CLEFT LIP &PALATE MANAGEMENT IN ORTHODONTICS /certified fixed orthodontic courses by Indian dental academy


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CLEFT LIP &PALATE MANAGEMENT IN ORTHODONTICS /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Cleft lip and palate - Management and role of orthodontist
  3. 3. Introduction Epidemiology and etiology Classification Management  Cleft lip and palate team  Goals and objectives of treatment  Various procedures undertaken from infancy to adulthood  Outline of various protocols used in different centers across the world  Conclusion
  4. 4. Introduction Cleft lip and palate is the most common developmental anomaly of the craniofacial region, and they have been depicted throughout in the past civilizations. Records suggest that hare lip was reported as far back as 1000 AD .
  5. 5. Management of these clefts patients have been attempted with varying success. Parea (1561), a French dentist was the first to put an obturator to fill the cavity of cleft in order to facilitate eating and speech.
  6. 6. Le Monnier (1764), a French surgeon tried to repair cleft palate surgically. In following years, many attempts were made to close cleft palate surgically but failed due to tension developed at median suture. Fergusson (1844) and Van Langenback (1862) greatly improved surgical techniques for repairing clefts.
  7. 7. Keeping in mind that cleft patient need services from specialist in different fields, cleft palate centers were formed across the world. All these centers have cleft palate team which work for common goal of “look well, eat well and speak well”
  8. 8. At such a center, the cleft team may appropriately evaluate the deformity, coordinate a plan of care, and offer the best attention to the patient.
  9. 9. The team is usually formed by a group of professionals in the fields of plastic surgery, pediatrics, speech therapy, pediatric dentistry, orthodontics, oral and maxillofacial surgery, and prosthodontics, among others.
  10. 10. Over the years of treatment that cleft patients require, the orthodontist is involved in all stages of care to achieve optimal dental and jaw relationships.
  11. 11. Epidemiology and etiology The incidence varies widely and is the least in the Negroid (Blacks). The Mongoloids show the highest incidence (Asian, mainly Japanese and Chinese). In India – 1 in every 750-800 live births
  12. 12. Gorlin and Cohen (2000) in their review study of large series of patients with clefts founded that approximately : 45% of cases have cleft lip and palate 25% have cleft lip only 30% have cleft palate only.
  13. 13. - Unilateral cleft lip tends to occur more commonly on the left side (2 left:1 right). - In general, more severe the defect, the greater the proportion of males affected cleft lip-palate, 2 males:1 female; cleft lip only 1.5 males:1 female).
  14. 14. Etiology     Genetics Syndromes Teratogens Embryological basis
  15. 15. GENETICS Much evidence supports the view that genetic factors are associated with orofacial clefting. In twins with cleft lip-palate, concordance is far greater for monozygotic twins (40%) than for dizygotic twins (4.2%). (Wyszynski and Beaty 1996)
  16. 16. various genes associated with orofacial clefting
  17. 17. SYNDROMES Syndrome delineation involving orofacial clefting has been discussed and reviewed by Cohen and Bankier (1991). By 1991, they have reported more than 340 syndromes. (Van der Woude syndrome, Treacher Collins syndrome etc)
  18. 18.
  19. 19. TERATOGENS Teratogens responsible for birth defects have been reviewed by Cohen (1997). Cigarette smoking appears to be correlated with clefting and may act alone or synergistically with TGFa (Shaw et al 1996, Kallen 1997).
  20. 20. Tolarova and Harris (1995) reported that dietary supplements of folic acid are known to reduce the frequency of neural tube defects. Mills et al (1999) studied the folate metabolism in cleft palate and general population. Their results strongly suggested that impairment of folate metabolism may play role in the etiology of orofacial clefting
  21. 21. EMBRYONIC BASIS OF ORO FACIAL CLEFTING Neural crest cells play an integral part in facial morphogenesis. Neuro-ectoderm form the skeletal and connective tissue of the face: bone cartilage, fibrous connective tissue (Sulik 1985, Cohen 1990)
  22. 22. Genetic and/ or environmental factors that inhibit the flow of neural crest cells or decrease their number may affect their masses so that contact between the facial prominences is inadequate or impossible, leading to orofacial clefting, including cleft lip and palate
  23. 23. Cleft palate may result from : - Defective growth of palatine shelves - Micrognathia may lead to wedging of tongue between shelves hence causing mechanical obstruction (Robin syndrome) - Failure of fusion of palatine shelves - Post-fusion rupture of shelves
  24. 24. Classification - Facilitates communication among team members - Concise & clear description - Comparison of progress among different groups of patients
  25. 25. Davis & Ritchie(1922) Group I - PRE ALVEOLAR CLEFTS - clefts of lip (unilateral / median / bilateral) Group II- POST ALVEOLAR CLEFTS -clefts of soft palate -clefts of soft & hard palate up to the alveolar ridge -submucous clefts GROUP III- ALVEOLAR CLEFTS involving palate ,alveolar ridge & lip (unilateral / median / bilateral)
  26. 26. Veau (1931) Group 1- cleft of the soft palate only Group2- cleft of the soft & hard palate extending no further than the incisive foramen ,thus involving the secondary palate alone Group3-complete unilateral cleft of the soft hard palate ,alveolar ridge& lip Group4-complete bilateral cleft of the soft hard palate ,alveolar ridge& lip
  27. 27. FOGH ANDERSON (1942) Group 1 cleft lip only Single- Unilateral or median clefts . Double-Bilateral clefts Group2 Cleft lip and palate. Single-Unilateral clefts Double-Bilateral clefts. Group3 clefts palate only extend up to the incisive foramen.
  29. 29. KERNAHAN'S STRIPPED ‘Y' CLASSIFICATION (1971) Block I and 4 - Lip Block 2 and 5 - Alveolus Block 3 and 6 -Hard palate anterior to the incisive foramen Block 7 and 8 - Hard palate posterior to incisive foramen Block 9 - Soft palate
  30. 30. MILLARD'S MODIFICATION OF THE KERNAHAN'S STRIPPED "Y" CLASSIFICATION Millard added two triangles over the tip of the "Y“ to denote the nasal floor. This increased the number of boxes to 11. Block I and 5 - Nasal floor Block 2 and 6 - Lip Block 3 and 7 - Alveolus Block 4 and 8-Hard palate anterior to the incisive foramen Block 9 and IO-Hard palate posterior to the incisive foramen Block 11- Soft palate.
  31. 31. ELSAHY'S MODIFICATION OF THE KERNAHAN'S STRIPPED "Y" CLASSIFICATION Elsahy modified the Stripped "Y" further by double lining the blocks 9 and 10 in the hard palate area and used arrows to indicate the direction of deflection in complete clefts.
  32. 32. He also placed a circle 12 under the stem of the "Y" to represent the pharynx and a dotted line from the Y to circle 12 reflecting the velopharyngeal competence. Another circle 13 was also added to represent the premaxilla, and the amount of its protrusion was indicated by the dotted line with an arrow.
  34. 34. LAHSHAL CLASSIFICATION (1987) This is one of the simplest classifications and was formulated by kriens o. LAHSHAL is a paraphrase of the anatomic areas affected by the cleft.
  35. 35.
  36. 36.
  37. 37. Management and role of orthodontist
  38. 38. The functional and aesthetic problems associated with cleft lip and palate depend on the size of the cleft and whether it is unilateral or bilateral.
  39. 39. All complaints are dealt by cleft palate team to restore aesthetic and functional harmony. Goals and objectives of treatment are to : 1. Close vestibular and palatal oronasal fistula 2. Restore physiologic continuity of the dental arch to enable oral and dental health to be maintained
  40. 40. 3. Provide bone for stability and continuity of the dental arch (bone grafting) 4. Allow eruption of the permanent teeth or placement of dental implants through bone graft. 5. Provide support for the lateral ala of the nose
  41. 41. 6. Orthodontic alignment of teeth 7. Facilitate nasolabial muscle and soft tissue reconstruction 8. Establish functional nasal airway 9. Provide support for the lip 10. Prevent tooth loss caused by lack of periodontal bone support
  42. 42. Role of the Cleft Palate Team Members Plastic and Oral and Maxillofacial Surgeon All surgical management of the cleft patient is performed by these surgeons. They evaluate the effects of lip and palate surgery and do extensive planning in surgical procedures, including secondary corrections of the lip-nose and palate deformities, bone grafting, and surgical-orthodontic treatment.
  43. 43. Pediatrician The pediatricians advise on nutrition and physical condition. Also, they make recommendations for the appropriate timing for surgery. Speech Therapist The speech therapist evaluates speech and language development.
  44. 44. Pedodontist The pedodontists are responsible for the prevention of dental caries. When patients are admitted for lip or palate surgery, the pedodontist educate parents about oral hygiene.
  45. 45. Prosthodontists Prosthodontists are usually concerned with the permanent replacement of missing teeth or severe tissue defects following surgical and orthodontic treatment.
  46. 46. Orthodontist Role of orthodontist extends from infancy to adulthood and during this long period of service, he actively participate by :  Facilitating surgical repair of cleft lip and palate by aligning cleft segments  Removing any interference to normal growth  Preparing cleft sites for grafting
  47. 47.  Analyzing maxillomandibular growth harmony/disharmony  Attempt to modulate growth  Integrating surgical and orthodontic treatment.  Providing good occlusion
  48. 48. Various procedures undertaken from infancy to adulthood (in sequence)       Presurgical orthopedics Lip repair Alveolar molding Primary bone grafting Palatoplasty Expansion during primary dentition
  49. 49.  During mixed dentition Alignment of arches Expansion and protraction of maxilla Secondary bone grafting  During permanent dentition Establishment of occlusion Camouflage of skeletal discrepancy Preparing patient for orthognathic surgery  In adulthood stage Orthognathic surgery Esthetic surgeries
  50. 50. Presurgical orthopedic treatment Presurgical orthopedic treatment is undertaken to prepare an infant with a cleft for surgical repair of the lip. The technique is derived from the work begun by Kerr McNeil, a prosthetist in Glasgow, Scotland (1947).
  51. 51. Impression is taken as soon as possible after birth and an appliance inserted within the first 24 to 48 hours. Appliance may be in form of passive plates which merely obturate the cleft, or active that attempt to move the segments and reduce their displacement.
  52. 52. Passive presurgical appliance
  53. 53.
  54. 54.
  55. 55. Active presurgical appliance McNeil's used active appliances which are made by cutting the model along the line of the cleft and repositioning the segments The plate is then constructed on this modified model, so that when worn, it gradually corrected the position of the segment.
  56. 56.
  57. 57. Over the past 5 decades, there is strong controversy regarding whether presurgical orthopedics therapy should be an integral part of treatment or it’s entirely trauma, physical to infant and psychological to parents.
  58. 58. Proponent strongly recommend presurgical orthopedics based on their following observation : - Presurgical orthopedic treatment facilitates feeding - by narrowing the cleft, it reduces the amount of muscle that must be freed to produce a tension-free repair of lip.
  59. 59. - As far as skeletal growth concerned, Ross (1987) came to conclusion. "Presurgical orthopaedics in the neonatal period has no apparent long-term effect on facial growth."
  60. 60. On the other hand, various studies demonstrated ill effect of presurgical orthopedics : - Prozansky (CPJ 1964) - reported interference with normal growth & development of maxilla. - Friede & Pruzansky (CPJ 1985) evaluated the long term effects of presurgical orthopedics and observed sagital deficiency of the premaxillary segment
  61. 61. - Shaw & Mars(1996) reported better outcome in those centers that didn't practice presurgical orthopedics - Berkowitz(1996) concluded “the present consensus is that these procedures offer less long term benefit than expected”.
  62. 62. Jean Delaire (2000) admits the supplemental role of infant orthopedics to plastic surgical procedures during lip closure without any long term effects on growth.
  63. 63. Most obvious advantage of presurgical orthopedics is seen in complete bilateral cleft lip and palate where protruded premaxilla prevent satisfactory lip closure without previous alignment with the help of orthopedics.
  64. 64. Role of presurgical orthopedics in bilateral cleft patients
  65. 65. The general opinion is that presurgical orthopedics is an useful preliminary measure that should be carried out whenever possible provided that it does not impose too much on the parents and patient.
  66. 66. Lip repair Once the segmented are aligned with presurgical orthopedics if used, lip are ready to be repaired surgically. Timing of lip repair Healthy infant can undergo surgery anytime after birth.
  67. 67. It is preferable to wait at least until the end of the third month when labial musculature has developed significantly to adequately support sutures Moreover, immune system of child also develops significantly
  68. 68. These are the reasons for the universal acceptance of Millard's rule of 10. According to Millard's rule of 10 – infant should be at least 10 weeks old, 10 pounds weight with 10 % Hb
  69. 69. In bilateral complete clefts where premaxilla is lengthened and often considerably advanced, it is preferable to close both sides of the cleft lip simultaneously using two step protocol.
  70. 70. During the fourth month, primary lip adhesion is undertaken (Johanson,1954) This procedure starts aligning premaxillary cleft segments under the influence of physiologic lip force.
  71. 71. Three months later, during the seventh month, the dentoalveolar elements of the premaxilla are adequately aligned which permit closure of remaining cleft of lip
  72. 72. Choice of Lip Repair Tennison and Millard repairs are preferred procedures and both are modification of Z-plasties. These techniques does not discard fullthickness vermilion, so natural lip contour is restored.
  73. 73. Alveolar molding A passive alveolar molding appliance is an attempt to control the segmental relationships of cleft segments by guiding the forces produced by lip repair. (Rosenstein 1969) Lip forces can cause collapse of the alveolar segments if left unsupported.
  74. 74. Typical arch alignment of the maxilla of patient at birth with a complete unilateral cleft. Maxillary arch alignment which usually results after lip closure without early segment guidance.
  75. 75. In unilateral cleft lip and palate, the lesser segment is held passively by the appliance while the greater segment rotates, ultimately abutting with the lesser segment.
  76. 76. Molding passive appliances which maintains relation of arch segments as larger segment responds to molding pressure of surgically closed lip.
  77. 77.
  78. 78. In bilateral cleft lip and palate, both lateral segments are held passively while the forces of lip closure move the premaxillary segment posteriorly to abut and align in a relatively normal arch configuration.
  79. 79. The appliance is placed either before or at the time of lip closure. It is not removed for about a week after the surgical procedure, in order to allow the lip to heal. Thereafter it may be removed daily or as desired for cleansing.
  80. 80. Rosenstein (1969) claimed that there Is no growth attenuation, either antero posteriorly or laterally due to the presence of the appliance Thus, the appliance, when passively placed, has no untoward effect on growth.
  81. 81. Once the butting of the segments has occurred, primary bone grafting if required, is performed. The appliance is kept in place to aid in graft stabilization until the palate is closed, at which time the appliance is discarded.
  82. 82. Primary bone grafting Primary bone grafting is performed along with the primary repair surgeries. (usually before the age of 18 months) (Dado, Cln.Plast.Surgery,Oct 1993)
  83. 83. Although the first reports of primary bone grafting were published in the German literature by Lexer (1908) and Drachter (1914), the procedure was not popularized until the l950s, when Eduard Schimd extensively used this primary grafting technique.
  84. 84.
  85. 85. Goals of primary bone grafting - Preserve & improve the arch form Stabilize a floating premaxilla in B/L CLP Achieve tooth eruption in the area of cleft Achieve functional & esthetic goals by closing the defect
  86. 86. Protocol (Dado Cln. Plast. Surgery, 1993) - Performed after lip repair but before palate closure - Done in conjunction with molding appliance - Graft is placed only after the alveolar segments are molded & grown into a butt joint - Minimal soft tissue dissection of the alveolus & maxilla
  87. 87. Ideal arch alignment prior to primary bone grafting.
  88. 88. There is long lasting controversy regarding cost/benefit ratio of primary bone grafting. Although at one time this procedures was done routinely, but over the years, use of primary grafting is reduced significantly.
  89. 89. Proponents claim the following advantages of primary bone : - Prevention of maxillary collapse (Pickrell, Quinn, and Massengill 1968) - Improved bony support that enhances soft-tissue repair (Freide, Johanson 1974)
  90. 90. - Improved ability to eat and enhanced potential to develop normal dentition. (Nylen, Körlof, Arnander, et al.1974) - Support for the alar base (Abyholm, Bergland, Semb 1980) - Significantly fewer anterior and posterior crossbites (Helms, Speidel,and Denis 1987)
  91. 91. - No facial growth attenuation -long term longitudinal evaluation (Steinhauser1987) - No inhibition of facial growth or maxillary segment collapse (Rosenstein,1991; Dado1993)
  92. 92. Opponents of primary bone grafting claim that : - The graft does not keep pace with vertical development of the alveolar process (Jolleys, Robertson.1972) - Inhibits lateral and anterior growth of the maxilla. (Rehrmann, Koberg, Coch H. 1970) - Restriction of maxillary growth in all three palnes (Hoberg, I970; Friede & Johnso, 1982)
  93. 93. - Controversial, counterproductive with growth restriction in long term (Wits enberg, 1987) - Poor outcomes are associated with primary bone grafting (Shaw & Mars, 1992) - Retrusion of maxilla due to growth inhibition (Shafer, 1995)
  94. 94. Stal (1998) concluded that primary bone grafting has fallen into disrepute because of limited experience & variability of protocol
  95. 95. Jean delaire (2002) recently reviewed primary bone grafting procedures and came to conclusion that the main factor responsible for any ill effect produced by primary bone grafting is surgical trauma (scar) to palatal tissue which subsequently interfere with normal growth.
  96. 96. Therefore, if performed carefully, there may not be any growth interference but the main factor which discourage primary grafting procedure is insufficient amount of bone during eruption of permanent dentition which invariably need another secondary bone graft.
  97. 97. Deficiency of bone at age of 8 years in spite of primary bone grafting done at age of I year.
  98. 98. Hence, if anyways we have to perform secondary bone graft, then why to take any possible risk of growth retardation with primary bone graft. (Jean delaire, 2002)
  99. 99. Palatoplasty Objectives of palatoplasty The major objectives of a cleft palate surgeries are : 1.To produce anatomic closure. 2 To produce normal speech. 3. To minimize maxillary growth inhibition and dentoalveolar deformities.
  100. 100. Timing of palatoplasty Veau (1952) suggested that the best time to close the palate (hard and soft) is at the age of 18 months. Malek (1983) advises closure of the soft palate before the lip to allow development of normal speech pattern (integrity of soft palate is must for normal articulation).
  101. 101. Jean delaire (2000) recommend simultaneous closure of the soft palate and the lip. But closure of the hard palate at this time leads to major problems with growth in this area of great activity.
  102. 102. It is better to delay closure of the hard palate until the age of 18 months, by which time defect become sufficiently narrow and can be closed with only minimal displacement of the palatal maxillary fibromucosa. (less scar tissue)
  103. 103. In the exceptional cases where cleft is too wide, it is better to postpone closure to the end of the third year, by which time all the deciduous teeth have erupted. (erupted deciduous molars acts as guide and stabilizing factors by articulating with mandibular teeth)
  104. 104. In more severe cases in which the maxilla fails to respond to palatoplasty as expected, it is better to postpone palate closure till the age of 5 - 7 years. (when it is possible to maintain the correct dimensions of the palatal arch by a fixed orthodontic appliance).
  105. 105.
  106. 106. Treatment in deciduous dentition Primary objective of orthodontic treatment in the primary dentition is to correct crossbite which may interfere with normal growth. Almost in all cases, cross bite at this stage is posterior cross bite.
  107. 107. Possible causes for this cross bite are : - The most obvious cause is hypoplastic maxillary segment on the cleft side - Palatal scar tissue resulting from traumatic surgery - The canine adjoining the cleft will erupt palatally because of the displacement of its developing tooth bud.
  108. 108. Timing of treatment Awaiting full eruption of the deciduous dentition before initiating orthodontic treatment can be important because the mandibular arch affords an excellent basis for determining where to position the distorted maxillary parts and the dentition.
  109. 109. In most of the cases, occlusal interference in canine region leads to mandibular shift and gives impression of buccal cross bite. Before attempting expansion, this possible cause should always be eliminated.
  110. 110. Contact between the palatally displaced primary canine on the cleft side with the mandibular canine causes a mandibular shift and subsequent crossbite occlusion (A-C). Reduction of the cusps corrected the occlusion.
  111. 111. If cross bite still persist, orthodontic expansion can be undertaken. Because there is no bony union at midpalatal area, very light force by any appliance (quad helix etc) can accomplish the job.
  112. 112. Orthodontic forces move the unfused bony maxillary segments containing the erupted deciduous teeth as well as unerupted permanent teeth. This separation of unfused maxillary segments is absolutely desirable in cleft patients. (Subtenly and Brodie 1954)
  113. 113. One of the reason not to perform primary bone graft is avoidance of any bony union between maxillary segments which will prevent separation/expansion at this stage.
  114. 114.
  115. 115. Retention after expansion Some form of prolonged, adequate retention is imperative because it may not be possible to stabilize the effects of the adverse muscular forces and soft tissue constrictive influences.
  116. 116. Because retention appliances may be lost by young child, a fixed or cemented, welladapted, maxillary lingual arch appliance is recommended.
  117. 117. In case where palatal closure is delayed till the age of 6-7 years, It is recommended that removable, palatal coverage retention be constructed in addition to the fixed arch wire retainer. The coverage can serve the added function of anterior obturator while the fixed retainer maintains the stability of the repositioned bony parts.
  118. 118.
  119. 119. Treatment in mixed dentition Primary goal of orthodontic treatment during mixed dentition is to prepare cleft area for secondary bone graft. But all the alignment tasks and cross bite corrections should be achieved before graft placement.
  120. 120. Invariably, there are rotations and displacements of teeth especially near the cleft site. Subtenly and Ogidan (1983) studied patterns of eruption and malalignment of the permanent incisors and cuspid teeth.
  121. 121. They found that : - incisors bordering the cleft erupted downward and backward into a position more retroclined than normal and almost always with rotations - Maxillary cuspids closely approximating the cleft were found to be positioned more palatally with crowns tipped toward the cleft and distally inclined roots.
  122. 122.
  123. 123. Controlled positioning of the permanent anterior teeth can aid in more adequate development of the alveolar bone surrounding cleft. Correction of malpositioned teeth is best accomplished by using fixed appliance.
  124. 124.
  125. 125.
  126. 126. Cross bite correction About 70% of cleft palate children demonstrate severe malocclusion in form of anterior and posterior cross bite during early mixed dentition stages. (Dahl , Hanusardottir 1979)
  127. 127. There should not be any posterior or anterior cross bite by the time of graft placement. Orthodontic expansion of maxilla should precede bone grafting because once a bony bridge is established in this region, cross bite correction becomes difficult.
  128. 128. Expansion can be achieved by : Slow maxillary expansion quad-helix Nickel Titanium Expander Rapid palatal expansion. Advantage of RPE is that it can be used along with maxillary protraction.
  129. 129.
  130. 130. Nickel Titanium Expander Unlike normal patients, one has to be very careful regarding force level in cleft patients. A tandem-loop, nickel titanium, temperatureactivated palatal expander with the ability to produce light, continuous pressure is very useful tool for arch expansion in cleft patients.
  131. 131. A Degree of compression when prototype appliance was chilled to 20° below transition temperature. B. Effect of shape memory when appliance was warmed to body temperature.
  132. 132. NiTi expander in cleft patient
  133. 133. Rapid Maxillary Expansion in Cleft Lip and Palate Patients Like normal individuals, the pattern of expansion is triangular with a greater opening in the anterior region. But as there is no midpalatal suture, expansion moves unfused segments apart.
  134. 134. Rapid expansion opens circum-maxillary sutures (e.g zygomatico-maxillary, fronto-maxillary etc ) which displaces the maxilla forward and downward, opening the bite and moving Point A anteriorly. Also, loosening of these sutures help in protraction of maxilla with reverse headgear/face mask
  135. 135. Activation schedule in cleft patients The appliance is first activated with four quarter-turns 24 hours after placement. For the next four days, the screw is activated two quarterturns in the morning and two quarter-turns in the evening. At this point, the orthopedic force should be sufficient, and activation can be reduced to a more comfortable one quarter-turn in the morning and one in the evening.
  136. 136. The average activation period is from one to two weeks, depending on the degree of maxillary constriction and the resistance of the patient's maxillofacial structures. A 2-3mm overcorrection at the molars is recommended to counteract any relapse.
  137. 137. A. Upper arch before expansion. B. Haastype expander in place.
  138. 138. After full expansion
  139. 139. Once the desired expansion is obtained, the screw is immobilized by acrylic. The appliance is kept in place for three months of retention, which further reduces the possibility of relapse.
  140. 140. Maxillary Protraction to correct anterior cross bite After the first reported successful protraction of maxilla in children with cleft lip and cleft palate using Delaire's face masks (Delaire, Verdon, Kénési 1973), a number of reports have been published in the literature.
  141. 141. Face mask can be used with rapid maxillary expansion appliance where two hooks, each on one side in premolar-canine region are soldered to framework of expansion appliance. When using with fixed orthodontic appliance, two hooks are soldered and extended from the first permanent molars to the region of the first deciduous molars or premolars.
  142. 142. Extraoral elastics applying 450 to 500 gm of force per side is applied from the hooks to the extraoral component, the reverse headgear, at an angle of 10° downward to the occlusal plane. The elastic traction are worn 12 to 14 hours daily.
  143. 143. The patient wearing an orthopedic face mask appliance.
  144. 144. Pre treatment Post treatment
  145. 145. Maxillary and mandibular skeletal and dental changes contributing to overjet correction in unilateral complete cleft lip and cleft palate patient treated with reverse headgear.
  146. 146. Once the most optimal alignment and cross bite correction (anterior and posterior) has been achieved, patient is ready for secondary bone grafting. Secondary bone grafting is an important mean to stabilize the maxillary segments after expansion and/or protraction (Rune, 1980)
  147. 147. Secondary bone graft Goals of secondary bone grafting : - Closure of vestibular and palatal oral nasal fistulae . - Providing sufficient quantity and appropriate quality of bone to allow eruption of the permanent lateral incisor and canine teeth
  148. 148. - Provision of support for the lateral ala of the nose. - Provision of suitable bony architecture of the premaxilla - Provision of adequate bone stock for ultimate placement of osseointegrated implant
  149. 149. Timing of secondary grafting - Success of secondary alveolar bone grafts is time dependent. - Single most important factor deciding the timing for grafting is developmental status of dentition In cleft area.
  150. 150. Tooth must erupt through the graft material because the erupting tooth will stimulates growth of graft bone, thereby will maintain vitality of graft material. When bone graft is performed before eruption of the permanent canine tooth (910 years), the result is almost always successful.
  151. 151. The graft material of choice is autogenous cancellous marrow of the ilium (iliac crest bone graft), which is packed into the alveolar cleft defect.
  152. 152.
  153. 153. Case example
  154. 154.
  155. 155.
  156. 156. Criteria of success of bone graft : (1) long-term preservation of alveolar bone stock (2) eruption and periodontal health of the permanent central incisor, lateral incisor, and canine teeth, (3) equality of clinical crown length of the maxillary permanent central incisor teeth
  157. 157. (4) adequate width of attached gingiva in the region of the cleft (5) absence of exposed cementum on teeth adjacent to the cleft, and (6) successful placement of osseointegrated implant.
  158. 158. Various levels of interdental bone present after secondary bone grafting
  159. 159. If secondary graft fail……. In spite of great advance in surgical technique, still there may be failure of secondary graft. The most important and common cause for this failure is infection at graft site. Infection leads to necrosis of graft material which eventually get resorbed by macrophages (host’s immune defense)
  160. 160. In general, more the number of times graft is repeated, failure rate increases proportionally. The teeth next to the cleft are partially erupted and are often poorly aligned in the alveolus, which limits the possibility to place a bone graft successfully and adequately create a watertight buccal, palatine, and nasal surfaces closure.
  161. 161. The saliva and bacteria can contaminate the graft through the periodontal ligament or through the wound, which produces partial or total graft failure.
  162. 162. Cesar A. Guerrero (2002) explored the possibility of distraction osteogenesis in cleft patients to treat cases where secondary graft failed. He named this procedure as Intra oral bone transport in clefting
  163. 163. Intra oral bone transport in clefting The possibility of using distraction osteogenesis to treat alveolar clefts after the age of 13 years seems attractive to avoid all the complications related to bone grafts, especially in failure cases.
  164. 164. Procedure Patients should undergo orthodontic treatment and once teeth are aligned and leveled in segments with heavy rectangular arch wires, patient is ready for distraction osteogenesis.
  165. 165.
  166. 166.
  167. 167. Latency period of 7 days followed by 0.5 mm distraction twice a day.
  168. 168.
  169. 169.
  170. 170. The advantages of this technique over the traditional alveolar reconstruction are : - no need for bone grafts, which involve a donor site - minimal surgical time - natural reconstruction.
  171. 171. - bone height and width that are similar to the neighboring alveolus with excellent possibilities for dental implants. Implant placement ideally should happen 6 to 8 months after the initial surgery. - Finally, failure rate is minimal.
  172. 172. The disadvantage is long treatment duration which requires patient cooperation and close follow-up.
  173. 173. After grafting, a good removable retainer is placed along with artificial teeth to replace any missing tooth. Typically it takes 2-3 years for canine to fully erupt through the graft. Once canine erupt, treatment in permanent dentition starts.
  174. 174.
  175. 175. Treatment in permanent dentition For the patient who has been under the supervision of a cleft palate team and received the coordinated care of an orthodontist and a surgeon, orthodontic treatment at the time of the permanent dentition is forecasted.
  176. 176. At the time of permanent dentition : - A bone graft, if indicated, would have been placed. - The lateral incisor and canine on the cleft side would have erupted through the bone graft in the line of the cleft. - potential maxillomandibular disproportions would have been identified.
  177. 177. Objectives of treatment in permanent dentition are : To provide good occlusion To monitor and if feasible, correction of any skeletal base discrepancy To provide good long term retention  Preparing patient for surgery, if needed
  178. 178. Occlusion considerations Once all the teeth are erupted, precise space planning can be done. Minor space discrepancies can be resolved without extraction by carefully advancing the incisors which will improve patient’s profile also.
  179. 179. First advancing the incisors root tips labially followed by crown movement frequently make it possible to achieve sufficient arch length. Incisor labial root torque and incisor advancement can promote observable development of bone in the anterior maxillary region. (Delaire 1971, Verdon and salognoc 1977)
  180. 180. But most of the times, space discrepancy will be severe enough to warrant extraction of teeth, maxillary or mandibular, to achieve an acceptable occlusion
  181. 181. Extractions, although undesirable in the upper arch, may be necessary because the bony segments may not be adequate to accommodate all of the maxillary teeth. However, if feasible, extractions should be avoided in the maxillary arch because it can further increase the undesirable retruded relationship of the maxillary complex.
  182. 182. Consideration of skeletal base discrepancy When maxillary retrusion is mildly evident, it may be advisable to extract the mandibular bicuspids to do dentoalveolar camouflage (normal overbite, overjet and desirable lip contour relationships).
  183. 183. But in most of the cases, this dentoalveolar camouflage may not be sufficient to mask the underlying skeletal base discrepancy (class III skeletal base relationship)
  184. 184. Even though maxillary protraction was undertaken during mixed dentition stage, still during the later stages of growth, retrusion of the midface (particularly in the area of the upper lip) may become obvious.
  185. 185. Possible reasons for this progressive maxillary retrusion are - Inadequate expression of skeletal growth - Secondary bone grafting may inhibit expression of any residual growth of maxilla during pubertal spurt. - The lower portion of the face may continue to grow
  186. 186. In these instances, it becomes important to again undertake maxillary protraction to improve the facial profile and facial appearance. (Simonsen 1981, Galletto 1988)
  187. 187. However, Subtenly (1980) claimed that during later stage of growth, face mask do little enhancement of skeletal maxillary development and changes are seemed to be restricted to maxillary dental arch advancement.
  188. 188. Therefore in most of the cases, correction of maxillary skeletal retrusion by orthopedic means may be beyond the realm of possibility, and the adjunctive help of orthognathic surgery is required.
  189. 189. At the completion of treatment in permanent dentition, long term retention is required because : - there is a long time interval (3-5 years) between completion of orthodontic treatment and orthognathic surgery.
  190. 190. - Even if no orthognathic surgery is required, fixed bridge as a retainer can not be used before completion of late vertical alveolar growth. (approx. age of 18 years)
  191. 191. - A partial denture serve effectively as a long term retainer. It helps to : stabilize the orthodontic correction, replace missing teeth, add sublabial bulk under the upper lip, it can also obturate sublabial and palatal fistulas if they remain due to graft failure.
  192. 192. Treatment in adult patients When the proper maxillomandibular relationship is not obtained in cleft patients with conventional orthodontic/orthopedic methods, orthognathic surgery is indicated.
  193. 193. It has been estimated that 25% to 60% of all patients born with complete unilateral cleft lip and palate require maxillary advancement to correct the maxillary hypoplasia and improve aesthetic facial proportions (Ross,1987)
  194. 194. In some cleft patients who seem to have been treated successfully by conventional orthodontia during adolescence, Ross (1987) observed that there is relapse of anterior and lateral crossbites. This is not caused by the excessive growth of the mandible itself, however, but the less sagittal or vertical growth of the maxillary bone.
  195. 195. Rosa Carolina (2002) recommended that in these cases, the orthodontist should not prolong orthodontic treatment but recommend surgical advancement of the maxilla at the Le Fort I level as the final stage of treatment. Sometimes mandibular setback is also required in patients who have a real mandibular prognathism.
  196. 196. The timing of orthognathic surgery must be planned carefully by the surgeon and orthodontist. Controversies exist about the timing of the osteotomies in adolescent patients.
  197. 197. Freihofer (1977) claimed that the only osteotomies that can be performed in adolescents without great likelihood of relapse are anterior maxillary segmental retropositioning and mandibular advancement. Both of these procedures are almost never done in cleft patients. Hence all orthognathic surgeries are done in adulthood.
  198. 198. The surgery is usually performed at approximately 14 - 16 years of age for females and 17 - 20 years for males when active facial growth is decreasing to minimum.
  199. 199. In the past, it was common for the mandible to be set back to produce a normal occlusion with the retropositioned maxilla (this was mainly because of fear of devitalizing maxilla from the surgery), but this produced a flat, unaesthetic facial appearance.
  200. 200. Currently, the standard treatment is a Le Fort I maxillary advancement. If the patient has a small chin or if an extensive setback of the mandible is required, an advancement genioplasty can be performed during the same time . If the chin is excessively long, it can be reduced in vertical height at the same time (Munro, Salyer, 1990)
  201. 201. Lefort I
  202. 202. Lefort I
  203. 203. Lefort I and mandibular setback (discrepancy more than 10 mm)
  204. 204. Case report
  205. 205.
  206. 206.
  207. 207.
  208. 208.
  209. 209. Distraction osteogenesis as an alternative to maxillary advancement surgery Distraction osteogenesis is also an effective procedure to achieve maxillary advancement. Figueroa and Polley (1999, AJODO) treated 14 patients and concluded that maxillary distraction technique is a highly effective treatment modality to manage cleft related maxillary hypoplasia.
  210. 210. Maxillary distraction osteogenesis in cleft patients with severe maxillary deficiency is achieved using Rigid External Distraction (RED) device
  211. 211. A complete Le Fort I osteotomy is performed Latency period is of 5 – 7 days Distraction is performed by turning the activating screw at a rate of 1 mm per day (2 turns). Once the appropriate amount of distraction was achieved, the RED system was left in place for 2 to 3 weeks to permit bone consolidation.
  212. 212. Esthetic surgeries (like Rhinoplasty, cheileoplasty etc.) can be undertaken once the final picture of facial features is visible after correcting skeletal bases.
  213. 213. After surgical phase of treatment, general dental care can be planned in consultation with other specialist (Prosthodontist, Endodontist, Periodontist etc) - All decayed teeth are restored - In case of poor periodontal health of teeth (especially near the cleft site), gingival grafts are placed - Finally, removable or preferably fixed bridges are placed to replace missing teeth
  214. 214. Various protocols Paris, France: Based on the school of Pierre Petit Protocol: - passive presurgical orthopedics - Soft palate closure at 3 months - unilateral cleft lip repair done at 6 months - for bilateral cleft lip, two sides being repaired separately at 2 months interval (6 month, 8 month) - hard palate is also closed at age of 6-8 months
  215. 215. - No Orthodontic treatment until mixed dentition - Expansion and alignment in anticipation of SABG at 10 years of age - Osteotomy followed by rigid fixation to correct skeletal base discrepancy. - Lip and nose correction
  216. 216. In UK Protocol - Still use active dentofacial orthopedics to a large extent - Lip surgery done mostly at 3 moths of age. - Palatal surgery at 9 to 12 months
  217. 217. - Expansion during mixed dentition to relieve functional interference - Expansion, alignment and reverse head gear for maxillary protraction at age of 8 9 years - SABG at of age 9-10 years.
  218. 218. - Complete fixed orthodontic appliances in the permanent dentition. - Surgical correction of skeletal discrepancy in adulthood
  219. 219. Taiwan: Based on the principles of the Zurich Cleft palate center - Passive presurgical orthopedics - Lip repair done at 3 months of age - If cleft is large, then a lip adhesion done at 3 months followed by definite closure at 6 months
  220. 220. - Soft plate repair done at 18 to 24 months and hard plate closure at around 5 to 7 years - Orthodontic treatment in the deciduous dentition is not done except in cases with functional shift of the mandible especially anterior shift
  221. 221. - Alignment and cross bite correction during mixed dentition - SABG preferred before canines erupted (9-10 years) - Extra oral orthopedics used in cases of maxillary retrusion, both during mixed dentition and early adolescence period - Surgical correction in adulthood
  222. 222. Oslo, Norway Established in 1968 by Loennecken, Harvold and Bohn. Protocol : - No presurgical orthopedics - Closure of cleft lip at 3 months age - Closure of cleft palate in 18 to 24 months
  223. 223. - Secondary operation (e.g lip lengthening) if indicated, are performed at age of 5 years. - No treatment in deciduous dentition - Mixed dentition preparation to receive a bone graft - SABG at 9 to 11 years.
  224. 224. - Permanent dentition treatment started 2 -3 years after graft - Surgical correction of skeletal base discrepancy in adulthood
  225. 225. Osaka; Japan Treatment in 4 phases: Phase I: presurgical management using presurgical orthopedics Phase II: surgical management of lip at 4 - 5 months of age and palate at 14 to 24 months of age.
  226. 226. Phase III: Mixed dentition phase with emphasis on SABG Phase IV: Management of orthodontic, prosthodontic and surgical-orthodontic treatment
  227. 227. Prague, Czechoslovakia - Rarely indicate presurgical orthodontics - Lip repair carried out in 5 to 7 months of age - Cleft palate repair at 4 years of age - Primary alveolar bone grafting done in selected cases
  228. 228. - Primary dentition – maxillary expansion to correct functional mandibular shift - Majority of orthodontic treatment done in mixed dentition to prepare cleft site for secondary alveolar bone graft
  229. 229. - Maxillary protraction to correct anterior cross bite. It maintains configuration of facial profile and prevent anterior displacement of mandible. Acc. to their survey, early orthopedic therapy reduces the need for orthognathic surgery by almost 50%.
  230. 230. - Permanent dentition Final refinement of occlusion and if required, second phase of maxillary protraction - If required, surgical correction of skeletal base discrepancy in adulthood
  231. 231. Conclusion There is no perfect method of treating a cleft patients, patient and his individual treatment needs must be taken into account. Decision should be made along with other team members who all are responsible for the well being of the patient form infancy to adulthood.
  232. 232. Leader in continuing dental education