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THE ORTHODONTIST'S ROLE IN A
CLEFT PALATE-CRANIOFACIAL TEAM1112
PRESENTED BY-
Dr.Sita Niure
PG resident
CONTENTS
• Introduction
• Epidemiology
• Embryology
• Etiology
• Classification of clefts
• Management of cleft lip and pa...
• Surgical orthodontics
• Distraction osteogenesis
• Velo pharyngeal Incompetence
• Conclusion
• References
3112
INTRODUCTION
• Orofacial clefts are among the second most common congenital
anomalies of all kinds. Such anomalies results...
Members in the team approach to patients with craniofacial anomalies 5112
EPIDEMIOLOGY
• Cleft lip and palate is a global problem.(0.28 to 3.74/1000 live births globally)
• Least incidence in negr...
ETIOLOGY
GENETIC
TERATOGEN
ASSOCIATED WITH
OTHER MEDICAL
CONDITIONS
7112
Genetics
• Genetic disorders are classified into the following
groups:
1. Chromosomal disorders
2. Monogenic/Single gene d...
9112
SYNDROMES WITH CLEFT LIPAND PALATE
• Van der woude Syndrome
• Apert syndrome
• Treacher Collins Syndrome Autosomal Dominan...
• Roberts Syndrome
• Christian Syndrome Autosomal Recessive
• Meckel Syndrome
11112
ENVIRONMENTAL FACTORS: TERATOGENS
• The impact of a teratogen is determined by the genotype
of the mother and the child an...
• Medications implicated to cleft formation:
1. Diazepam and other benzodiazepines
2. Steroids(0.07% to 1.9%)
3. Amphetami...
Environmental teratogens:
- Ethyl Alcohol- causes FAS (fetal alcohol Syndrome).
- Cigarette smoking- 30% increase in cleft...
• Nicotine acts synergistically with TGF.
• An important initial step in development of the
primary palate is a forward mo...
• Hypervitaminosis A: acute maternal exposure to 13-cis
retinoic acid during first trimester causes cell death in the
phar...
INFECTION DURING PREGNANCY:
• Rubella infection during the first 3 months associated
with clefting.
PARENTAL AGE:
• Shaw e...
EMBRYOLOGY
18112
Elevation of palate
• Descent of tongue influenced by the growth of mandible and meckel’s cartilage
• Myoneural activity o...
20112
• Transition from vertical to horizontal is completed within hours
Mechanisms proposed for this rapid elevation of palatal...
22112
Prenatal Diagnosis of Cleft Lip/Palate
• Ultrasonography is a noninvasive diagnostic tool now
widely used as a routine com...
24112
Advantages of prenatal diagnosis
1. Psychological preparation of parents and caregivers.
2. Patient education
3. Preparati...
Disadvantage
• An emotional disturbance and high maternal anxiety
after prenatal diagnosis.
• Families choosing to termina...
27112
DAVIS AND RITCHIE CLASSIFICATION (1922):
Group I-Pre alveolar clefts Lip clefts only
with subdivisions for unilateral, med...
A) Cleft lip
Class I-unilateral and bilateral cleft of the
Vermillion border not extending into the
lip.
Class II-unilater...
B) Cleft palate
• Class I- cleft involving
only soft palate
• Class II- cleft involving
hard and soft palate
extending no ...
KERNAHAN’S STRIPED “Y” CLASSIFICATION
(1971)
• In this classification the incisive
foramen is taken as the reference
point...
MILLARD’S CLASSIFICATION (1977):
• A modification of Kernahan’s striped
“Y” classification.
• The inverted triangles repre...
MANAGEMENT OF
CLEFT LIP AND CLEFT
PALATE
33112
• During different stages of the physical and social
development of the cleft patient, role of one specialist
may be more ...
• Similarly, later during the late mixed dentition stage
orthodontist would need greater indulgence.
• At adulthood, plast...
Feeding issues
• Bottle feeding
• Cup & spoon feeding
• Tube feeding
• Posture: Infant must
be held at 30 – 45
degrees or ...
Feeding obturator
• The feeding obturator is a prosthetic aid that is designed to obturate the cleft and
restore the separ...
ORTHODONTISTS ROLE
38112
• Timing and sequencing of orthodontic care may be
divided into four distinct developmental periods.
• These periods are d...
Preoperative orthopaedic treatment
• In 1954, Mc Neil advocated the placement of a
prosthesis immediately after birth to h...
• Goal- to move abnormally positioned maxillary
arches and the pre maxilla into a normal
relationship prior to surgery .
i...
LIP TAPING
PRESURGICAL ORTHOPEDIC TREATMENT(PSOT)42112
Advantages of lip taping:
• the cosmetic appearance is improved with a minor
initial surgical procedure
• parents are not ...
44112
Nasoalveolar molding GRAYSON
• Esthetically pleasing result in the treatment of cleft lip
and palate difficult to achieve ...
UNILATERAL DEFORMITY
• wide nostril base
• separated lip segments on the
cleft side.
• affected lower lateral nasal
cartil...
BILATERAL DEFORMITY
• Procumbent and/or rotated
premaxilla.
• Increased alar base width
• lip segments are widely separate...
Pre -Orthodontic treatment After 3 months of Grayson
molding plate application
48112
Concept-molding the cartilage
• The original research for molding cartilage was
performed by Matsuo.
• Cartilage in the ne...
• The primary objective of the treatment is stimulation
and redirection of alveolar growth aiming for the non
surgical app...
Procedure
• Timing: immediately after birth
Impressions-heavy body impression material
Infants position-upside down-presen...
• Molding plate is fabricated in such a way that there
are no extensions of the plate into the alveolar or
palatal cleft s...
45 degrees
Nasal stent is added to the molding plate when
the cleft alveolar gap is reduced to 5mm or less.
53112
a.As the wire armature of the
nasal stent extends into the nostril, it
is curved back on itself to create a small
loopfor ...
Bilateral complete cleft
4months 1.6 years
55112
56112
Complications Complications and Solutions in
Presurgical Nasoalveolar Molding Therapy
Daniel Levy-Bercowski, D.D.S., M.S.D...
Overstretching of the columella in a patient
with bilateral cleft, as a result of the
pressure exerted by the prolabium ta...
HARD TISSUE COMPLICATIONS
Figure: A)Patient with complete unilateral cleft lip and palate with a
severe nasal deformity (p...
FIGURE. A) Premature eruption of primary maxillary incisors due to the pressure
exerted by the molding plate in a patient ...
Compliance related problems
•Eight (39%) of the patients had at least one broken appointment.
•The NAM appliance was remov...
Cleft lip repair
Goal: goal of all repairs is a normal looking lip and nose
which will not be distorted by the growth or a...
Timing :
• Rule of “over ten” – 10 weeks, 10 pounds, 10 gm
of Hb.
• Preferably 3 – 6 months.
• Techniques used:
1. Tenniso...
Cleft Palate repair
• Aim – speech, chewing & aesthetics.
• Timing : previously the surgeons involved in cleft
palate trea...
• The timing of closure is controversial. Can be done early
at 18-24 months or at 9-12year
• At 18-24 month-
• Development...
• Latest suggestion-
• Closure of soft palate –age of 12 month
• Help in development of Speech
• No growth retardation wit...
Primary Dentition Stage
(2 to 6 Years of Age)
• Establishment of primary dentitions-enables to predict the
developing malo...
• Treatment priorities are:
1. To correct crossbite by using removal plates or
lingual arch.
2. To control or eliminate or...
Mixed Dentition Stage
(7 to 12 Years of Age)
•A tentative decision on extraction of
supernumerary teeth and overretained t...
Because deficiency of tissue is an inevitable consequence of facial
clefting, not only are the teeth missing but also the ...
Alveolar bone grafting
• Primary alveolar bone grafting: done at the time of
lip closure at around 10-12 weeks. Common in ...
• Intermediate (6-15years): performed in late mixed
dentition time to allow the eruption of the permanent
canine in the gr...
Rationale for bone grafting
1. To restore physiologic continuity of arch for esthetic and
hygenic replacement
2. To provid...
• Bergland and coworkers have given an index to
evaluate success of the grafted bone based on the
height of the interdenta...
THREE CONTEMPORARY CONTROVERSIES ARE:
1) Timing of grafting
2) The type of bone for alveolar grafting and donor site
3) Se...
GRAFTING MATERIAL
Autogeous Advantages
• Iliac crest adequate quantity easily condensed &
placed, little donor site morbid...
EXPANSION should be done before grafting, as after the graft
mature and sutures fuse it is difficult to expand maxilla lat...
Protraction of maxilla-Face mask therapy
•Used in mild maxillary deficient cleft patient
•Orthopedic forces for maxillary ...
•Protraction face mask-
mid facial orthopedic
forces applied
– increase growth at the
circum maxillary sutures.
79112
PERMANENT DENTITION :
Clinical feature of this stage :
• Medial displacement of the maxillary segment-buccal cross
bite
• ...
81112
ALIGNMENT OF INCISOR TEETH
– Incisors usually rotated and in crossbite. Corrected by means of fixed
orthodontic appliance....
Orthognathic Surgery combined with
Orthodontics
•Due to severe skeletal discrepancy, there is deterioration of esthetics
a...
Decompensation:
•Usually requires 12 months.
•Multiple segment maxillary osteotomies requires segmental
treatment. The bra...
• Proffit recommends overcorrecting the anterior crossbite
in excess of positive overjet- compensate for post surgical
rel...
TIMING
• Never indicated in active facial growth
• Ideal time : age 18-19
•Post surgical orthodontics: involves detailing ...
Decompensation
Age-16 years
87112
Patient at 17 years of age following maxillary advancement and mandibular setback
surgery and undergoing postsurgical orth...
DISTRACTION OSTEOGENESIS
• With the advent of distraction osteogenesis, correction of
severe maxillary hypoplasia solely b...
Maxillary surgery required in 25-60% of cases with clcp. (Ross and Subtenly)
Distraction osteogenesis allows soft tissue a...
A, Frontal view of 19-year-
old man with repaired
bilateral complete cleft lip
and palate, with rigid
external distractor
...
INTERNAL DISTRACTORS
Advantage:
•Esthetics
•Psychological relilef
Disadvantage:
•Difficult to control the direction of for...
VELOPHARYNGEAL INSUFFICIENCY
Velopharyngeal insufficiency is a
disorder resulting in the improper
closing of the velophary...
• VPD is of 3 types:
a)Velopharyngeal Mislearning: due to
articulation difficulties
b)Velopharyngeal Incompetence: Due to
...
VPI may be found in children who have:
• Cleft palate (about 20-30 percent of children who have
cleft palate will still ha...
• The main speech symptoms of velopharyngeal
insufficiency are:
1. Hypernasality and
2. Nasal air emission.
3. Misarticula...
Treatment of VPI
Speech Therapy
• Some speech problems linked with VPI, such as
mispronouncing words, can be treated by sp...
•An obturator can be a short-
term or long-term option for
children with VPI.
•It can be used before or
instead of surgery...
Surgical intervention:
1. Palatoplasty
2. Sphincter pharyngeoplasty
99112
Different protocols for the management of CLP
Nether lands protocol
• Presurgical orthopedic treatment appliance(PSOT) –
b...
Oslo protocol
• Evolved at the Oslo Cleft Centre.
• does NOT follow preoperative orthopedics
• Millard lip repair at age o...
Zurich concept
• Aim – to maximize palatal growth.
• Passive plates used in conjunction with delayed
surgical procedures w...
103112
Zurich protocol
• Passive plates worn for 16 – 18 months
• Plate changed every 6 months
• Reduction of gingival side of th...
A Modified Surgical Schedule for Primary Management
of Cleft Lip and Palate in Developing Countries
Karoon Agrawal, M.S., ...
• Modified Protocol: A new surgical protocol has been
designed for patients with CLP in whom the cleft palate is
first rep...
• In presence of unrepaired cleft lip, the mouth opening is
better and hence the visibility of the palate, so the cleft
pa...
Treatment of CLCP: A brief Overview 108112
CONCLUSION
• The management of a patient with cleft lip and palate
deformity definitely requires a multidisciplinary
appro...
Past Questions
1. You are a member of CLP team.
Q. What is the best time for cleft lip repair?
A. 3 to 6 months
Q. When do...
Q. What is the most commonly used orthopedic
appliance in CLP cases?
A. Face mask
Q. At what age is usually pre-surgical o...
REFERENCES
• CRANIOFACIAL DEVELOPMENT- Sperber
• Samuel Berkowitz-Cleft Lip and Palate: Diagnosis and management-
2nd Edit...
• Grayson et al, Pre surgical naso alveolar molding, cleftliip- craniofacial
journal 1999:35
• B. H. Grayson and C. B. Cut...
114112
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role of orthodontist in Cleft lip and palate management

  1. 1. THE ORTHODONTIST'S ROLE IN A CLEFT PALATE-CRANIOFACIAL TEAM1112 PRESENTED BY- Dr.Sita Niure PG resident
  2. 2. CONTENTS • Introduction • Epidemiology • Embryology • Etiology • Classification of clefts • Management of cleft lip and palate: - Infant orthopedics-nasoalveolar molding - Treatment in mixed dentition - Treatment in permanent dentition 2112
  3. 3. • Surgical orthodontics • Distraction osteogenesis • Velo pharyngeal Incompetence • Conclusion • References 3112
  4. 4. INTRODUCTION • Orofacial clefts are among the second most common congenital anomalies of all kinds. Such anomalies results in several handicaps such as impaired suckling, defective speech, deafness, malocclusion, gross facial deformity and severe psychological problems. • Cleft of lip and the palate is one such condition, that occurs at such a strategic place in the orofacial region and at such a crucial time that it becomes a complex congenital deformity requiring a multidisciplinary team approach in its management. 4112
  5. 5. Members in the team approach to patients with craniofacial anomalies 5112
  6. 6. EPIDEMIOLOGY • Cleft lip and palate is a global problem.(0.28 to 3.74/1000 live births globally) • Least incidence in negroids(0.021 to 0.41 per 1,000 live births) and maximum in afghans(4.9%) • Orientals(esp Japanese)-1.14 to 2.13 per 1000 live births • In India 1.7 cases are seen in every 1000 individuals. • In India - CL+CP-1.25/1000 • CP 0.46/1000 • The incidence of oral clefts is seen more in males than in females. • Cleft lip alone- more in males than female • Cleft palate- more in females than males 6112
  7. 7. ETIOLOGY GENETIC TERATOGEN ASSOCIATED WITH OTHER MEDICAL CONDITIONS 7112
  8. 8. Genetics • Genetic disorders are classified into the following groups: 1. Chromosomal disorders 2. Monogenic/Single gene disorders 3. Polygenic/Multifactorial disorders 4. Mitochondrial disorders • The expression of a multifactorial disorder is based on a threshold model(Melnick 1972), whereby those with more of the disease causing genes and environmental factors are likely to exceed the theshold and express the disorder. 8112
  9. 9. 9112
  10. 10. SYNDROMES WITH CLEFT LIPAND PALATE • Van der woude Syndrome • Apert syndrome • Treacher Collins Syndrome Autosomal Dominant • Cleidocranial Syndrome • Ectodermal Dysplasia • Stickler’s Syndrome • Oro-facial digital syndrome • Pierre Robin syndrome 10112
  11. 11. • Roberts Syndrome • Christian Syndrome Autosomal Recessive • Meckel Syndrome 11112
  12. 12. ENVIRONMENTAL FACTORS: TERATOGENS • The impact of a teratogen is determined by the genotype of the mother and the child and the timing and the dose of the drug. • Usually occurs due to various influences during 1st trimester. 12112
  13. 13. • Medications implicated to cleft formation: 1. Diazepam and other benzodiazepines 2. Steroids(0.07% to 1.9%) 3. Amphetamine 4. Diabetes- a medical condition 5. Anti seizure drugs.eg: diphenyl hydantion and trimethadione.also causes growth retardation, craniofacial dysmorphism, mental deficiency including oral cleft. 13112
  14. 14. Environmental teratogens: - Ethyl Alcohol- causes FAS (fetal alcohol Syndrome). - Cigarette smoking- 30% increase in cleft lip and palate and 20% increase in cleft palate in smoking during pregnancy. 14112
  15. 15. • Nicotine acts synergistically with TGF. • An important initial step in development of the primary palate is a forward movement of the lateral nasal process which positions it so that contact with the median nasal process is possible. • The hypoxia associated with smoking probably interferes with this movement. 15112
  16. 16. • Hypervitaminosis A: acute maternal exposure to 13-cis retinoic acid during first trimester causes cell death in the pharygeal arch leading to facial clefting. Vit A analogue used as an anti-acne drug-Also proved by animal experiments. • Folic Acid: Deficiency of folic acid affects virtually every organ system. It affect the neural tube- neural crest cell migration and differentiation. • Anaemia and anorexia 16112
  17. 17. INFECTION DURING PREGNANCY: • Rubella infection during the first 3 months associated with clefting. PARENTAL AGE: • Shaw etal presented evidence that women above the age of 35 had a doubled risk of having a child with CLCP. above 39- tripled risk. • Consanguineous marriages- increased risk of CLCP in child 17112
  18. 18. EMBRYOLOGY 18112
  19. 19. Elevation of palate • Descent of tongue influenced by the growth of mandible and meckel’s cartilage • Myoneural activity of tongue • Mouth opening reflexes 19112
  20. 20. 20112
  21. 21. • Transition from vertical to horizontal is completed within hours Mechanisms proposed for this rapid elevation of palatal shelves: 1. Biochemical transformations in the physical consistency of the connective tissue matrix of the shelves 2.Variations in vasculature and blood flow to these structures 3.Sudden increase in their tissue turgor 4.Rapid differential mitotic growth 5.An intrinsic shelf-elevating force-chiefly generated by accumulation and hydration of hyaluronic acid 21112
  22. 22. 22112
  23. 23. Prenatal Diagnosis of Cleft Lip/Palate • Ultrasonography is a noninvasive diagnostic tool now widely used as a routine component of prenatal care. • Ultrasonography serves to confirm fetal viability, determine gestational age, establish the number of fetuses and their growth, check placental location, and examine fetal anatomy to detect any malformations. • Three-dimensional ultrasound imaging is a new technology that presents views of the fetal face with greater clarity than the conventional two-dimensional imaging 23112
  24. 24. 24112
  25. 25. Advantages of prenatal diagnosis 1. Psychological preparation of parents and caregivers. 2. Patient education 3. Preparation for neonatal care and feeding 4. Opportunity to investigate for other structural or chromosomal abnormalities 5. Possibility for fetal surgery 6. Customized surgical treatment plan by the plastic surgeon. 25112
  26. 26. Disadvantage • An emotional disturbance and high maternal anxiety after prenatal diagnosis. • Families choosing to terminate the pregnancy even in the absence of other malformations. 1. perceived burden, 2. expectation of recurrence, 3. religious and cultural beliefs, 26112
  27. 27. 27112
  28. 28. DAVIS AND RITCHIE CLASSIFICATION (1922): Group I-Pre alveolar clefts Lip clefts only with subdivisions for unilateral, median, bilateral. Group II-Post alveolar clefts degrees of involvement of soft and hard palate to be specified till the alveolar ridge, submucous clefts included. Group III-Alveolar clefts is complete clefts of palate, alveolus ridge and lip with subdivisions for unilateral, median, bilateral. They classified congenital clefts based on the position of the cleft in relation to the alveolar process. 28112
  29. 29. A) Cleft lip Class I-unilateral and bilateral cleft of the Vermillion border not extending into the lip. Class II-unilateral and bilateral notching of Vermillion with cleft extending into the lip, but not including the floor of the nose. Class III- unilateral and bilateral cleft of vermilions border, involving lip and extending into the floor of the nose. Class IV-any bilateral cleft of the lip whether incomplete or complete. VEAUS CLASSIFICATION - 1931 29112
  30. 30. B) Cleft palate • Class I- cleft involving only soft palate • Class II- cleft involving hard and soft palate extending no further than the incisive foramen • Class III- complete unilateral or bilateral cleft extending from uvula to incisive foramen then deviating to one side • Class IV- complete bilateral cleft similar to class III with two clefts extending forward from the incisive foramen into the alveolus 30112
  31. 31. KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971) • In this classification the incisive foramen is taken as the reference point • “Y” logo are each divided into three sections, representing the lip, the alveolus and the hard palate as far back as the incisive foramen. The stem of the “Y” is also divided into three parts, representing varying degrees of clefting of the hard and soft palates. 31112
  32. 32. MILLARD’S CLASSIFICATION (1977): • A modification of Kernahan’s striped “Y” classification. • The inverted triangles represent the nasal arch the upright triangles represent the nasal floor. LAHSHAL CLASSIFICATION: L- lip A- Alveolus H- hard palate S– soft palate 32112
  33. 33. MANAGEMENT OF CLEFT LIP AND CLEFT PALATE 33112
  34. 34. • During different stages of the physical and social development of the cleft patient, role of one specialist may be more significant than the other. • During early days, immediately after birth the feeding specialist, neonatologist, orthodontist and the cleft surgeon take the lead role. • After the first year, issues with hearing, middle ear infections and speech therapy are more relevant and important issues to be tackled with. 34112
  35. 35. • Similarly, later during the late mixed dentition stage orthodontist would need greater indulgence. • At adulthood, plastic surgeons, would play a key role in the correction of secondary deformities of lip and nose. • A prosthodontist may be required to rehabilitate missing teeth and form aesthetic treatment of the dentition. 35112
  36. 36. Feeding issues • Bottle feeding • Cup & spoon feeding • Tube feeding • Posture: Infant must be held at 30 – 45 degrees or in upright position in order to aid in swallowing and prevent aspiration 36112
  37. 37. Feeding obturator • The feeding obturator is a prosthetic aid that is designed to obturate the cleft and restore the separation between the oral and nasal cavities. • It creates a rigid platform • The obturator also prevents the tongue from entering the defect and interfering with spontaneous growth of the palatal shelves. • reduces nasal regurgitation, • reduces the incidence of choking, • also helps in the development of the jaws and contributes to speech 37112
  38. 38. ORTHODONTISTS ROLE 38112
  39. 39. • Timing and sequencing of orthodontic care may be divided into four distinct developmental periods. • These periods are defined by age and dental development and should be considered as time frames in which to accomplish specific objectives. 1. Neonate and Infant (Birth to 2 Years of Age) 2. Primary dentition( 2 to 6 years) 3. Mixed dentition stage 4. Permanent dentition 39112
  40. 40. 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 maxillary orthopaedics” 40112
  41. 41. • Goal- to move abnormally positioned maxillary arches and the pre maxilla into a normal relationship prior to surgery . intra oral • Appliances extra oral 41112
  42. 42. LIP TAPING PRESURGICAL ORTHOPEDIC TREATMENT(PSOT)42112
  43. 43. Advantages of lip taping: • the cosmetic appearance is improved with a minor initial surgical procedure • parents are not required to remove or adjust appliances, • postoperative care by the parents is minimal. Disadvantage: • potential of wound dehiscence and the need for an additional surgery 43112
  44. 44. 44112
  45. 45. Nasoalveolar molding GRAYSON • Esthetically pleasing result in the treatment of cleft lip and palate difficult to achieve due to the actual anatomical deformity of the nose. • Abnormal nasal cartilage morphology, deviated nasal septum and columella, asymmetry of the alar, and a short or even absent columella, depending on the type of cleft. • Therefore Dr. Grayson and Dr. Cutting emphasize the importance of presurgical correction of the nasal cartilage and soft tissue deformity, which can be achieved by a combination of nasal and alveolar orthopedic molding. 45112
  46. 46. UNILATERAL DEFORMITY • wide nostril base • separated lip segments on the cleft side. • affected lower lateral nasal cartilage is displaced laterally and inferiorly -depressed dome • appearance of an increased alar rim • an oblique columella, • overhanging nostril apex • If there is a cleft of the palate, the nasal septum will deviate to the noncleft side with an associated shift of the nasal base. 46112
  47. 47. BILATERAL DEFORMITY • Procumbent and/or rotated premaxilla. • Increased alar base width • lip segments are widely separated • severely deficient or absent columella- flattened nasal tip appears tethered directly to the prolabium • lower lateral alar cartilages are flared and concave where they should be convex. Esthetic reconstruction of the deficient or absent columella-biggest challenge 47112
  48. 48. Pre -Orthodontic treatment After 3 months of Grayson molding plate application 48112
  49. 49. Concept-molding the cartilage • The original research for molding cartilage was performed by Matsuo. • Cartilage in the newborn is soft and lacks elasticity. • High maternal level of estrogen at the time of birth correlates with an increase in hyaluronic acid, which inhibits the linking of the cartilage intercellular matrix. • necessary to relax the cartilages, the ligaments and connective tissue- enabling the fetus to pass through birth canal-estrogen level decline after birth. 49112
  50. 50. • The primary objective of the treatment is stimulation and redirection of alveolar growth aiming for the non surgical approximation of the cleft deformity. • To achieve this it is planned to treat the patients with molding appliance in conjunction with a traction force across the cleft lip followed by a nasal stent later. • The nasal stent and alveolar molding plate help in achieving nasal and alveolar symmetry, nasal tip projection, and contact of the cleft alveolus just before primary lip, nasal and alveolar surgical repair. 50112
  51. 51. Procedure • Timing: immediately after birth Impressions-heavy body impression material Infants position-upside down-presence of suregon important. cast poured with dental stone-molding plate fabricated (hard clear acrylic and lined with a thin coat of soft denture material) 51112
  52. 52. • Molding plate is fabricated in such a way that there are no extensions of the plate into the alveolar or palatal cleft space. • Full time wear- except for cleaning • The appliance is secured extraorally to the cheeks, bilaterally by surgical tapes, which have an orthodontic elastic band at one end. • The elastics loop over a retention arm extending from the anterior flange of the plate. 52112
  53. 53. 45 degrees Nasal stent is added to the molding plate when the cleft alveolar gap is reduced to 5mm or less. 53112
  54. 54. a.As the wire armature of the nasal stent extends into the nostril, it is curved back on itself to create a small loopfor retention of the intranasal portion of the nasal stent. b. Hard acrylic(methylmethacrylate) is applied to the wire armature and shaped into a bi-lobed form that resembles a kidney. c. The hard acrylic nasal stent is coated with a thin layer of soft denture liner for comfort. d The upper lobe of the nasal stent enters the nose and gently lifts the dome until a moderate amount of tissue blanching is evident. The lower lobe of the nasal stent lifts the nostril apex and defines the top of the columellaNASAL STENT 54112
  55. 55. Bilateral complete cleft 4months 1.6 years 55112
  56. 56. 56112
  57. 57. Complications Complications and Solutions in Presurgical Nasoalveolar Molding Therapy Daniel Levy-Bercowski, D.D.S., M.S.D., Amara Abreu, D.D.S., M.S.D., Eladio DeLeon, D.M.D., M.S. et al Cleft Palate–Craniofacial Journal, September 2009, Vol. 46 No. 5 Contact dermatitis SOFT TISSUE HARD TISSUE COMPLIANCE RELATED Overactivation of the nasal stent may produce bruising or petechiae in the dome area. 57112
  58. 58. Overstretching of the columella in a patient with bilateral cleft, as a result of the pressure exerted by the prolabium tape and the nasal stents. 58112
  59. 59. HARD TISSUE COMPLICATIONS Figure: A)Patient with complete unilateral cleft lip and palate with a severe nasal deformity (pretreatment with NAM). B)After 18 weeks of NAM treatment, nasal morphology improved significantly. However, a T-shaped maxillary arch was created. 59112
  60. 60. FIGURE. A) Premature eruption of primary maxillary incisors due to the pressure exerted by the molding plate in a patient with bilateral cleft lip and palate. B)Patient continues with NAM treatment after the extraction of the primary incisor. Figure: NAM modification to permit the eruption of primary incisor 60112
  61. 61. Compliance related problems •Eight (39%) of the patients had at least one broken appointment. •The NAM appliance was removed with the tongue in seven patients (26%) and with the hands in three (11%) 61112
  62. 62. Cleft lip repair Goal: goal of all repairs is a normal looking lip and nose which will not be distorted by the growth or aging. Criteria for satisfactory repair: • Accurate skin, muscle & mucous membrane union. • Symmetrical nostril floors • Symmetrical vermilion border • Slight eversion of the lip • Minimum scars • Preservation of cupids bow & vermilion cutaneous ridge. • Production of symmetrical nostrils as well as symmetrical nasal floors. 62112
  63. 63. Timing : • Rule of “over ten” – 10 weeks, 10 pounds, 10 gm of Hb. • Preferably 3 – 6 months. • Techniques used: 1. Tennison's triangular flap procedure 2. Millard's rotation flap 63112
  64. 64. Cleft 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 defect as early as possible without considering the ultimate effect on surgery on palatal, facial or speech development. 64112
  65. 65. • The timing of closure is controversial. Can be done early at 18-24 months or at 9-12year • At 18-24 month- • Development of normal speech • Tendency towards maxillary underdevelopment • At 9-12year- • Normal growth of maxilla with unrepaired cleft • Reduces surgical morbidity and infection 65112
  66. 66. • Latest suggestion- • Closure of soft palate –age of 12 month • Help in development of Speech • No growth retardation with early soft palate closure • Closure of hard palate –age of 5-6year 66112
  67. 67. Primary Dentition Stage (2 to 6 Years of Age) • Establishment of primary dentitions-enables to predict the developing malocclusion • Facial soft tissues may mask the underlying skeletal deficiency of the midface in young children. 7 years 9 years 67112
  68. 68. • Treatment priorities are: 1. To correct crossbite by using removal plates or lingual arch. 2. To control or eliminate oral habits, functional shift or space loss after premature loss of primary teeth 3. After the first phase, a removable retainer (at least night time) is worn till the next phase is begun. 68112
  69. 69. Mixed Dentition Stage (7 to 12 Years of Age) •A tentative decision on extraction of supernumerary teeth and overretained teeth. •Correction of cross bite- jack screw, RME, quad helix, Niti expanders •Maintain space for proper eruption of teeth. •Expand collapsed segment to improve surgical access to the graft site. • Traumatic occlusion is eliminated in preparation of alveolar graft. (By aligning offending tooth) • Correction of jaw relationship- Face mask Therapy 69112
  70. 70. Because deficiency of tissue is an inevitable consequence of facial clefting, not only are the teeth missing but also the supporting alveolar bone at the cleft site is compromised. Bone defect before grafting 7 months 4 years after alveolar bone grafting 70112
  71. 71. Alveolar bone grafting • Primary alveolar bone grafting: done at the time of lip closure at around 10-12 weeks. Common in 1950s. Causes hinderance in maxillary growth. • Secondary alveolar bone grafting: Boyne and Sands in 1972 • done after lip closure at later stage. This is can be divided into three: • Early (2-5 years): performed in primary dentition. Rationale is to allow eruption of the lateral incisor if present. Can affect growth of midface. 71112
  72. 72. • Intermediate (6-15years): performed in late mixed dentition time to allow the eruption of the permanent canine in the graft. There is minimal interference in growth. • Late secondary alveolar bone grafting (adolescence to adulthood): • Aids in replacement of missing teeth with implants 72112
  73. 73. Rationale for bone grafting 1. To restore physiologic continuity of arch for esthetic and hygenic replacement 2. To provide bone for stability of dental arch and the premaxillary segment 3. Bone is provided into which unerupted teeth may erupt. 4. At the time of placement of graft, patent oronasal fistulas can be closed 5. To allow orthodontic alignment of teeth 6. To provide support for the lip and the alar base and the nasal tip. 73112
  74. 74. • Bergland and coworkers have given an index to evaluate success of the grafted bone based on the height of the interdental septum on IOPA X-ray films • Type I—normal • Type II—75% of normal bone height • Type III—less than 75% • Type IV—no bony ridge. Post bone graft follow up 112 74
  75. 75. THREE CONTEMPORARY CONTROVERSIES ARE: 1) Timing of grafting 2) The type of bone for alveolar grafting and donor site 3) Sequencing of orthodontic expansion. Favor of 8-10 year of age (when canines about to erupt-one quarter to two thirds of root complete)- Bergland etal • Erupting tooth is a potent stimulus for bone formation. • After tooth eruption is complete, it can be very difficult to induce the formation of new bone. • Prevents eruption into cleft-periodontal defect • If placed after eruption of permanent teeth then chances of damaging roots and resorption 75112
  76. 76. GRAFTING MATERIAL Autogeous Advantages • Iliac crest adequate quantity easily condensed & placed, little donor site morbidity • Tibia adequate volume quality similar to iliac crest • Rib for infants. • Cranial bone inadequate quantity, less resorption, rapid vascularization, predictable quality Allogenic grafts: it acts a scaffold into which new bone develops. Freeze dried bone( increased chances of immune reaction, HIV infection, longer post operative phase) REVASCULARISATION OF GRAFT IS SLOW. 76112
  77. 77. EXPANSION should be done before grafting, as after the graft mature and sutures fuse it is difficult to expand maxilla later. Also Expanding the arch before grafting increases the size of cleft and thus more area for placement of bone. But increased amount of bone is required and requires more soft tissue dissection for closure. Expansion can also be done 6wks after grafting. It has a potential of stimulating immature bone which may enhance graft survival 77112
  78. 78. Protraction of maxilla-Face mask therapy •Used in mild maxillary deficient cleft patient •Orthopedic forces for maxillary protraction -350-500 gm per side over 10-12 hr / day for an average of 12-15 months. • Stability is questionable Because of two reasons 1.Counter pressure of a tight lip on the maxilla, which inhibits its growth 2.Scarring in pterygo maxillary region after extensive tissue mobilization for palatal closure 78112
  79. 79. •Protraction face mask- mid facial orthopedic forces applied – increase growth at the circum maxillary sutures. 79112
  80. 80. PERMANENT DENTITION : Clinical feature of this stage : • Medial displacement of the maxillary segment-buccal cross bite • Relative maxillary retrognathism-reversed incisal overjet. • Deficiency of vertical growth of the upper jaw – REDUCED FACIAL HEIGHT • Rotation, malposition and hypodontia of teeth. • Supernumerary teeth • Accentuated curve of spee in maxilla • Collapsed arch forms • Poor oral hygiene and caries 80112
  81. 81. 81112
  82. 82. ALIGNMENT OF INCISOR TEETH – Incisors usually rotated and in crossbite. Corrected by means of fixed orthodontic appliance. CORRECTION OF LATERAL DIMENSION – Lack of bony union between two sides of the maxilla, correction in lateral dimension is relatively straight forward. – By expansion appliance Quad Helix Rapid Maxillary Expansion (RME) Patients with CLP have class III malocclusion because of maxillary deficiency (A-P and Vertically), coupled with mandibular overclosure. In such cases use of class III elastics after leveling and aligning will result in upper molar extrusion and favorable downward and backward rotation of mandible. 82112
  83. 83. Orthognathic Surgery combined with Orthodontics •Due to severe skeletal discrepancy, there is deterioration of esthetics and occlusion, psychological implications leading to low self esteem, defective speech, oronasal fistulas. Such cases require a combined orthodontic and orthognathic approach. •Size and position of maxilla is often a problem, thus maxillary advancement and occasional down grafting needs to be performed. To correct the transverse problem multiple segment LeFort I osteotomies may be required. For a bilateral CLCP three-piece maxillary surgery (allows rotation of segments also) required while for unilateral CLCP a two piece is sufficient.(Vlachos 1996) 83112
  84. 84. Decompensation: •Usually requires 12 months. •Multiple segment maxillary osteotomies requires segmental treatment. The bracket positions are altered for teeth adjacent to the osteotomy site. •Dental compensations in the lower arch also should be addressed i.e, alleviation of crowding and proclination. •Gaps present in the arches due to the missing teeth must be either closed- stable result and prevents reopening of oronasal fistula. Pre-surgical orthodontics 84112
  85. 85. • Proffit recommends overcorrecting the anterior crossbite in excess of positive overjet- compensate for post surgical relapse. • In cases with an overjet(reverse) of more than 8mm mandibular surgery (BSSO) also must be considered. If not then over advancement of maxilla – unstable and speech defects. 85112
  86. 86. TIMING • Never indicated in active facial growth • Ideal time : age 18-19 •Post surgical orthodontics: involves detailing of occlusion, closure of residual spaces and maintenance of transverse dimension (overlay arches). Lasts for 4-6 months. •Retention: After removal of appliance retainers should be placed immediately. Temporary vacuum filled retainers to be avoided-transverse control inadequate. Soldered lingual arch preferred. 86112
  87. 87. Decompensation Age-16 years 87112
  88. 88. Patient at 17 years of age following maxillary advancement and mandibular setback surgery and undergoing postsurgical orthodontic treatment 88112
  89. 89. DISTRACTION OSTEOGENESIS • With the advent of distraction osteogenesis, correction of severe maxillary hypoplasia solely by advancing the maxilla may be possible. 1903 . Dr. Gavril of Russia-Bone lengthening of leg. • It is a procedure that moves two segment of bone slowly apart in such a way that new bone fills the gap. • In distraction osteogenesis, a surgeon makes an osteotomy in an bone and attaches a device known as distractor to both sides of osteotomy. • The distractor is gradually adjust over a period of days or week to stretch the osteotomy so new tissue fills it. 89112
  90. 90. Maxillary surgery required in 25-60% of cases with clcp. (Ross and Subtenly) Distraction osteogenesis allows soft tissue adaptation, including scar tissue. Therefore doesn’t cause a problem with velopharyngeal insufficiency thus good results. Distraction Of maxilla first proposed by Molina & Oritz-Monasterio(1998) EXTERNAL DISTRACTORS Advantage: •Direction of force is well controlled Disadvantage: •Cranial surgery is required •Esthetics are compromised 90112
  91. 91. A, Frontal view of 19-year- old man with repaired bilateral complete cleft lip and palate, with rigid external distractor (RED)apparatus in place. B, Profile view with distraction osteogenesis appliance for advancement of the maxilla. C, Profile view before distraction osteogenesis. severe maxillary deficiency present. D, Profile view after distraction osteogenesis. improved position of maxilla relative to mandible. 91112
  92. 92. INTERNAL DISTRACTORS Advantage: •Esthetics •Psychological relilef Disadvantage: •Difficult to control the direction of force 92112
  93. 93. VELOPHARYNGEAL INSUFFICIENCY Velopharyngeal insufficiency is a disorder resulting in the improper closing of the velopharyngeal sphincter (soft palate muscle in the mouth)during speech, allowing air to escape through the nose instead of the mouth. 93112
  94. 94. • VPD is of 3 types: a)Velopharyngeal Mislearning: due to articulation difficulties b)Velopharyngeal Incompetence: Due to functional abnormalities.(paresis, dysarthia) c)Velopharyngeal Insufficiency: Structural problems like cleft or bifid uvula etc 94112
  95. 95. VPI may be found in children who have: • Cleft palate (about 20-30 percent of children who have cleft palate will still have VPI after the palate repair) • Submucous cleft palate • Certain syndromes, such a velocardiofacial syndrome • Had previous adenoid removal • Weak throat muscle • Too much space between the palate and the throat Some children have VPI from an unknown cause. 95112
  96. 96. • The main speech symptoms of velopharyngeal insufficiency are: 1. Hypernasality and 2. Nasal air emission. 3. Misarticulations of certain words 96112
  97. 97. Treatment of VPI Speech Therapy • Some speech problems linked with VPI, such as mispronouncing words, can be treated by speech therapy. Treatment focuses on teaching the child the correct manner and place of articulation Non-surgical management: • Sometimes an obturator is recommended to treat VPI. • An obturator is like a modified dental retainer with a speech bulb or palatal lift attached to the back. Each obturator is shaped uniquely to fit the patient’s muscle movements. 97112
  98. 98. •An obturator can be a short- term or long-term option for children with VPI. •It can be used before or instead of surgery. •The child may start with an obturator and have surgery when he is older or they may continue to use an obturator as an adult. 98112
  99. 99. Surgical intervention: 1. Palatoplasty 2. Sphincter pharyngeoplasty 99112
  100. 100. Different protocols for the management of CLP Nether lands protocol • Presurgical orthopedic treatment appliance(PSOT) – birth to 1 1/2 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. 100112
  101. 101. Oslo protocol • Evolved at the Oslo Cleft Centre. • does NOT follow preoperative orthopedics • Millard lip repair at age of 3 months • In cases with an associated cleft of the alveolus and palate, a cranial base single layer vomer flap is sutured under the alveolus palate periosteum at the time of lip closure. 112 101
  102. 102. 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. 102112
  103. 103. 103112
  104. 104. 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. 104112
  105. 105. A Modified Surgical Schedule for Primary Management of Cleft Lip and Palate in Developing Countries Karoon Agrawal, M.S., M.Ch., Kasinath Panda, M.S. Cleft Palate–Craniofacial Journal, January 2011, Vol. 48 No. 1 • Introduction: In developing countries cleft lip and palate (CLP) patients arrive late, and there is a risk of drop out for functionally important palatoplasty after lip repair. Patients may be underweight, anemic, and prone to recurrent infections. • Objective: To repair cleft palate at an appropriate time and secondly to avoid the drop out after the first surgery. 105112
  106. 106. • Modified Protocol: A new surgical protocol has been designed for patients with CLP in whom the cleft palate is first repaired at 6 to 9 months of age or whenever the patient presents at the clinic. The cleft lip is repaired 3 to 6 months after the first surgery. • Advantages of the modified protocol 1. Cleft palate is repaired at the most accepted time schedule for palatoplasty at 6–9 months for good speech result. 2. Compliance for second surgery for cleft lip repair improved. 106112
  107. 107. • In presence of unrepaired cleft lip, the mouth opening is better and hence the visibility of the palate, so the cleft palate repair is technically easier. • During cleft lip repair, the anterior palate repair is done under good vision; hence, incidence of anterior palatal fistula is very low. • While performing the cleft lip repair, there is an opportunity to examine the palate under GA for any abnormality. • Cleft palate fistula if identified can be repaired along with the lip repair. 107112
  108. 108. Treatment of CLCP: A brief Overview 108112
  109. 109. CONCLUSION • The management of a patient with cleft lip and palate deformity definitely requires a multidisciplinary approach and the orthodontist has proven to be an essential member in the cleft palate team. The orthodontist is not only responsible for the active orthodontic treatment but also and facial orthopedic treatment of the child with a cleft. The ultimate outcome for team-based care is to have a fully rehabilitated patient who is satisfied with the treatment outcomes in terms of speech, occlusion, facial and dental aesthetics, and function. 109112
  110. 110. Past Questions 1. You are a member of CLP team. Q. What is the best time for cleft lip repair? A. 3 to 6 months Q. When do you recommend for secondary alveolar bone grafting? A. Ideally, the permanent canine root should be half to two thirds formed at the time the graft is placed. Permanent canine root formation generally occurs between the ages of 8 and 11 years. Occasionally the graft may be placed at an earlier age to improve the prognosis of a lateral incisor. 110112
  111. 111. Q. What is the most commonly used orthopedic appliance in CLP cases? A. Face mask Q. At what age is usually pre-surgical orthodontics preferred for this kind of patients? A. Presurgical orthodontics or neonatal maxillary orthopedics is initiated during the first or second week following birth unless complications arise from other congenital anomalies or medical problems 111112
  112. 112. REFERENCES • CRANIOFACIAL DEVELOPMENT- Sperber • Samuel Berkowitz-Cleft Lip and Palate: Diagnosis and management- 2nd Edition • Thomas M. Graber, Katherine W. L. Vig, Robert L. Vanarsdall Jr. Orthodontics: Current Principles and Techniques. • WR Profitt:Contemporary orthodontics-5th edition • OP Kharbanda; Orthodontics-Diagnosis and management of malocclusions and dentofacial deformities;First edition • Cleft lip and palate, Seminars in Orthodontics 112112
  113. 113. • Grayson et al, Pre surgical naso alveolar molding, cleftliip- craniofacial journal 1999:35 • B. H. Grayson and C. B. Cutting, “Presurgical Nasoalveolar Orthopedic Molding in Primary Correction of the Nose, Lip, and Alveolus of Infants Born with Unilateral and Bilateral Clefts,” The Cleft Palate-Craniofacial Journal, Vol. 38, No. 3, 2001, pp. 193-198. • Advances in management of cleft palate: Edwards and Watson • Baik et al. surgical orthodontic treatment in patients with clcp: conventional surgery v/s maxillary distraction, world J Orthod;2:331-40 113112
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