Cleft lip and palate can occur individually or together, with varying severity and combinations. Management requires a multidisciplinary approach across several stages: early intervention with feeding techniques and obturators, primary surgical repairs of the lip and palate, presurgical orthopedics to align dentition, and multiple stages of orthodontic treatment using appliances like facemasks. The goal is to address dental, speech, esthetic and psychological issues while coordinating care between specialists from infancy through adulthood.

1. CLEFT LIP AND
PALATE
DR KANCHAN AGRAWAL
DEPT. OF CLEFT AND CRANIOFACIAL ORTHODONTICS

2. CLEFTS OF LIP AND PALATE CAN OCCUR INDIVIDUALLY OR TOGETHER
IN VARIOUS COMBINATIONS.
THEY CAN ALSO OFFER ALONG WITH CONGENITAL DEFECTS THAT
AFFECT OTHER PARTS OF THE BODY.
INCIDENCE -
•INCIDENCE IN INDIA, 1 IN EVERY 600 – 1000 BIRTHS.
•THE NEGROID -1 IN EVERY 2000 BIRTHS
•CLEFT LIP M>F,
•CLEFT PALATE F>M.
•UNILATERAL CLEFTS ACCOUNT FOR 80% OF CASES, LEFT>RIGHT.

3. ETIOLOGY OF CLEFT LIP AND PALATE
HEREDITY -
•DOMINANT OR RECESSIVE TRAIT.
•1 IN 3 CHILDREN.
ENVIRONMENT -
CERTAIN TERATOGENS – LIKE VIRUS AND DRUGS LIKE CORTISONE,
VALIUM, DILANTIN ETC.
MULTIFACTORIAL ETIOLOGY -
THE ETIOLOGY CANNOT BE ATTRIBUTED TO ANY SINGLE FACTOR,
GENETIC OR ENVIRONMENTAL.

4. PREDISPOSING FACTORS
INCREASED MATERNAL AGE
RACIAL
BLOOD SUPPLY

5. EMBRYOLOGYEMBRYOLOGY
THE FIRST PHARYNGEAL ARCH (MANDIBULAR ARCH)(MANDIBULAR ARCH)
DEVELOPS TWO PROMINENCES –DEVELOPS TWO PROMINENCES –
1) THE MAXILLARY PROMINENCE1) THE MAXILLARY PROMINENCE
2) THE MANDIBULAR PROMINENCE2) THE MANDIBULAR PROMINENCE

10. AS THE MEDIAL NASAL PROMINENCES MERGE WITH THE MAXILLARYAS THE MEDIAL NASAL PROMINENCES MERGE WITH THE MAXILLARY
PROMINENCE, THEY FORM AN INTERMAXILLARY SEGMENT.PROMINENCE, THEY FORM AN INTERMAXILLARY SEGMENT.

11. THE INTERMAXILLARY SEGMENT GIVES RISE TO -THE INTERMAXILLARY SEGMENT GIVES RISE TO -
1) PHILTRUM OF THE UPPER LIP1) PHILTRUM OF THE UPPER LIP
2) THE PREMAXILLARY PART OF THE MAXILLA2) THE PREMAXILLARY PART OF THE MAXILLA
3) THE PRIMARY PALATE3) THE PRIMARY PALATE

13. MECHANISM OF PALATAL SHELF ELEVATION
- INTRINSIC FORCE WITHIN SHELF
- ACCUMULATION OF GLYCOSAMINOGLYCANS
- ACCUMULATION AND HYDRATION OF HYALURONIC
ACID
- INCREASE IN VASCULARITY
- CONTRACTION OF ELASTIC FIBRES OR MUSCLE FIBRES
- UNEQUAL DIVISION IN THE PALATAL AND THE ORAL
EPITHELIUM
- NEUROTRANSMITTERS LIKE SEROTONIN
- INCREASE IN VIMENTIN EXPRESSION
- MASTER CONTROLLING GENE IS FSP-1, SSH

16. LOCAL FACTORS
1) FAILURE OF THE HEAD TO ELEVATE & BECOME ERECT AT 7-9TH
WEEK
2) FAILURE OF TONGUE TO DESCEND DOWNWARDS & THEREBY
CAUSING A
MECHANICAL INTERFERENCE TO FUSION OF THE PALATINE SHELVES
3) DEFICIENCY OF OXYGEN
4) SHIFT OF BLOOD SUPPLY OF FACE - DURING THE 6TH
WEEK, MOST OF
THE
MID-FACE IS SUPPLIED BY THE STAPEDIAL ARTERY, WHICH IS A
BRANCH
OF THE INTERNAL CAROTID ARTERY
5) AT AROUND THE 7TH
WEEK, STAPEDIAL ARTERY SEVERS FROM THE

17. - CLASSIFICATIONS -
DAVIS AND RITCHIE’S CLASSIFICATION
GROUP I – PRE ALVEOLAR CLEFTS
SUBCLASSIFIED AS – UNILATERAL
BILATERAL
MEDIAN
MORPHOLOGICAL CLASSIFICATION.
GROUP II – POST ALVEOLAR CLEFT
GROUP III – ALVEOLAR CLEFTS
SUBCLASSIFIED AS – UNILATERAL
BILATERAL
MEDIAN

18. VEAU’S CLASSIFICATION
GROUP I – CLEFTS INVOLVING ONLY THE SOFT PALATE
GROUP II – CLEFTS INVOLVING THE SOFT AND HARD PALATE,
EXTENDING UPTO THE INCISIVE FORAMEN
GROUP III – THESE ARE COMPLETE UNILATERAL CLEFTS
INVOLVNG SOFT PALATE, HARD PALATE, LIP AND THE
ALVEOLAR RIDGEGROUP IV – THESE ARE COMPLETE BILATERAL CLEFTS
INVOLVNG SOFT PALATE, HARD PALATE, LIP AND THE
ALVEOLAR RIDGE

19. KERNAHAN’S STRIPPED ‘Y’ CLASSIFICATION
IT USES A STRIPPED ‘Y’ HAVING NUMBERED
BLOCKS. EACH BLOCK REPRESENTS A SPECIFIC
AREA OF THE ORAL CAVITY.
BLOCK 1 & 4 - LIP
BLOCK 2 & 5 - ALVEOLUS
BLOCK 3 & 6 - HARD PALATE ANTERIOR TO
INCISIVE FORAMEN
BLOCK 7 & 8 - HARD PALATE POSTERIOR TO
INCISIVE FORAMEN
BLOCK 9 - SOFT PALATE
1 4
5
63
2
7
8
9
R L
KERNAHAN’S
CLASSIFICATION

20. MILLARD’S CLASSIFICATION
A MODIFICATION OFA MODIFICATION OF
KERNAHAN’S STRIPED ‘Y’KERNAHAN’S STRIPED ‘Y’
CLASSIFICATIONCLASSIFICATION
THE INVERTED TRIANGLESTHE INVERTED TRIANGLES
REPRESENT THE NASAL ARCHREPRESENT THE NASAL ARCH
AND THE UPRIGHT TRIANGLESAND THE UPRIGHT TRIANGLES
REPRESENT THE NASALREPRESENT THE NASAL
FLOORFLOOR

21. L - A - H - S - H - A - L CLASSIFICATION
IT REPRESENTS THE ANATOMIC AREAS AFFECTED BY THE CLEFT
L - LIP
A - ALVEOLUS
H - HARD PALATE
S - SOFT PALATE
H - HARD PALATE
A - ALVEOLUS
L - LIP

22. C
L
E
F
T
L
I
P

23. CLEFT PALATE
CLEFT PALATE

24. CLEFT PALATE
CLEFT PALATE

25. CLEFT LIP

26. CLEFT PALATE

27. CLEFT PATIENT

28. PROBLEMS ASSOCIATED WITH CLEFTS
3. SPEECH AND HEARING PROBLEMS
1. DENTAL PROBLEMS
2. ESTHETIC PROBLEMS
4. PSYCHOLOGICAL PROBLEMS

29. THERE ARE 3 TYPES OF BOTTLES FOR FEEDING CLEFT
BABIES -
1) THE MEAD-JOHNSON CLEFT PALATE NURSER
2) THE HABERMAN FEEDER, AND
3) THE PIGEON NIPPLE
FEEDING
TECHNIQUES

30. MANAGEMENT
MULTIDISCIPLINARY
STAGE I - BIRTH – 18 MONTHS
STAGE II - 18 MONTHS – 5 YEARS
(PRIMARY DENTITION)
STAGE III -6 – 11 YEARS
(MIXED DENTITION)
STAGE IV - 12 – 18 YEARS
(PERMANENT DENTITION)
TREATMENT INVOLVES 4 DISTINCT STAGES

31. STAGE I TREATMENT
(Birth – 18 months)
IT INCLUDES -
1. FABRICATION OF A PASSIVE OBTURATOR
2. PRESURGICAL ORTHOPAEDICS
3. SURGICAL MANAGEMENT OF CLEFT LIP
4. SURGICAL MANAGEMENT OF CLEFT PALATE

32. OBTURATOR
EXTRA-ORAL STRAPPING

33. ADVANTAGES OF PRESURGICAL ORTHOPAEDICS
1. IT REDUCES THE SIZE OF CLEFTS, AIDING IN SURGERY
2. PARTIAL OBTURATION OF CLEFT ASSISTS IN FEEDING
3. SPEECH IS IMPROVED AS THE SIZE OF DEFECT IS REDUCED
4. REASSURES THE PARENTS AT A CRUCIAL TIME

34. 3. SURGICAL LIP CLOSURE -
THE EARLY school- within 45 days
WHEREAS, THE LATE SCHOOL- completion of dentition,
‘MILLARD’ HAS SUGGESTED - THE RULE OF TEN.
10 WEEKS OF AGE,
10 POUNDS
10% GRAMS HAEMOGLOBIN
4. SURGICAL PALATE CLOSURE -
IT IS CARRIED OUT BETWEEN 1 – 2 YEARS OF AGE. THIS FACILITATES
NORMAL SPEECH, HEARING AND IMPROVES SWALLOWING. BONE
TRANSPLANT FROM RIBS, ILIAC CREST ETC. CAN BE USED.

35. STAGE II TREATMENT
(18 months – 5 years)
PRIMARY DENTITION.
1. Adjustments in the intra-oral obturator to accommodate the erupting
deciduous teeth
2. Check on erupting pattern and timing
3. Oral hygiene
4. Restoration
NO ORTHODONTIC TREATMENT
STAGE III TREATMENT
(From 6 – 11 years)
MIXED DENTITION.
1. Correction of anterior crossbites
2. Buccal segment crossbites (with quad-helix, screws)

36. FACEMASK

37. STAGE IV TREATMENT
(From 12 – 18 years)
PERMANENT DENTITION PHASE.
• FIXED ORTHODONTIC
• FACE MASK.
• PROSTHESIS
AFTER ORTHODONTIC THERAPY, THE PATIENT IS PLACED
ON A RETENTION PHASE.
• Long term retention
• Due to inadequate bone support,
• The absence of teeth and presence of stretched scar tissue.
• .

38. EXTERNAL DISTRACTOR
INTERNAL DISTRACTOR
INTERNAL DISTRACTOR

39. TREATMENT OF CLEFT – A BRIEF OVERVIEW

40. THANK
YOU