous positive airway pressure (CPAP) may also be helpful.
 If a nonsurgical approach is unsuccessful, lip-to-tongue adhesion,
mandibular distraction or tracheostomy may be necessary.

114.  Cheiloplasty –
 Cleft lip repair is typically
performed in infants at
approximately 3 months of
age. Primary nasal
reconstruction is commonly
performed at the time of lip
repair.

115.  Prior to the start of surgery, when the infant is under general
anesthesia, if an obturator has been necessary, an impression is made
of the maxillary arch for construction of a new obturator. This is
necessary to accommodate craniofacial growth during the first few
months of life.

116.  Maxillary orthopedics –
 After definitive lip closure, maxillary arch collapse in the unilateral
or bilateral complete cleft may occur.
 This is attributed to the increased tension placed on the segments by
the repaired lip. To prevent this collapse, an obturator may be used to
provide cross-arch stability and support.

117. Sequential maxillary arch dental models demonstrating maxillary orthopedic
molding in an infant with a unilateral complete cleft lip and palate. Notice that,
as the cleft defect closes with time, lateral arch dimension is maintained, which
produces optimal maxillary arch symmetry.
Jones JE, Kerkhof RL, Nelson CL, Sadove AM. Maxillary arch expansion in cleft lip and palate infants prior to primary
autogenous alveolar bone graft surgery. Quintessence international. 1986 Apr 1;17(4):245-8.

118.  When the maxillary segments are in good alignment and abut across
the cleft sites, a primary cleft bone graft can be considered.

119.  Primary alveolar cleft bone grafting –
 Primary bone grafting refers to bone-grafting procedures involving
alveolar cleft defects in children younger than 2 years of age
 Primary alveolar cleft bone grafting is controversial. The concept fell
into disfavor in the early 1970s amid numerous reports of significant
attenuation in midfacial growth.
 Use of a primary alveolar cleft bone graft does not necessarily
preclude a later secondary alveolar cleft bone graft if it is indicated.

120.  A survey of American Cleft Palate–Craniofacial Association teams
conducted by Murthy AS & Lehman JA (2005) reported that only 3%
of teams perform primary alveolar cleft bone grafting.
Murthy AS, Lehman JA. Evaluation of alveolar bone grafting: a survey of ACPA teams. Cleft Palate Craniofac J. 2005;42(1):99-101.

121.  Palatoplasty –
 A cleft palate is repaired between the
ages of 9 and 18 months, most often by
age 1.
 Early repair of the palate has the
advantage of better speech development
but the downside is that scar tissue can
form and inhibit proper maxillary
growth, leading to malocclusion
(typically class III malocclusions and
skeletal pattern) and poor facial
esthetics.

122.  Conversely, if palate repair is done late, after 18 months, the opposite
is true and growth may occur normally but speech will likely be
negatively impacted.
 The procedure may also improve hearing and swallowing by aligning
the cleft palatal musculature.

123.  After primary closure of the cleft palate, some patients may
demonstrate velopharyngeal insufficiency requiring secondary
surgery.
 A persistent inability to close the nasopharynx may result in
unsatisfactory speech (nasality and articulation problems),
regurgitation of fluids from the nose and facial grimacing.
 The procedure is generally performed before the child begins
school.

124.  Establishment of Dental Home –
 One of the most important aspects of cleft lip and palate care is
infant oral health care. It is during this time that the American
Academy of Pediatric Dentistry advocates the “age one” dental visit.
 During this visit, the pediatric dentist examines the oral cavity, notes
any abnormalities in the soft and hard tissues, and provides
anticipatory guidance to the parents regarding oral health care. Also,
during this visit, emphasis is placed on the prevention of oral disease.

125. 2. Stage II (Primary dentition stage: 18 months to 5 years of age) –
 Treatment during the primary dentition stage of dental
development is initially focused on establishing and maintaining
oral health.
 Ectopic eruption of the primary maxillary anterior dentition is
common around the cleft defect.
 Special care should be taken to keep these teeth free from caries
because food is often lodged in and around the cleft defect.

126.  An increase in the frequency of periodic recall examinations,
possibly to 3- to 4-month intervals, enables the dentist to intercept
areas of decalcification.
 This preventive regimen is continued throughout all subsequent
stages in the management of the cleft.

127. 3. Stage III (Late primary or early mixed dentition stage: 6
to 10 or 11 years of age) –
 Many problems encountered
during the late primary and
mixed dentition stages of dental
development arise from
ectopically erupting permanent
central and lateral incisors or
crossbites of the posterior dental
segments.

128.  Treatment therefore
concentrates on correction of a
developing traumatic occlusion
and posterior segmental
alignment.

129.  Secondary alveolar cleft bone graft –
 Patients with clefts of the alveolus often
have collapsed maxillary arches and
require alveolar bone grafting.
 Alveolar bone grafting enables the surgeon
to obtain maxillary arch continuity, provide
support for the dentition to erupt and
stabilize the maxillary arch prior to any
orthodontic treatment.

130.  The timing of alveolar bone grafting is dependent on the presence of
a viable maxillary permanent lateral incisor adjacent to the alveolar
cleft area and proximity of the roots of central incisors to the alveolar
cleft.
 If a viable permanent lateral incisor is present or if the root of the
developing maxillary central incisor is too close to the alveolar cleft,
alveolar bone grafting is recommended by 5 to 7 years of age.
 A number of craniofacial centers elect to perform the alveolar bone
grafting at a later time, closer to eruption of the maxillary permanent
canines.

131.  The most frequently used donor site for alveolar bone grafting is the
iliac crest because of ease of access and abundance of bone.
 Alternative donor sites include the mandibular symphysis, rib,
cranial bones and tibia.
 A few craniofacial centers also use bone morphogenetic protein
(BMP)

132. 4. Stage IV (Permanent dentition stage: 12 to 18 years of age)
 The majority of persons with cleft
lip and palate require some degree
of orthodontic management and
can be treated conventionally.
 Some patients with clefts,
however, will require a combined
orthodontic-surgical approach in
the permanent dentition to achieve
optimal outcome.

133.  Cosmetic surgeries –
 Cosmetic repair is also carried out during this phase but is probably
the last treatment to be undertaken.

134. Craniofacial cleft treatment
foundations in India

135. Conclusion
Pediatric dentist performs a dual role in both improving the personal
impact as well as improving the surgical outcome. Patients with CLCP
are a priority group. Pedodontist has a key role to play in providing
continuing, high-quality, preventive-based dental care. Thorough
treatment planning, patient support and skillful behavior management
are important aspects of this multifaceted care. Good communication
on a regular basis between the pedodontist and relevant members of the
cleft team helps to achieve the best oral health outcome for the patient.

136. References
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