Tackling an iatrogenic problem

Tackling an
iatrogenic
problem!!
www.indiandentalacademy.com

Introduction
• All modern mechanics have a double scale of ladder
ascendant & descendant , ascending from experiment to the
invention of causes & descending from causes to the
invention of new experiments
• Anchorage plays a very vital role in orthodontics. Loss of
anchorage can take place during
• Aligning, leveling and retraction stages.
www.indiandentalacademy.
com

Reasons for anchor loss
during aligning
•Lower molars normally drift mesially to
occupy the lee-way space after shedding of
lower primary second molars which can be
restricted by timely placement of lingual
arch.
•Anchorage requirement in upper arch is
greater compared to lower arch
•Improper positioning of brackets. Under estimating
anchorage requireme
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Reasons for anchor loss
during retraction
iatrogenic
factors
incorrect
alpha &
beta
bends
excessive forces
used during
retraction.
posterior segments
are not consolidated
during retraction.
Improper
positioning
of loop
Improper bracket
positioning
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HOW TO
PREVENT
ANCHOR
LOSS ?
When in doubt use
a wire applying
lighter forces
Bracket
tip
Anchorage
reinforceme
nt
Use light
Continuous
force
During
aligning….
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How to control anchorage
during leveling ?
•Using light continuous forces
•Maintain the direction of force
•Rein force anchorage
•Proper bracket positioning.
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Anchorage control during
retraction
retractionretraction
individualindividual
enmasseenmasse
Walking of
canine
Walking of
canine
Rein force
anchorage
Rein force
anchorage
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Anchorage
reinforcement
EO
high
cervi
cal
straight
com
bi
IO
TPA
Nance button
Class –II elastics
Lingual arch www.indiandentalacademy.
com

how to correct
anchor loss ?
Anchor loss
occurs by mesial
tipping of molars
Hence distalize
molars
Extra oral
Intra oral
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Extra oral
High pull
Cervical pull
Combi pull
distalizing effect
on molars and
premolars
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Intra oral
Inter maxillary
Intra maxillary
Absolute
anchorage
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IO non compliance
appliances
Intermaxillary
Elastics
Modular appliance
Intra maxillary
Modified nance arch with NiTi coils
distalising bow Absolute
anchorage
Palatal
implantswww.indiandentalacademy.
com

APPLIANCE
DESIGN:
• Modular appliance is made up of 0.016
x0.0 22 rectangular SS / TMA wire
• Modular appliance consists of an omega
loop touching the mesial aspect of buccal
tube and there is an upward curve in the
mesial part of the canine bracket, which
ends in a hook on the upper or gingival
part.
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•The gingival part of the hook is
helicoidally recurred with the end inward
to avoid erosion of the vestibular mucosa.
•Tip back bend of 45 degrees is given
distal to omega loop .
•The wire should be cinched distal to the
molar buccal tube
•The buccal segment should be contoured
to prevent tissue impingement.
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APPLIANCE DESIGN
omega
loop
hook to
engage
elastics
tip back bend of
45 degrees www.indiandentalacademy.
com

•Class II elastics ( preferably blue
or green ) applying 100 – 150 gm
force are used from the hook mesial
to canine and to the lower molar
hook.
•The modular sectional arch blocks
the segment between the canine and
the upper first molar in one unit ,
which it moves in distal direction.
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BIOMECHANICS
•Based on cantilever mechanism
Mechanics
of spring
elastics
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•These mechanics can
effectively tip back an upper
molar and rotate the molar
mesial out.
•Distal end of omega loop acts
as a stop and applies the
tipping force on upper molar.www.indiandentalacademy.
com

•A light class II elastic is
placed from lower arch
•Class –II elastic is effective ,
not only because of its distal
force but because a very large
moment is produced tipping
the molar distally.
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• Class – II elastics can flare the lower
arch, increase the vertical and steepen
the occlusal plane.
• Hence elastics are used for a short period
of time.
• Because the molars tip back rapidly, only
a short period of class – II elastic wear
is required leading to negligible side
effects
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Case -
I
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Pre -
treatment
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Pre-treatment
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Upper
5’s
lower
4’s
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Pre -
surgical
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Post surgical
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Post -
surgical
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Case -
3
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Case - 3
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Post treatment
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Modular
appliance
Fabricationquite simple
Less time
consuming
Won’t interfere with
other treatment
mechanics
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advantages
fixed into the
auxiliary tube
•Distalisation is brought
about in short duration
of time……..
versatile
Unilateral or bilateral
Class II
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Conclusion
If anchor loss is noticed
early and timely
intervention of modular
appliance is made, it saves
a lot of drudgery.
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TREATMENTTREATMENT
PROTOCOL FORPROTOCOL FOR
CLEFT LIP &CLEFT LIP &
PALATE.PALATE.

OVER VIEW
•neonatal management
•obturator feeding plate
•Neonatal Maxillary orthopedics.
•Lip surgery
•Palatal surgery
•Velopharyngeal incompetence $ its
management
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•Speech management
•Grafts
•Maxillary orthopedics
•Maxillary expansion appliances
•Protraction appliances
•Distraction osteogenesis
•Orthognathic surgery.
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Neonatal
management:www.indiandentalacademy.com

Neonatal management:
• Feeding problems – as air tight
contact cannot be made.
• Food tends to return down the nose
& attacks of coughing & cyanosis
may occur.
• Lot of air is sucked in the gap &
results in aerophagia which results
in frequent burping.
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• Feeding problem is more severe in cleft
palate with or with out a cleft lip.cl pts
develop a – ve pressure when sucking
& tire easily, resulting in unfinished
feedings.
• A feeding device that delivers formula
into mouth is necessary to conserve
infants energy.
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Methods of feeding:
• Bottle feeding
• Cup & spoon feeding
• Feeding with a paladai
• Tube feeding
• Posture:Infant must be held at 30 – 45
degrees or in upright position in order to
aid in swallowing and prevent aspiration.
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Feeding
obturator

Feeding obturator
• Appliance of choice in pre surgical
orthopedic treatment –acrylic
denture without teeth
• Oral surface of the appliance is
made of hard acrylic which carries
the expansion screw.
• Palatal surface consists of soft
acrylic that reaches high into the
nasal cavity but not so high as to
obstruct the nasal air way.www.indiandentalacademy.
com

Uses :
• Serves as a feeding aid by preventing
aspiration of liquids.
• It realigns cleft max segments into a
harmonious alveolar arch.
• It helps to prevent the upper respiratory tract
infections that tend to occur with greater than
normal frequency in cleft children
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• It forces the tongue to occupy a normal
position rather than to lie between the
cleft max segments.
• It provides psychological support for
parents.
• While taking impressions in newborn ,
alginate is not used .
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• Thermoplastic material with min
distortion should be used.
• Philips cameo compound or paribur are
used.
• Appliance is discontinued after palatal
closure which is done at around 2 – 2
&1/2 years
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Obturators
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Preoperative
orthopaedic treatment
• In 1954 Mc Neil advocated the
placement of a prosthesis immediately
after birth to help align max segments in
patients, with complete cleft of lip,
alveolus and palate.
• This approach is known as “infant max
orthopaedics”
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• Goal- to move abnormally positioned
maxillary arches and the pre maxilla into
a normal relationship prior to surgery .
intra oral
• Appliances
extra oral
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Intra oral devices
• Active
• Passive - palatal obturators mold for
self retention.
• - disadvantages –need
adjustment or replacement in a
rapidly growing child.
• Self/ pin retained-exert active
molding force upon the max
segment.
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Neo natal maxillary
orthopedics:
• Kernahan rosenstein procedure
• Huddart procedure
• Zurich concept
• Netherlands approach
• Millard – Latham procedure
• Brophy compression technique
• Rubberdam strap technique
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Kernahan – rosenstein
procedure:
• passive orthopedic appliance to
cover the lateral palatal
segments to permit the
premaxilla to be molded back by
an elastic extra oral facial strap.
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• If the palatal segments overlap,
Rosenstein uses a small jack screw to
create a gradual expansion of the
contracted arch, prior to uniting the lip.
• The appliance is worn for 6-8 weeks &
may be used untill just before closure of
the cleft palate at approximately 18
months of age .
• They claim arches are stabilized with in
4 – 5 months.
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Huddart procedure
• It is a simple plastic plate that is
inserted 24-48 hrs after birth.
• It obturates the cleft space but not
extend into the nasal cavity.
• It protects the under side of the nasal
septum during feeding.
• It consists of 2 adjustable wire wings
that extend laterally from the corner
of the mouth to prevent baby from
swallowing the appliance.www.indiandentalacademy.
com

Zurich concept
• Aim – to maximize palatal growth.
• Passive plates used in conjunction
with delayed surgical procedures
were introduced in zurich ,
switzerland in 1960.zurich appliance
is a combination of both soft & hard
acrylic.
• It is worn continuously for 16 – 18
months & is replaced every 6
months.www.indiandentalacademy.
com

Zurich protocol
• Passive plates worn for 16 – 18
months
• Plate changed every 6 months
• Reduction of gingival side of the
plate every 3-8 weeks.
• Lip closure - 6months of age
• Soft palate – 18 months
• Hard palate – 4-5 years.
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Netherlands approach
• In 3 centers in Nether lands – nijmejen ,
Amsterdam & Rotterdam.
• Uclp – a plate consisting of compound
of soft & hard acrylic is carefully
designed & fabricated to obturate the
whole cleft laterally from right buccal
vestibulum to the left ( soft palate &
alveolar ridge included) & placed insitu
with in a few days.
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• The plate keeps the tongue out of the
cleft.
• The support offered by the artificial
alveolar ridge is thought to be important
for speech development.
• The plate is worn 24hrs a day & held by
suction & adhesion only.
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• A new plate is made the week before the lip
closure which is done at approximately 5 – 6
months of age , to ensure that a well fitting
plate can be placed immediately after lip
surgery
• After lip closure , the new plate is inserted the
same day to prevent positional changes of
the maxillary segments , which are
undesirable side effects of the operation.
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• Then a 2 stage palate closure is
performed i.e the soft palate is closed at
about 12 – 18 months & hard palate
closure is done at 6 – 9 years of age
together with bone grafting of the
alveolar cleft.
• The plate is worn until soft palate
closure is performed ( about 12 – 18
months of age)
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• In bilateral cleft lip & palate the same
procedure is performed , but extra oral
strapping is used . A one stage lip
closure is performed at about 6 – 9
months of age.
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Nether lands protocol
• Presurgical orthopedic treatment
appliance(PSOT) – birth to 11/2
years.
• Lip closure – 5-6months
• 2 stage palatal closure – soft palate-
12-18months,hard palate-6-9 years
of age.
• Bone grafting of alveolar cleft.
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Millard – latham
procedure:
• He bases his treatment concept on the
facial growth thesis put forth by James
scott.
• Orthopedic forces are applied in the
new born period using a pinned
maxillary appliance to bring the
dispersed alveolar segments into close
approximation , followed by
alveoloperioplasty to close the cleft.
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• The split appliance is secured to the palatal
segments with pins in the horizontal processes
of the maxilla.
• ML combined surgical – orthodontic procedure
for blcp is used soon after birth to retro
position the protruding pre maxilla while
expanding or holding the lateral maxillary
segments to make room for pre maxilla.
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• A 0.7mm ss pin is inserted through a drilled
hole in the posterior stem of thepremaxillary
bone.
• An orthodontic plastic chain is placed on
either side of the premaxillary pin.
• It then passes posteriorly to pulley wheels &
anteriorly to buttons on the expansion
appliances , creating a force of 3 ounces or 90
gm on either side .
• Alignment of the 3 palatal segments can be
accomplished in 8 – 14 days.
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• The palatal cleft space is closed
between 8 – 24 months of age using a
modified Von Langenbeck procedure.
• Berkowitz ‘s follow up serial periapical
films of the alveoloperiosteoplasty show
that the anticipated bone migration
across the cleft at the alveolar ridge
does not always occur.
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Brophy compression
technique
• Bct of the 1920s used intraosseous
silver wiring with metal plates.
• Brophys guiding principle was to
place deficient tissue into n
relationship at birth so that they
would develop normally.
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• All cleft spaces were closed as soon as
palatal segments were aligned, usually
with in 6months of age.
• Due to the destruction of maxillary
growth centers by excessive traction
forces, along with extensive
mucoperiostial undermining,the resulting
scarred palate led to severe midfacial
and palatal deformities, poor occlusion
and often in intelligible speech.
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Rubber dam strap
technique:
• Complete uni & bilateral clefts
are treated by using of rubber
dam strapping.
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Lip surgery

Lip surgery
• Goal: goal of all repairs is a normal
looking lip & a N looking nose which
will not be distorted by the growth or
aging.
• Criteria for satisfactory repair:
• Accurate skin, muscle & mucous
membrane union.
• Symmetrical nostril floors
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• Symmetrical vermilion border
• Slight eversion of the lip
• Min scars
• Preservation of cupids bow & vermilion
cutaneous ridge.
• Production of symmetrical nostrils as
well as symmetrical nasal floors.
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Timing :
• Rule of “over ten” – 10 weeks, 10 pounds, 10
gm of Hb.
• Preferably 3 – 6 months.
• Various surgical techniques:
• Randall – graham lip adhesion- when cleft is
wide & repair is considered difficult.2
rectangular flaps are elevated &
interdigitated.if necessary to avoid tension, the
lateral lip segment & adjacent cheek can be
mobilized through a labial sulcus incision
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Randall – graham lip adhesion
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• Rose Thompson lip st line repair- for
min degrees of cleft lip.
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• Tennisons lower 1/3 triangular flap repair.
• Modification of Tennisons lower 1/3rd
triangular
flap
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Millard I rotation
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Millard II rotation
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Repair of bilateral cleft
lips:
• Straight line operation (veau III)
• Upper 1/3rd
triangular flap
operation.
• Lower 1/3rd
triangular flap
operation.
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Straight line operation
Millard 2 stage repair.
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Palate repair

Palate repair
• Aim – speech, chewing & aesthetics.
• Timing : previously the surgeons involved in
cleft palate treatment usually performed
surgical procedures whose sole purpose was
to close the hole as early as possible without
considering the ultimate effect on surgery on
palatal, facial or speech development.
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• The present concept is to lengthen the
palate by detaching the soft palate from
hard palate & the cleft in the hard palate
is closed before speech generally
began at 2 years of age.
• The cleft palate closure is done after
the deciduous or permanent teeth have
erupted.
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Surgical approaches to
close cleft palate.
• Early complete palate repair ( 3 – 9
months).
• Delayed complete palate repair (12 –
24 months).
• Late complete palate repair(2 – 5
years).
• Early lip & soft palate repair(2 – 9
months) & delayed hard palate
repair.
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According to Millard:
• Flaps from other parts of the
body
• Treating the edges of the cleft
so that they could be sutured
together by pulling the
mucoperiosteum over the cleft.
• Staged surgical treatment.
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Von langenbeck
procedure
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Veau Wardill Killner
operation:
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Velopharyngeal
incompetence
• Anatomy
• Function
• Diagnosis
• Velopharyngeal closure
• Surgical repair.
• Prosthetic repair.
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Speech management:
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• Birth to 6 months
• 6 – 18 months
• 18 months – 3 years
• 3 – 5 years
• 5 – 10 years
• 10 – 15 years
• 15 – 20 years.
Speech management:
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Grafts
•Primary
•Secondary
•Tertiary
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Primary bone grafts:
• Originated in Europe in mid 1950’s
• Grafts - iliac crest or autogenous rib
• graft – bony bridge into which new
bone & teeth would migrate.
• Bone graft utilizes the thrust of the
growing nasal septum.
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• Cross bite due to maxillary collapse would
decrease if a bone graft bridged the cleft.
• By 70’s they realized that it has a negative
effect on the growth of maxilla & midface.no
positive effects.
• Peat suggested that it might have a place as a
secondary procedure after the age of 6 years.
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Secondary alveolar bone grafts:
• Grafts done after palatal cleft closure.
• Adv- no need of prosthesis
• Better periodontal & bone support
• Prevents nasal irritation
• Prevents escape of air through oronasal
fistula
• Stabilization of palatal segments
• Improvement of appearance
• Allow tooth movement across & adjoining the
cleft.
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• Timing – 7- 9 years of age.After aligning
central incisors and one quarter to one
half of the canine root is formed.
• Sources – auto grafts are superior to
allogenic grafts
• Auto- rib,ilium,tibia,mandible,cranium.
• Allo – hydroxyapetite,tricalcium
phosphate.
• Only instance where non porous
hydroxyapatite is used is -
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Tertiary grafts
• After maxillary protraction is
done grafting is done distal to
the maxilla to prevent relapse.
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Orthodontic
treatment

Orthodontic treatment
• Orthodontic treatment of cleft lip &
palate may be required at any or all
of four separate stages.
• In infancy before lip surgery
• Late primary or early mixed dentition
• Late mixed or early permanent
• Orthognathic surgery.
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Appliance
• Preadjusted edge wise appliance is
not suitable for cleft patients instead
edge wise appliance is preferable
because PAE torques the roots into
cleft area.
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Infant orthopedics
• Pioneered by Burstone in Liver
pool in late 1950’s.
• Timing – 3 – 6weeks of age.
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Late primary or early
mixed dentition
• Orthodontic problems – effects of
surgical repair.
• Anterior & lateral cross bites.
• Timing – when permanent incisors
erupt.
• Necessary alignment of incisors or
expansion of the posterior segments
should be done before secondarywww.indiandentalacademy.
com

Early permanent
• Space closure after sec.bone
grafting.
• If orthodontic tooth movement is not
possible for space closure ,position
teth as abutments and place fixed
prosthodontics.(preferable than
removable)
• Completed at age 14.www.indiandentalacademy.
com

Maxillary orthopaedicsMaxillary orthopaedics
Maxillary expansion appliancesMaxillary expansion appliances
Protraction appliancesProtraction appliances
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Maxillary expansion
appliances:
• Telescopic maxillary expander
• Fan shaped maxillary expander
• Spring jet for slow palatal expansion
• Butter fly expander
• Bonded RPE
• Banded RPE
• Rapid maxillary expansion
• Hyrax
• Niti palatal expander
• Quad helix expansion appliance
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Telescopic maxillary
expander
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HYRAX
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NICKEL TITANIUM PALATAL
EXPANDER
Developed by Wendell V. Arndt in 1993
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Mechanism of action of NiTi expander
• Shape memory effect
• Transition temperature effects
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Butter fly expander
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Fan shaped maxillary
expander
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Spring jet for slow
palatal expansion
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Protractio
n
appliances

Protraction appliances
• Protraction face mask- mid facial
orthopedic forces apply – increase
growth at the circum maxillary sutures.
• Berkowitz used modified protraction
face mask .
• Protraction forces – 350 – 450 gms for
12 hrs per day from a hook located
mesial to maxillary cuspids.
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• Pulling downwards from molars
should be avoided.
• If the treatment is started in mixed
dentition period, treatment time may
extend to years in such cases
treatment should be done in
intermittent periods.
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Distraction
osteogenesis

Distraction osteogenesis
• 1954 – Ilizarov to align fractured
segments of long bones.
• 1973 – Snyder did mandibular
lengthening
• 1992 – Mc Carthy etal – elongation of
mandible by bicortical osteotomy
followed by rigid external fixator.
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Maxillary Distraction
Procedure
Maxillary Distraction procedures
deliver traction forces through the
dentition to the maxillary bone. To
apply traction through the dentition a
rigid intraoral splint is required.
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The Intraoral Splint:
Orthodontic bands with 0.050inch
headgear tubes are fitted either on
first permanent molars or second
primary molars(below 6yrs). The
splint is made with 0.045/0.050 SS
rigid wire.
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Transpalatal bars can also be used to
enhance rigidity.
The splint is fitted and two markings are
made on the labial wire medial to both
commisures.
Two straight pieces of 0.050 SS wire are
soldered perpendicular to the labial wire.
The long ends of these wires are bent
under,over and anterior to the lips in a circle
to eliminate sharp ends as well as have a
rigid eyelet to apply traction.
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The traction eyelet is at the level of the
nasal floor and its purpose is, to
control the direction of traction
forces relative to the approximate
center of resistance of the maxilla
and also to avoid irritation to the lip.
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The splint is cemented and during surgery
circumdental wires are used to increase rigidity
and stabilty. The splint can also be made with a
orthodontic headgear facebow. In cases where
the arch is to be surgically created the splint is
cemented after the osteotomy .
The Osteotomy:
A complete Le Fort 1 osteotomy including
pterygomaxillary and septal dysjunction is
performed. Metallic markers are placed above
and below the osteotomy, and in the anterior
aspect of the maxilla for follow-up.
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In young children a modified high Le
Fort 1 osteotomy with minimum
downfracturing is performed to avoid
disturbing developing tooth buds and
prevent an anterior open bite or
elongation of the lower face.
Advancements at the Le Fort 11, 111,
monobloc and fronto-orbital levels are a
few recent modifications.
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The RED Device :
After completion of the osteotomy, the
halo portion of the RED device is
adjusted and rigidly fixed around the
head with scalp screws. A vertical bar
was connected to the halo and a
horizontal bar with the distraction
screws. The traction hook and traction
screws were connected with a 25guage
surgical wire.
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Distraction was done at the rate of 1mm(2
turns) per day. The RED was left in
place 2 to 3weeks after distraction to
permit bone consolidation. Traction was
continued with one or two 6 oz elastics
on each side through a facemask.
Retention period -6 to 8 weeks.
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Orthognathic surgery:
• Timing – 18 years.
• After active orthodontic treatment the
mand continues to grow and leads to
ant & post cross bites.
• Due to deficient maxillary growth.
• Orthognathic surgery is done to bring
the max downward & forward.
• Rarely surgical mandibular set back
is necessary.www.indiandentalacademy.
com

Presurgical orthodontics
• As the last of permanent teeth erupt
– full fixed appliance.
• Goals – to achieve alignement &
arch form which almost are distorted
in the cleft area.
• To resolve any tendencies towards
posterior or anterior cross bite.
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Pts with small or missing
laterals
• Close lateral space & substitute
canine for lateral. Bring posteriors to
class – II
• Maintain or create space for
prosthetic replacement of lateral.
Bring posteriors to class I & non
extraction approach to the lower jaw.
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• Situation becomes more complex if there
is a jaw discrepancy associated with
alignment problems.
• If mild – orthodontic treatment is enough
• If severe – jaw surgery is indicated.
• Class III camouflage treatment is never
done in a cleft palate patients.
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Orthognathic
surgery:

Orthognathic surgery:
• Timing – 18 – 19 yrs
• Indications - if discrepancy is too
great to be corrected with
orthodontic treatment
alone.orthognathic surgery is
required in clft pts involves both max
advancement associated with
mandibular set back.
• Isolated mandibular set is rarely
indicated or performed.www.indiandentalacademy.
com

Special considerations in
cleft palate:
• 2 limiting factors-
• Scarring due to multiple surgeries.
• In non cleft pts velopharyngeal mech
has compensatory reserve to
tolerate even massive amounts of
max advancements. But in cleft pts
deterioration of velopharyngeal
incompetence occurs following
minimal max advancement (3mm).
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• Surgical – orthodontic coordination :
• Operating class – III early leads to
relapse. So surgery should be postponed
till the growth is completed.
• Removing dental compensation is not a
major goal in cleft lip & palate cases.
• Moderate over correction of anterior
cross bite to the extent of 2mm excess
over jet immediately after surgery is
advantageous.
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Protocols

Stage I
Maxillary
orthopedic
stage
Birth to 18
months
Stage II
Primary
Dentition
18 months to
5yrs
Stage III
Late Primary or
Mixed dentition
6 to 11 yrs
Stage IV
Permanent
dentition
12 to 18 yrs
a)Maxillary
obturator to
prevent feeding
problems,
increasing
burpingand
chocking.
b)“Bulb”
prosthesis to
position
premaxilla in
midline
c)“Bonnet
& Strap”
prosthesis for
retraction of
premaxilla
d) Cheiloplasty
“Rule of Tens”.
a) Establishing
maintaining
oral health.
b) Palatoplasty
(12 to 14
months) for
normal
speech.
Improves
hearing and
swallowing
c) Early
secondary
bone
grafting. (2
to 4 yrs)
a) Orthodontic
treatment 7 to 8
yrs. Started 12
months before
grafting.
*Arch
expansion to
correct posterior
cross bite –
Quad Helix.
*Alignment of
maxillary
incisor.
b) Secondary
bone grafting (6
to 15 yrs) for
eruption of
permanent
canine.
a) Final tooth
alignment
and
interdigitation
b) Rapid palatal
expansion.
c) Cosmetic
surgery for
nasal bone,
tip and
symmetry.
FISHMAN
protocol
e) Bone grafting
for alveolar
defects primary
grafting (< 2 yrs)
f) Orthopedics for
reapproximating
maxillary
segments and
normalizing
oral function. www.indiandentalacademy.
com

University of Bergen,
Norway
• Age (after birth)
• orthodontics-presurgical
orthodontics for a few pts with wide
clefts or asymmetry of jaw segments
• Plastic surgery- information seminar
for parents.
• Speech -
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• 3months- O -
• p.s – closure of lip & ant palate.BCLP at 5
weeks interval( millard tech)
• S-parent counseling on speech dev.
• 12 months-
• P.s – closure of soft palate – vonlengenbeck
tech
• S- further parent counselling contact local
speech therapist.
• 4yrs – p.s -BCLP sulcus plasty ,columella
plasty
• S - Diagnosis of speech dev , articulation &
nasality
com

5 years – o- clinical CLP conference
1. Diagnostic work up by the complete team.
2. Team reviews all individual treatment plans
3. Treatment plans sent to all patients &
parents.
5 – 7 yrs – dentofacial orthopedics
1. Transverse expansion
2. Ant protraction
3. Fixed retention
com

7 – 9 yrs o- alignment of upper incisors
10 yrs – o- observation
p.s – secondary bone grafting
11 – 13 yrs – conventional orthodontic treatment
13 yrs –o- fixed retention upper jaw
15 yrs – o-clinical CLP conference.same
procedure as at 6 yrs.
S – individualised treatment if necessary from 5
– 15 yrs.
com

15 – 16 yrs – p.s – adjustment of lip & nose
S – individual observation & treatment if
necessary.
18 – 19 yrs – dental adjustments pre & post
surgical orthodontics followed by prosthetics
Orthognathic surgery.
com

Conclusion :
• Evidence based clinical practice is a way
of thinking about orthodontic treatment
decisions.
• The underlying theme is that decisions
made every day for our patients should
use the most reliable information
available.
com

Thank you
Thank you

Tackling an iatrogenic problem

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