This document discusses orofacial clefts, including their formation, classification, incidence, etiology, associated problems, and management through a multidisciplinary team approach. Orofacial clefts result from disturbances in the growth and fusion of facial tissue processes during development. They can involve the lip, palate, or both. Management involves surgery to repair the cleft in stages from infancy through adolescence, along with orthodontic treatment and prosthodontic care to address dental, speech, hearing and psychological issues. The goal of a coordinated team approach is to enable patients with clefts to achieve normal facial and dental development.

1. OROFACIAL CLEFTS
Dr.Kailash Rathi
Dept of Orthodontics and
Dentofacial Orthopedics
S.B. Patil intitute for Dental
Sciences and Research

2. The formation of the face and oral cavity is
complex in nature and involves the
development of multiple tissue processes
that must merge and fuse in a highly
orchestrated fashion.

3. Disturbances in the growth of these tissue
processes or their fusion may result in the
formation of orofacial clefts.

4.  Development of the central face begins
around the end of the fourth week of
human development, with the
appearance of the nasal (olfactory)
placodes on either side of the inferior
aspect of the frontonasal process.

5. Proliferation of ectomesenchyme on both
sides of each placode results in the
formation of the medial and lateral nasal
processes. Between each pair of
processes is a depression, or nasal pit,
that represents the primitive nostril.

6.  During the sixth and seventh weeks of
development, the upper lip forms when
the medial nasal processes merge with
each other and with the maxillary
processes of the first branchial arches.

7. Thus the midportion of the upper lip is
derived from the medial nasal processes
and the lateral portions are derived from
the maxillary processes.
 The lateral nasal processes are not
involved in the formation of the upper lip,
but they give rise to the alae of the nose.

9.  Defective fusion of the medial nasal
process with the maxillary process leads
to cleft lip (CL)
 Likewise, failure of the palatal shelves to
fuse results in cleft palate (CP).

11.  Median cleft of the upper lip is an
extremely rare anomaly that results from
failure of fusion of the medial nasal
processes.

12. CLEFT LIP AND PALATE

13.  The most common congenital defect
involving the face and jaws, second only
to clubfoot in the entire spectrum of
congenital deformities, is clefting of the lip,
palate, or, less commonly, other facial
structures.

14. INCIDENCE
 The incidence of cleft lip and palate is
found to be different among different
races.
 Studies done in India reveal an incidence
of 1 in every 600-1000 births. The Negroid
race has the least incidence (one in every
2000 births) while the mongoloids have
the highest incidence.

15.  Cleft lip is common among males while cleft
palate is more common among females.
 Unilateral clefts account for 80% of the incidence
while bilateral clefts account for the remaining
20%.Among the unilateral clefts, clefts involving
the left side are seen in 70% of the cases. The
reason for this is not yet known.

16. etiology
 Multifactorial
 Hereditary
 Environment.
 Predisposing factors are
increased maternal age.
 racial
 decreased blood supply.

17. 1
2
3
4
5

18. MECHANISM OF CLEFT
FORMATION
 William Harvey1651: was the first to
observe that the essential cause of cleft
lip was the persistance of a temporary
phase of embryonic development.
 Tondury1964:Delay in the timing of
palatal shelf alignment. (human
embryos).
 Kraus1970:Failure of palatal shelves to
become horizontal. (man & primates).

19. Frazer et al1957:In vivo studies suggested
1. a force building up in the shelves overcame
the resistance of tongue.
2. cortisone interferes with this force build up.
3. The shelves needed the stimulus of fusion to
continue to grow.
4. Hence, if no fusion occurred, there would be
little further growth in their width and,
5. The lateral growth of the head would pull the
shelves apart.

20. The shelf force was influenced by maternal & fetal
genes, cortisone & other environmental
factors.
This led to the following hypothesis of cleft
etiology:
1. Interference with the intrinsic shelf force.
2. Excessive head width or dimunitive palatal
shelves;
3. Excessive tongue resistance;
4. Non fusion of shelves;
5. Fusion of shelves with subsequent breakdown.

21. CLASSIFICATION
 A no. of classification is put forward by
various authors

22. DAVIS AND RITCHIE
CLASSIFICATION (1922)
 GROUP I :–Pre alveolar clefts they are
clefts involving only the lip and are
subclassified as
-unilateral
-bilateral
-median

23. Group II:-post alveolar clefts: this group
comprises of different degrees of hard and
soft palate clefts that extend upto the
alveolar ridge.

24.  Group III:-alveolar clefts: they are
complete clefts involving the palate,
alveolar ridge and the lip. They can be
subdivided into
-unilateral
-bilateral
-median.

25. VEAU’S CLASSIFICATION OF CLEFTS(
1931)
 GROUP I:- cleft of the soft palate only.
 GROUP II:-Cleft of the hard and soft palate to the
incisive foramen.
 GROUP III:-Complete unilateral cleft of the soft and
hard palate, and the lip and alveolar ridge on one
side.
 GROUP IV:-Complete bilateral cleft of the soft and
hard palate ,and the lip and alveolar ridge on both
sides.

26. CLASSIFICATION BY FOGH
ANDERSEN [1942]
 GROUP–I :- They are clefts of the lip it can
be subdivided into
Single – unilateral or median
Double - bilateral clefts

27.  GROUP-II : they are clefts of the lip and
the palate they are once again sub
classified into
Single : unilateral clefts
Double : bilateral clefts
GROUP-III : they are clefts of the palate
extending upto the incisive formation

28. LAHSHAL CLASSIFICATION
BYOKRIENS IN 1987

29. KERNAHAN’S STRIPPED ‘Y’
CLASSIFICATION

30. MILLARD’S MODIFICATION OF
STRIPPED ‘Y’

31. SCHUCHARDT AND PFEIFER’S
SYMBOLIC CLASSIFICATION

33. PROBLEMS ASSOCIATED
WITH CLEFT LIP AND PALATE
 Dental
 Esthetic
 Speech and Hearing
 Psychologic

34. Dental
 Congenitally missing teeth (most commonly
the upper laterals)
 Presence of natal or neonatal teeth
 Presence of supernumerary teeth
 Ectopically erupting teeth
 Anomalies of tooth morphology
 Enamel hypoplasia

35.  Microdontia
 Fused teeth, Spacingcrowding.
 Aberrations in crown shape
 Macrodontia
 Mobile and early shedding of teeth due to poor
periodontal support
 Posterior and anterior cross bite
 Protruding premaxilla
 Deep bite

36. Esthetic problems
 The clefts involving the lip can result in facial
disfigurement varing from mild to severe. The
oro-facial structures may be malformed and
congenitally missing. Deformities of nose can
also occur. Thus esthetics is greatly affected.

37. Hearing and speech
 Cleft lip and palate are sometimes
associated with disorders of the middle ear
which may affect hearing. The presence of
hearing problems can cause difficulties in
language uptake and speech.

38. Psychological problems
 Due to their abnormal facial appearance
they have to put up with staring, curiosity,
pity, etc.,.
 They also face problems in obtaining
jobs and making friends.

39.  Studies have shown that these patients
fare badly in academics. This is usually as
a result of hearing impairment, speech
problems and frequent absence from
school.

40. In 1943,the establishment of the American Cleft Palate Association
fostered the approach of team care.
There has been consensus since the that a multidisciplinary team within
a center takes care of craniofacial anomalies. The success of the
interaction between different specialities depends on the active
coordination of the sequence and timing of the various aspects of
treatment.
Management of cleft lip and palate

41. Team care
•Genetic scientist
•Peditrician
•Pedodontist
•Orthodontist
•Oral surgeon
•Prosthodontist
•Social worker
•ENT surgeon
•Plastic surgeon
•Psychiatrist
•Speech therapist

42. Management of cleft lip and palate
 Stage one:-this comprises of the treatment done from
birth to 18 months of age.
 Stage two:- this is from the 18th month to the 5th year of
life. It generally corresponds to the primary dentition
stage.
 Stage three:-this includes treatment that is carried out
during the mixed dentition stage. It spans from the 6th to
the 11th year of life.
 Stage four:- this includes treatment done during the
permanent dentition stage i.e. 12-18th of age.

43. Stage one treatment
 The treatment modalities carried out during
the first stage includes
- Fabrication of a passive obturator.
- Pre surgical orthopaedics.
- Surgical management of cleft lip.
- Surgical management of cleft palate.

44.  Millard has suggested the rule of ten.
Surgery should not be performed less than
10 weeks of age, when the body weight is
not less than 10 pounds and the blood
hemoglobin not less than 10grams%

45. Surgical palate closure
 The palatal repair should be attempted
between 12-24 months of age. This
facilitates normal speech, hearing and
improves swallowing. The palatal repair
can be accomplished by using bone
transplants that are taken from rib, iliac
bone, mandibular symphysis, tibial bone or
outer table f parietal bone.

46. Stage two treatment
 The procedure carried out during this phase
are:-
-adjustments in the intra-oral obturator to
accommodate the erupting deciduous teeth.
-to maintain a check on eruption pattern
and timing.
-oral hygiene instructions.
-restoration of decayed teeth.

47. Stage three treatment
 The stage three includes treatment carried out during the mixed
dentition phase. the orthodontic procedures usually carried out
are:-
-correction of anterior cross bites using removable or fixed
appliances. The anterior cross bite should be corrected to avoid
functional mandibular displacements and retardation of
maxillary growth due to locked in maxilla. Removable
appliances incorporating Z spring can be used to treat the
anterior cross bite.
-buccal segment cross bites are also treated using quad
helix or expansion screws.

48. Stage four treatment
 The patient is treated using a fixed orthodontic
appliance. All local irregularities like crowding,
spacing, cross bites and over jet /over bite
problems are corrected. Patients with Hypoplastic
maxilla may be given face mask to advance the
maxilla. Prosthesis can be given in case of
missing teeth after completion of orthodontic
therapy.

49. conclusion
Most infants born with clefts have the potential
for normal facial & occlusal development. The
limiting factors, should not be a self imposed
mental attitude that only a limited success is
to be expected.
With a coordinated team management &
accurate timing, the facial deformity can
harnessed well in the innocence.

50. Thank you