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Congenital abnormal space or gap in the upper
lip, alveolus and palate
More common in south far Asians:
 1 in 500
Less frequent in Africans:
 1 in 2000
Prevalence in Europeans and Americans:
 1 in 750
Prevalence in Pakistan1
:
 1 in 523
1. Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A. Epidemiology of cleft lip and
cleft palate in Pakistan. Otolaryngol Clin North Am. 2007 Feb; 40(1):27-60.
Male to female ratio – 3 : 2
Cleft Lip and Palate are twice as common in
boys as in girls
Isolated Clefts of Palate are more common in
girls
75% of Clefts are Unilateral, rest are Bilateral
Left side is more frequently involved
The medial nasal swellings
enlarge, grow medially and
merge with each other in
the midline to form the
intermaxillary segment
Human embryo: 7 weeks
Kernahan “Striped Y”
Millard Modification of Kernahan “Striped Y”
Kriens “LAHSHAL”
Kernahan “Striped Y”
Lip
Alveolus
Primary Palate
Hard Palate
Hard Palate
Soft Palate
Millard Modification of Kernahan “Striped Y”
Kriens “LAHSHAL”
 Capital letter = complete cleft
 Lowercase letter = incomplete cleft
 “.” or “-” = normal
 Example:
 LA- - - - l = complete right cleft lip and alveolus,
incomplete left cleft lip
Microform Cleft:
 May look like
 a little dent in the red part of lip
 a scar from the lip up to nostril
 Muscle tissue underneath cleft can be affected
and may require surgery
Submucous Cleft Palate:
 Midline deficiency or lack of muscular tissue
 Often a submucous cleft palate is associated
with a bifid or cleft uvula
Posterior nasal spine is almost always missing
Speech problems are common
Transabdominal
Ultrasonography :
Reliable after 4th
month
Clefts of lip
Clefts of palate:
 Sagittal View
 Axial View
 Coronal View
Transvaginal
Ultrasonography
Three-dimensional
ultrasonography
 Advantages of Prenatal
Diagnosis:
1. Time for parental education
2. Time for parental psychological
preparation
3. Preparation for neonatal care
and feeding
4. Opportunity to investigate other
associated anomalies
5. Gives parents the choice of
continuing the pregnancy
6. Opportunity for fetal surgery
8-9 Year:
 Initial interventional
Orthodontics
 Preparation for
alveolar bone grafting
10 Year:
 Alveolar Bone Grafts
12-14 Year:
 Definite Orthodontics
16 Year:
 Nasal Revision Surgery
17-20 Year:
 Orthognathic Surgery
Birth:
 Initial Assessment
 Pre-surgical assessment
3 Month:
 Primary Lip repair
9-18 month:
 Palate Repair
2 Year:
 Speech assessment
3-5 Year:
 Lip Revision Surgery
 Genetic Scientist
 Pediatrician
 Pedodontist
 Orthodontist
 Oral and Maxillofacial Surgeon
 Prosthodontist
 ENT Surgeon
 Plastic Surgeon
 Psychiatrist
 Speech Therapist
 Social Worker
Feeding
Dental problems
Nasal Deformity and Esthetic Problems
Ear Problems
Speech Difficulties
Cleft lip
 Makes it more difficult for an infant to suck
Cleft Palate
 May cause milk to be accidently taken up into
nasal cavity
 Inability to create negative pressure inside oral
cavity
 Frequent regurgitations
 Upper respiratory tract infections
In Patient with Cleft lip
 Special nipples to allow baby to latch properly
Mead
Johnson/Enfamil
Cleft Feeder
Pigeon Feeder Dr. Brown’s Natural Flow
Special Needs Feeder /
Haberman Feeder
In patients with cleft
palate
 Avoid feeding without
palatal obturator
 Feeding in an upright
position
Local Dental Problems:
 Congenitally Missing teeth (Hypodontia, Oligodontia)
 Hyperdontia
 Presence of natal and neonatal teeth
 Abnormal tooth morphology (microdontia, macrodontia )
 Fused teeth
 Enamel Hypoplasia
 Gemination, Dilacerations
 Poor periodontal support
Orthodontics Problems:
 Class III tendency
 Anterior and Posterior Cross bite
 Spacing and crowding
 Facial Disfigurements
 Poor nasal shape
 Scar marks of surgeries
 Poor lip function during
speech
 Poor dental alignment and
smile
Middle ear disease - 22% to 88%
Conductive hearing loss and chronic
suppurative otitis media
Repeated tympanostomy tube placement
Abnormal curvature of eustachian tube lumen
Altered width and angulation of skull base
Abnormal insertions of the tensor and levator veli
palatini muscles into cartilages and skull base
 96% of children require
tympanostomy tube placement1
 50% of these children required
repeat tympanostomy tube
placement 1
 Frequency of otitis media
decreases as the child with CP
ages
 Audiology and tympanometry as
well as exams / clinical history
1
Muntz HR, An overview of middle ear disease in cleft palate children, Facial Plast Surg. 9
(1993) 177-180.
Hearing loss hampers proper development of
speech
Velopharyngeal Insufficiency (VPI)
Poor pronunciation of Bilabial, Labiodental,
Linguoalveolar sounds
Maxillary Strapping
Nasoalveolar Moulding Appliances (NAM)
Advantages:
1. Reduces the size of cleft; aids in surgery
2. Partial obturation aids in feeding
3. Parental reassurance at a crucial time
Indications of NAMs:
1. Large lip defect requiring presurgical
approximatiom
2. Severe deviations in nasal cartilages columella,
nasal tip, and lateral wall
3. Post surgical nasal molding and tension
reduction across suture line
 Premaxilla is extremely
protrusive
 Premaxilla and prolabium
can be of variable size
 Columella is deficient/almost
nonexistent
 Palatal shelves are collapsed
Bilateral Cleft Lip
Bilateral Cleft Lip
 Repositioning of protrusive
maxilla
 Support from intraoral
component
 Retention with
 Denture adhesive
 Elastic strap
• Time of surgery: approximately at10 weeks
“Rule of Ten”
 Child weighs 10 pounds
 Child has a hemoglobin of at least 10 grams/dl
 Child has a WBC count < 10 thousand
 Child is at least 10 weeks of age
Cleft Lip Repair
 Unilateral
 Millards’s rotation-advancement flap
Cleft Lip Repair
 Bilateral
 bilateral rotation advancement with attachment to
premaxilla mucosa
Dorf and Curtin1
 10% occurrence of articulation errors when
palatoplasty was completed by 1 year
 86% incidence of articulation errors when repair
was complete after 1 year
Haapanen and Rantala2
 Significantly fewer children in the groups repaired
before 18 months had hypernasal speech,
articulation errors, or required secondary surgery
to correct speech
1. Dorf DS, JW Curtin: Early cleft palate repair and speech outcome: A ten year experience. J Bardach
HL Morris Multidisciplinary Management of Cleft Lip and Palate. 1990 WB Saunders Philadelphia 341-
348.
2. Haapanen ML, Rantala SL. Correlation between the age at repair and speech outcome in patients
with isolated cleft palate. Scand J Plast Reconstr Surg Hand Surg. 1992;26(1):71-8.
1. Schweckendick’s Primary Veloplasty
2. Von Langenbeck Palatal Repair
3. V-Y Pushback
4. Furlow Palatoplasty
1. Schweckendick’s Primary Veloplasty
 Incisions made in soft palate
 Muscle bundles released from posterior hard
palate and rotated
 Reconstruction of levator sling
 Closure of mucosal layers separately
2. Von Langenbeck Operation
V-Y Pushback (WARDILL OPERATION)
 Two uni-pedicled flaps (greater palatine artery)
raised
 Posterior flaps rotated in a V-Y advancement
 Improved speech results
 Indicated for incomplete clefts
V-Y Pushback (WARDILL OPERATION)
Furlow Palatoplasty
 Lengthens soft palate
 Reconstructs the muscle sling
 Used to correct velopharyngeal insufficiency
 Can be used for treatment of submucous clefts
 Aim: Prepare the dentition adjacent to cleft
for the secondary alveolar bone graft
 Avarge Duration: 6-12 months
 Appliances:
1. Bonded edgewise appliance
2. Supported with a maxillary expander quad
helix expander
 Use of Quadhelix to expand maxillary arch
 Use of Spider appliance to expand maxillary
arch
 Use of bonded edgewise appliance
Primary Bone Grafting
1. Bone graft done at the time of primary
cheiloplasty
2. Bone graft done during the first 2 years of life
3. Bone graft done prior to the eruption of the
primary canine
Secondary Bone Grafting
Done before eruption of the permanent canine
 In CLP dental age lags behind chronological
age
 Early bone graft: 2-5 years of age
 Intermediate bone graff: 6-15 years of age
 Late bone graph: 16 year and older
Advantages:
1. Provides bone for eruption and orthodontic
repositioning of teeth
2. Closure of oro-nasal fistulas
3. Support and elevation of alar base
4. Stabilization of pre-maxilla in bilateral cases
5. Establishing continuity of alveolar ridge
Autogenous
 Cancellous- iliac crest
 Cortical- calvarium, mandible
 Cortico-cancellous- iliac, rib, tibia, mandible
Allogeneic1
 Graft resorbs, remodels, may contribute to
osteoinduction and osteoconduction
Alloplast2
 Bone grows into, around alloplast
 No active osteoinduction but some osteoconduction
 Teeth do not erupt through alloplast
1. Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary alveolar clefts in
humans- A preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987.
2. Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect in a primate
model. J Oral Maxiilofac Surg 47:946-952, 1989.
Preoperative Post Operative
Preoperative Cleft
Defect
Postoperative Bone Graft
• Correction of anterior
crossbite
• Arch expansion
• Stability of results is
questionable
• Slower results as
compared to normal
subjects
Face mask therapy:
Late mandibular growth may aggravate
problems
Hypernasality may increase
Definitive dental prosthesis may be planned
Treatment planning
 Mild skeletal discrepancy: Dental compensations
 Moderate skeletal discrepancy: Orthognathic surgery
 Severe skeletal discrepancy: Distraction osteogenesis
Lefort I maxillary advancement
 Relapse after rigid fixation1
 Mean maxillary horizontal relapse of 20.5%
 Mean vertical relapse of 22.2% within first year
 Velopharyngeal insufficiency
1. Heliövaara A, Ranta R, Hukki J, Rintala A. Skeletal stability of Le fort I osteotomy in
patients with unilateral cleft lip and palate. Scand J Plast Reconstr Surg Hand Surg
2001;35:43-49.
Maxillary advancement with distraction
Osteogenesis
Midfacial Advancement
 Pretreatment Decompensation
Maxillary advancement with intraoral distractor
Pretreatment Postreatment
Maxillary advancement with Extraoral distractor
 Patients with a cleft lip and palate requirePatients with a cleft lip and palate require
highest standard ofhighest standard of multidisciplinary caremultidisciplinary care
 Management starts pre-natally after initialManagement starts pre-natally after initial
diagnosis, followed by a long treatment aimingdiagnosis, followed by a long treatment aiming
at restoration of oral health and function whileat restoration of oral health and function while
achieving optimum estheticsachieving optimum esthetics
 Right intervention at right timeRight intervention at right time can significantlycan significantly
improve the quality of lifeimprove the quality of life
Timing: 17-20 years of age
Standard techniques
 Tip projection
 Alar rotation
 Columellar lengthening
Goals of Surgery
1. Reducing the size of opening between oral
and nasal cavities
2. Reconnecting palatal muscles to restore
function
3. Restore the anatomical length of soft palate
Dorrance and Brown’s – U shaped push back
palatoplasty
Use of Pharyngeal flap
Posterior pharyngeal wall augmentation with
implants and injections
Cleft lip and palate - Introduction and Orthodontic Considerations

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Cleft lip and palate - Introduction and Orthodontic Considerations

  • 1.
  • 2. Congenital abnormal space or gap in the upper lip, alveolus and palate
  • 3. More common in south far Asians:  1 in 500 Less frequent in Africans:  1 in 2000 Prevalence in Europeans and Americans:  1 in 750 Prevalence in Pakistan1 :  1 in 523 1. Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A. Epidemiology of cleft lip and cleft palate in Pakistan. Otolaryngol Clin North Am. 2007 Feb; 40(1):27-60.
  • 4. Male to female ratio – 3 : 2 Cleft Lip and Palate are twice as common in boys as in girls Isolated Clefts of Palate are more common in girls 75% of Clefts are Unilateral, rest are Bilateral Left side is more frequently involved
  • 5. The medial nasal swellings enlarge, grow medially and merge with each other in the midline to form the intermaxillary segment Human embryo: 7 weeks
  • 6.
  • 7. Kernahan “Striped Y” Millard Modification of Kernahan “Striped Y” Kriens “LAHSHAL”
  • 8. Kernahan “Striped Y” Lip Alveolus Primary Palate Hard Palate Hard Palate Soft Palate
  • 9. Millard Modification of Kernahan “Striped Y”
  • 10. Kriens “LAHSHAL”  Capital letter = complete cleft  Lowercase letter = incomplete cleft  “.” or “-” = normal  Example:  LA- - - - l = complete right cleft lip and alveolus, incomplete left cleft lip
  • 11. Microform Cleft:  May look like  a little dent in the red part of lip  a scar from the lip up to nostril  Muscle tissue underneath cleft can be affected and may require surgery
  • 12. Submucous Cleft Palate:  Midline deficiency or lack of muscular tissue  Often a submucous cleft palate is associated with a bifid or cleft uvula Posterior nasal spine is almost always missing Speech problems are common
  • 13. Transabdominal Ultrasonography : Reliable after 4th month Clefts of lip Clefts of palate:  Sagittal View  Axial View  Coronal View Transvaginal Ultrasonography Three-dimensional ultrasonography
  • 14.  Advantages of Prenatal Diagnosis: 1. Time for parental education 2. Time for parental psychological preparation 3. Preparation for neonatal care and feeding 4. Opportunity to investigate other associated anomalies 5. Gives parents the choice of continuing the pregnancy 6. Opportunity for fetal surgery
  • 15.
  • 16. 8-9 Year:  Initial interventional Orthodontics  Preparation for alveolar bone grafting 10 Year:  Alveolar Bone Grafts 12-14 Year:  Definite Orthodontics 16 Year:  Nasal Revision Surgery 17-20 Year:  Orthognathic Surgery Birth:  Initial Assessment  Pre-surgical assessment 3 Month:  Primary Lip repair 9-18 month:  Palate Repair 2 Year:  Speech assessment 3-5 Year:  Lip Revision Surgery
  • 17.  Genetic Scientist  Pediatrician  Pedodontist  Orthodontist  Oral and Maxillofacial Surgeon  Prosthodontist  ENT Surgeon  Plastic Surgeon  Psychiatrist  Speech Therapist  Social Worker
  • 18. Feeding Dental problems Nasal Deformity and Esthetic Problems Ear Problems Speech Difficulties
  • 19. Cleft lip  Makes it more difficult for an infant to suck Cleft Palate  May cause milk to be accidently taken up into nasal cavity  Inability to create negative pressure inside oral cavity  Frequent regurgitations  Upper respiratory tract infections
  • 20. In Patient with Cleft lip  Special nipples to allow baby to latch properly Mead Johnson/Enfamil Cleft Feeder Pigeon Feeder Dr. Brown’s Natural Flow Special Needs Feeder / Haberman Feeder
  • 21. In patients with cleft palate  Avoid feeding without palatal obturator  Feeding in an upright position
  • 22. Local Dental Problems:  Congenitally Missing teeth (Hypodontia, Oligodontia)  Hyperdontia  Presence of natal and neonatal teeth  Abnormal tooth morphology (microdontia, macrodontia )  Fused teeth  Enamel Hypoplasia  Gemination, Dilacerations  Poor periodontal support Orthodontics Problems:  Class III tendency  Anterior and Posterior Cross bite  Spacing and crowding
  • 23.  Facial Disfigurements  Poor nasal shape  Scar marks of surgeries  Poor lip function during speech  Poor dental alignment and smile
  • 24. Middle ear disease - 22% to 88% Conductive hearing loss and chronic suppurative otitis media Repeated tympanostomy tube placement
  • 25. Abnormal curvature of eustachian tube lumen Altered width and angulation of skull base Abnormal insertions of the tensor and levator veli palatini muscles into cartilages and skull base
  • 26.  96% of children require tympanostomy tube placement1  50% of these children required repeat tympanostomy tube placement 1  Frequency of otitis media decreases as the child with CP ages  Audiology and tympanometry as well as exams / clinical history 1 Muntz HR, An overview of middle ear disease in cleft palate children, Facial Plast Surg. 9 (1993) 177-180.
  • 27. Hearing loss hampers proper development of speech Velopharyngeal Insufficiency (VPI) Poor pronunciation of Bilabial, Labiodental, Linguoalveolar sounds
  • 28. Maxillary Strapping Nasoalveolar Moulding Appliances (NAM) Advantages: 1. Reduces the size of cleft; aids in surgery 2. Partial obturation aids in feeding 3. Parental reassurance at a crucial time
  • 29. Indications of NAMs: 1. Large lip defect requiring presurgical approximatiom 2. Severe deviations in nasal cartilages columella, nasal tip, and lateral wall 3. Post surgical nasal molding and tension reduction across suture line
  • 30.
  • 31.  Premaxilla is extremely protrusive  Premaxilla and prolabium can be of variable size  Columella is deficient/almost nonexistent  Palatal shelves are collapsed Bilateral Cleft Lip
  • 32. Bilateral Cleft Lip  Repositioning of protrusive maxilla  Support from intraoral component  Retention with  Denture adhesive  Elastic strap
  • 33. • Time of surgery: approximately at10 weeks “Rule of Ten”  Child weighs 10 pounds  Child has a hemoglobin of at least 10 grams/dl  Child has a WBC count < 10 thousand  Child is at least 10 weeks of age
  • 34. Cleft Lip Repair  Unilateral  Millards’s rotation-advancement flap
  • 35. Cleft Lip Repair  Bilateral  bilateral rotation advancement with attachment to premaxilla mucosa
  • 36. Dorf and Curtin1  10% occurrence of articulation errors when palatoplasty was completed by 1 year  86% incidence of articulation errors when repair was complete after 1 year Haapanen and Rantala2  Significantly fewer children in the groups repaired before 18 months had hypernasal speech, articulation errors, or required secondary surgery to correct speech 1. Dorf DS, JW Curtin: Early cleft palate repair and speech outcome: A ten year experience. J Bardach HL Morris Multidisciplinary Management of Cleft Lip and Palate. 1990 WB Saunders Philadelphia 341- 348. 2. Haapanen ML, Rantala SL. Correlation between the age at repair and speech outcome in patients with isolated cleft palate. Scand J Plast Reconstr Surg Hand Surg. 1992;26(1):71-8.
  • 37. 1. Schweckendick’s Primary Veloplasty 2. Von Langenbeck Palatal Repair 3. V-Y Pushback 4. Furlow Palatoplasty
  • 38. 1. Schweckendick’s Primary Veloplasty  Incisions made in soft palate  Muscle bundles released from posterior hard palate and rotated  Reconstruction of levator sling  Closure of mucosal layers separately
  • 39. 2. Von Langenbeck Operation
  • 40. V-Y Pushback (WARDILL OPERATION)  Two uni-pedicled flaps (greater palatine artery) raised  Posterior flaps rotated in a V-Y advancement  Improved speech results  Indicated for incomplete clefts
  • 42. Furlow Palatoplasty  Lengthens soft palate  Reconstructs the muscle sling  Used to correct velopharyngeal insufficiency  Can be used for treatment of submucous clefts
  • 43.
  • 44.  Aim: Prepare the dentition adjacent to cleft for the secondary alveolar bone graft  Avarge Duration: 6-12 months  Appliances: 1. Bonded edgewise appliance 2. Supported with a maxillary expander quad helix expander
  • 45.  Use of Quadhelix to expand maxillary arch
  • 46.  Use of Spider appliance to expand maxillary arch
  • 47.  Use of bonded edgewise appliance
  • 48. Primary Bone Grafting 1. Bone graft done at the time of primary cheiloplasty 2. Bone graft done during the first 2 years of life 3. Bone graft done prior to the eruption of the primary canine
  • 49. Secondary Bone Grafting Done before eruption of the permanent canine  In CLP dental age lags behind chronological age  Early bone graft: 2-5 years of age  Intermediate bone graff: 6-15 years of age  Late bone graph: 16 year and older
  • 50. Advantages: 1. Provides bone for eruption and orthodontic repositioning of teeth 2. Closure of oro-nasal fistulas 3. Support and elevation of alar base 4. Stabilization of pre-maxilla in bilateral cases 5. Establishing continuity of alveolar ridge
  • 51. Autogenous  Cancellous- iliac crest  Cortical- calvarium, mandible  Cortico-cancellous- iliac, rib, tibia, mandible Allogeneic1  Graft resorbs, remodels, may contribute to osteoinduction and osteoconduction Alloplast2  Bone grows into, around alloplast  No active osteoinduction but some osteoconduction  Teeth do not erupt through alloplast 1. Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary alveolar clefts in humans- A preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987. 2. Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect in a primate model. J Oral Maxiilofac Surg 47:946-952, 1989.
  • 52.
  • 53.
  • 54.
  • 55.
  • 58.
  • 59. • Correction of anterior crossbite • Arch expansion • Stability of results is questionable • Slower results as compared to normal subjects Face mask therapy:
  • 60. Late mandibular growth may aggravate problems Hypernasality may increase Definitive dental prosthesis may be planned Treatment planning  Mild skeletal discrepancy: Dental compensations  Moderate skeletal discrepancy: Orthognathic surgery  Severe skeletal discrepancy: Distraction osteogenesis
  • 61. Lefort I maxillary advancement  Relapse after rigid fixation1  Mean maxillary horizontal relapse of 20.5%  Mean vertical relapse of 22.2% within first year  Velopharyngeal insufficiency 1. Heliövaara A, Ranta R, Hukki J, Rintala A. Skeletal stability of Le fort I osteotomy in patients with unilateral cleft lip and palate. Scand J Plast Reconstr Surg Hand Surg 2001;35:43-49.
  • 62. Maxillary advancement with distraction Osteogenesis
  • 64. Maxillary advancement with intraoral distractor
  • 66.
  • 67. Maxillary advancement with Extraoral distractor
  • 68.  Patients with a cleft lip and palate requirePatients with a cleft lip and palate require highest standard ofhighest standard of multidisciplinary caremultidisciplinary care  Management starts pre-natally after initialManagement starts pre-natally after initial diagnosis, followed by a long treatment aimingdiagnosis, followed by a long treatment aiming at restoration of oral health and function whileat restoration of oral health and function while achieving optimum estheticsachieving optimum esthetics  Right intervention at right timeRight intervention at right time can significantlycan significantly improve the quality of lifeimprove the quality of life
  • 69.
  • 70.
  • 71. Timing: 17-20 years of age Standard techniques  Tip projection  Alar rotation  Columellar lengthening
  • 72. Goals of Surgery 1. Reducing the size of opening between oral and nasal cavities 2. Reconnecting palatal muscles to restore function 3. Restore the anatomical length of soft palate
  • 73. Dorrance and Brown’s – U shaped push back palatoplasty
  • 75. Posterior pharyngeal wall augmentation with implants and injections

Editor's Notes

  1. Done before eruption of the permanent canine Usually when the root of the canine is 1/3 to 2/3 formed