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  4. 4. Habilitation of cleft lip and palate patient INDIAN DENTAL ACADEMY Leader in continuing dental education
  5. 5. Contents History Embryology Etiology and pathogenesis Incidence Complications Classification Management
  6. 6. History • Hippocrates (400 BC) and Galen (150 AD) mentioned cleft lip, but not cleft palate. • For centuries, perforations of palate were considered secondary to syphilis • Cleft palate recognized as a congenital disorder in 1556, by Fanco.
  7. 7. History • The first successful closure of a soft palate defect was reported in 1764 by LeMonnier, a French dentist. • The first closure of the hard palate was performed in 1834 by Dieffenbach. • In the 1930's, Kilner and Wardill independently developed the "pushback" procedure.
  8. 8. Embryology "It is not birth, marriage, or death, but gastrulation, which is truly the most important time in your life."             Lewis Wolpert (1986)
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  11. 11. Etiopathogenesis • Clefts of lip and palate may be isolated deformities or may be part of a syndrome • Non syndromic clefts are multifactorial in origin
  12. 12. Drugs Phenytoin Maternal illness smoking Alcohol Polygenic inheritance Genetic predisposition Non syndromic clefts
  13. 13. Some of the more common syndromes associated with CL/P • Chromosomal – Trisomy 13 – Trisomy 18 – Velocardiofacial syndrome (22q11 deletion) • Non-Mendelian – Pierre Robin syndrome – CHARGE association – Goldenhar syndrome • Teratogenic – Fetal alcohol syndrome – Fetal phenytoin syndrome – Fetal valproate syndrome • Mendelian disorders – Ectrodactyly-eetodermal dysplasia-clefting syndrome (AD) – Gorlin syndrome (AD) – Oto-palato-digital syndrome (XL) – Oral-facial-digital syndrome (XL) – Smith-Lemli-Opitz syndrome (AR) – Stickler syndrome (AD) – Treacher Collins syndrome (AD) – Van der Woude syndrome (AD) • Unknown – de Lange syndrome – Kabuki syndrome
  14. 14. Incidence • Best data given by Fogh-anderson 1943, Jensen et al 1988 denmark, 1.45/1000 live births in 1942 to 1.89/1000 in 1981. • Racial difference: American Indians 3.7/ 1000 Japanese 2.7/1000 Maoris & Chinese 2.0/1000 Caucasians 1.7/1000 Blacks 0.4/1000 ( Vanderas 1987)
  15. 15. • Cl(P) male : female :: 2 : 1 • Unilateral cleft, right : left :: 1 : 2 • CP alone 1/500 live births, greater in females • Cleft deformities of all races grouped 50% CL(P) 30 – 35 % CP 15 – 20 % CL alone Incidence
  16. 16. Complications • Apart from deficient esthetics, patients with cleft palate may have the following complications: Abnormal midface development, Velopharyngeal incompetence, Speech defects, and Abnormal eustachian tube function.
  17. 17. • Disturbances in function of mastication, swallowing, speech, respiration & facial expression • Abnormal patterns of facial growth Premaxilla protrusion Medial position of maxillary segments Reduced maxillary development Apparently large mandible Open gonial angle Low tongue posture Anterior open
  18. 18. Classification • Early attempts at classification by  Davies & Ritchie in 1922  Veau in 1931 • Fogh-Anderson in 1942 studied incidence of CL(P) in Denmark a. Hare lip including alveolus as far back as incisive foramen b. Hare lip & CP c. Isolated clefts of palate as far forward as incisive foramen
  19. 19. Kernahan and Stark's classification of clefts (1958) Clefts of primary palate only • Unilateral (right or left) – Complete – Incomplete • Median – Complete (premaxilla absent) – Incomplete (premaxilla rudimentary) • Bilateral – Complete – Incomplete Clefts of secondary palate only – Complete – Incomplete – Submucous Clefts of primary and secondary palate • Unilateral (right or left) – Complete – Incomplete • Median – Complete – Incomplete • Bilateral – Complete – Incomplete
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  23. 23. Cleft lip and palate team Social worker Pediatric psychiatrist Geneticist Prosthodontist Speech pathologist Orthodontist Otolaryngologist Pedodontist Plastic surgeon Pediatrician Team approach
  24. 24. Role of prosthodontist in CL(P) management • Replacement of teeth and other missing anatomic structures • Stabilization of cleft maxillary segments • Retention of tooth position • Camouflage for inadequate treatment
  25. 25. Management • Diagnosis • Parent counselling • Presurgical orthopedics • Primary surgery • Pedodontic and preventive care • Speech development, assessment, early intervention and treatment
  26. 26. Management • Assessment and surgical management of velopharyngeal incompetance • Orthodontics • Secondary surgery of lip, nose, palatal fistulae • Alveolar bone grafting • Orthognathic surgery • Restorative dental treatment • Management of treatment failures
  27. 27. Treatment timing • Infancy – primary lip surgery, primary palate closure • Primary dentition • Mixed dentition • Adolescent • Adults
  28. 28. Diagnosis and examination • Intrauterine - Sonographic diagnosis - Karyotyping • Post partum - Clinical - Radiographic (intra and extraoral, cineradiography, laminography, pantography) - Additional aids (speech and sound recording, measurement of nasal and oral pressures, psychiatric examination)
  29. 29. Prenatal, perinatal & postnatal parental counselling • Requisites Accurate information should be given by an expert in the field Support must be available soon after diagnosis Parents and members of family given opportunity to express concern and emotional response
  30. 30. Prenatal, perinatal & postnatal parental counselling Give a clear view of how the baby is likely to look Discussion on pregnancy termination based on accurate information Promote early adjustment and acceptance of the baby by the parents and family Long term dependence on counselor should be avoided and normalization of family life should be encouraged
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  32. 32. Early feeding management • The most immediate problem caused by a cleft lip or palate is likely to be difficulty with feeding. • Many babies with a cleft lip can breastfeed. However, some have difficulty in forming a vacuum in order to suck properly. • Babies with these problems may need a special teat and bottle that allows milk to be delivered to the back of the throat where it can be swallowed.
  33. 33. Early feeding management • A more upright feeding position controls nasal regurgitation • In infants with failure to thrive because of cardiac problems, laryngospasm, gastric tube feeding is adviced. • Under these conditions small prosthesis to obturate cleft is indicated to encourage oral feeding, presently considered largely unhelpful. • Babies who find it difficult to feed may gain weight slowly at first, but have usually catch up by the time they are six months old.
  34. 34. Pre surgical orthopedics • Principal aim is to realign the bony elements of the cleft to provide a more normal base for surgery Bulb held by bonnet straps
  35. 35. Pre surgical orthopedics Di Biase appliance Modified bulb without bonnet
  36. 36. Primary surgery Clefts of primary palate • Timing of surgery Arbitrary criteria : 1. The child must be free of any systemic or local disease 2. Child must have a minimum weight of 7 lb 3. The child must be in a weight gaining phase
  37. 37. Unilateral cleft lip Le Mesurier Tennison Mirault Millard
  38. 38. Bilateral cleft lip – Bilateral Tennisons approach (2 – stage) First stage Second stage
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  40. 40. Secondary operations – Residual unilateral / bilateral deformities – Collumellar lift: Barsky, Modified Marcks procedure – Modified Erich procedure to create symmetry of nose – Lip shave operation – Delayed bone grafting
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  42. 42. Clefts of secondary palate • Surgical period varies from anywhere between 18 months to 4 years
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  45. 45. • Position of obtained maxillary segments is not lasting as dental crossbite is incidental as long as bone continuity in the upper arch is not established 10 years 16 years • Children with bilateral cleft , premaxilla is prominent at this age. • Lateral incisors may be in the cleft and must be preserved
  46. 46. • Parents must be instructed in preventive dental practices • Fistulae of palate or labial sulcus may be present • For palatal fistulae simple Hawley type prosthesis may be delivered for speech improvement • Repositioning of cleft segments seldom necessary before permanent incisors erupt
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  48. 48. • Treatment should be designed to secure optimal vertical height of maxilla, position of teeth and arch form • Lateral incisors are most commonly missing • Supernumerary teeth may be present adjacent to cleft, their prognosis is determined & extracted
  49. 49. • Premolar teeth when absent complicates development of an adequate upper arch • Appliances used to reposition maxillary segments • Speech and hearing evaluation • Secondary revision of lip, nose, palate considered Use of quad helix for arch expansion
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  51. 51. • Orthodontic treatment initiated to achieve – Normal positioning of maxillary segments – Adequate vertical development of maxilla – Alignment of teeth for efficient occlusion – Esthetics – Positioning of teeth to permit conservative prosthodontic replacement of missing teeth • Orthodontist and prosthodontist must be in consultation in later part of treatment
  52. 52. • When canine final positioning has been attained, permanent stabilization of the arch by establishing bone continuity considered • Bone grafting accomplished safely at 14 – 16 years – Inlay grafts – Onlay grafts – Combination • Prosthdontic replacement of missing teeth can be carried out
  53. 53. • Removable dentures given to maintain space and esthetics • Fixed prosthesis, implants planned in late adolescence • Final cosmetic revision of lip and nose may be planned in late adolescence • Considerations given for orthognathic surgery to improve esthetics by correcting skeletal malrelationship
  54. 54. Orthodontic correction
  55. 55. Bone grafting
  56. 56. Le Fort I osteotomy Sagittal split ostoetomy Genioplasty Orthognathic surgery
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  58. 58. • Some patients may not have received optimum treatment and may require removable prosthesis to camouflage collapsed segments and reduced vertical development of maxilla • Use of pharyngeal obturator to aid speech • Edentulous cleft patient represents a failure in habilitation
  59. 59. Prosthodontic rehabilitation
  60. 60. Indications of prosthesis • In unoperated patients – Wide cleft with deficient soft palate – Wide cleft of hard palate – Neuromuscular deficiency of soft palate and pharynx – Delayed surgery – Expansion prosthesis to improve spatial relationships – Combined prosthesis and orthodontic appliance
  61. 61. • In operated patients – An incompetant paltopharyngeal mechanism – Surgical failures • Contraindications for prosthesis – Surgical repair is feasible – Mentally retarded patient – Uncooperative child and parents – Rampant caries – Lack of prosthodontic training or skill
  62. 62. Premaxilla Positioning Appliance • In the case of a complete bilateral cleft lip, the premaxilla and prolabium are protrusive and rotated upward. • This makes surgical repair difficult because the clefts may be wide and there would be excessive tension along the suture lines of the surgically corrected lip.
  63. 63. Premaxilla Positioning Appliance • The premaxilla positioning appliance (Reisberg et al., 1988; Figueroa et al., 1996) is a nonsurgical technique that retracts and rotates the malposed segment to a more favorable position for lip repair.
  64. 64. Nasal Conformer • Surgical repair of a cleft lip can result in a flattened contour of the nasal alar cartilage. • Aside from the cosmetic deformity this presents, it can also contribute to nasal airway obstruction. • Often the patient must have a corrective surgical procedure at a later age. • Grayson et al. (1999) has described the use of a nasal orthopedic molding appliance to minimize or avoid this problem.
  65. 65. Articulation Development Prosthesis • Repair of a cleft palate is performed by 1 year of age in order to minimize speech articulation abnormalities (Dorf and Curtin, 1982). • However, in some cases surgical repair must be deferred. This may be due to an excessively wide cleft or a compromising medical condition that precludes surgery at that time. • An articulation development prosthesis (Dorf et al., 1985) is used to prosthetically create a normal palate for speech development until the surgical repair can be performed.
  66. 66. • This resin plate covers the gum pads and palate area but does not extend into the cleft. This design permits appositional growth at the cleft margins. • The prosthesis is retained with denture adhesive and is worn continuously except for cleaning several times a day. • The prosthesis will not impede the eruption of teeth, and if any teeth are already present, it can be designed to circumvent them.
  67. 67. Palatal Obturator • Even after cleft palate surgery residual oronasal communication may occur on the palate or in the alveolar ridge or labial vestibule. • It usually does not cause a problem for feeding, but speech may be affected. • A palatal obturator covers the opening and contributes to normal speech production. • It eliminates hypernasality and assists speech therapy for correction of compensatory articulations.
  68. 68. Palatal Obturator • The prosthesis consists of a resin palatal plate with retention clasps of stainless steel orthodontic wire. • If any teeth are congenitally missing, they can be attached to the plate to improve articulation and appearance. • This prosthesis is often used as an interim measure until the residual communication can be surgically closed. • If the oronasal opening cannot be surgically repaired, the palatal obturator may serve as a definitive treatment.
  69. 69. Oronasal Fistula
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  71. 71. Palatopharyngeal Obturator/ speech bulb • Velopharyngeal insufficiency occurs when a cleft palate is unrepaired or when a surgically repaired soft palate is too short to make contact with the pharyngeal walls during function. • There is excessive nasal airflow and inadequate oral pressure for normal speech. • There may also be nasal regurgitation during feeding. • A palatopharyngeal obturator provides velopharyngeal closure and contributes to normal function.
  72. 72. Palatopharyngeal Obturator/ speech bulb • The palatal portion of this resin plate covers the hard palate and is attached to several teeth with wire clasps. This serves to retain and stabilize the prosthesis. • The velar portion extends into the pharyngeal area at the level of the palatal plane and seals the nasal cavity from the oropharynx during function. • This prosthesis is most often used as an interim device until corrective surgery can be performed. • It may serve as the definitive therapy when no further surgery is planned.
  73. 73. Speech Bulb
  74. 74. Palatal Lift • Velopharyngeal incompetency occurs when the surgically repaired soft palate is of adequate length but of inadequate mobility to elevate to achieve velopharyngeal closure. • A palatal lift prosthesis covers the hard palate and extends posteriorly to engage the soft palate and physically elevate and extend it to the proper position to achieve closure
  75. 75. • This prosthesis is most effective when the soft palate has little muscle tone and offers little resistance to elevation. • Adequate retention must be achieved at the palatal portion by clasping multiple teeth. • A pharyngoplasty or pharyngeal flap surgical procedure may correct this problem.
  76. 76. Palatal Lift
  77. 77. Palatal Lift
  78. 78. Palatal Lift
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  81. 81. Tooth Replacement / Restorative treatment • Congenitally missing anterior teeth are common in cleft patients. • The lateral incisors are missing most often, but cuspids and central incisors may also be affected. • If not missing, these teeth may be malformed and malposed. • The bone support of teeth adjacent to the cleft is usually compromised. In bilateral clefts, the bone quality of the premaxilla is poor, which jeopardizes the central incisors.
  82. 82. • Edentulous spaces in which teeth are congenitally missing can be closed orthodontically or surgically during an orthognathic procedure. • Then tooth replacement is not necessary. • Most commonly, the cuspid is moved to the position at which the lateral incisor would be and the premolar is moved to the cuspid position.
  83. 83. • When edentulous cleft site is not closed orthodontically or surgically, some type of prosthetic treatment is required • Options for tooth replacement include – a fixed or – removable partial denture or – a dental implant
  84. 84. Removable prosthesis • A removable partial denture is most often used as a temporary form of tooth replacement. • Although it can provide good esthetics, portions of the prosthesis must rest on soft tissues of the palate and can cause irritation.
  85. 85. Removable prosthesis • There may be movement of the prosthesis during function. • The fact that it is removable accentuates its artificial character, which is a common objection from patients. • It is used only as a definitive means of tooth replacement, where multiple teeth are missing and the edentulous space is too long to be spanned by a fixed restoration.
  86. 86. Removable prosthesis in compromised dentition Precision attachments Removable denture
  87. 87. Fixed prosthesis • A fixed partial denture attaches to teeth on each side of the edentulous space to provide a more natural tooth replacement. • If the abutment teeth need no other restoration, then a resin bonded fixed partial denture can be used.
  88. 88. • Alternatively, a conventional fixed partial denture can be used. • Like the resin-bonded prosthesis, function and esthetics are excellent. Long-term success is more predictable. • In patients where bone grafting has not been done a fixed removable Andrews type of restoration may be used
  89. 89. Dental implants • If adequate volume of bone exists in the edentulous space, tooth replacement can be achieved using dental implants. • A titanium alloy analog of a tooth root is surgically placed in the bone at the site of the missing tooth. • This can be placed in natural bone or at a bone-grafted site.
  90. 90. • This restores the dental arch to the most natural state, provides excellent function and appearance, and does not require the involvement of adjacent natural teeth. • Major limitation : finding adequate bone of good quality particularly in the line of cleft, bone grafting improves success
  91. 91. General Dental Care
  92. 92. The Future of Prosthetics • There are currently many exciting areas of research that will impact on prosthetic habilitation. • In utero corrective surgery, the use of bone morphogenic protein, and tissue and genetic engineering will eventually play a significant role in the care of the cleft/craniofacial patient in general and on prosthodontics and prosthetics in particular.
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  95. 95. References • Management of cleft lip and palate. Watson, Sell and Grunwell • Maxillofacial rehabilitation. Beumer, Curtis & Fritell • Maxillofacial prosthetics. Chalian VA, Drane JB, Standish SM • Cleft lip and palate. Grabb, Rosenstein and Bzoch
  96. 96. References • Doddamani S, Patil RA, Nerli S. Multidisciplinary approach for improving esthetics in cleft palate and alveolus patient: A clinical report. JIPS 2005; 5: 39 – 42 • Reisberg DJ. Dental and Prosthodontic Care for Patients With Cleft or Craniofacial Conditions. The Cleft Palate-Craniofacial Journal: Vol. 37, No. 6, pp. 534–537.
  97. 97. References • Abadi BJ, Johnson JD. The prosthodontic management of cleft palate patients. J Prosthet Dent. 1982 Sep;48(3):297-302. • Mazaheri M. Prosthodontics in cleft palate treatment and research. J Prosthet Dent 1964; 14: 1146
  98. 98. References • Immekus JE, Armany M. a fixed removable partial denture for cleft palate patients. J Prosthet Dent 1975; 34: 286 • Arcuri MR. Implant supported prosthesis for treatment of adults with cleft palate. J Prosthet Dent 1994; 71: 375
  99. 99. References • Aram A, Subtelny JD. Velopharyngeal function and cleft palate prosthesis. J Prosthet Dent 1959; 9: 149 • Dalston RM. Prosthodontic management of the cleft palte patient: A speech pathologist’s view. J Prosthet Dent 1977; 37: 190
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