Management of Orofacial Cleft Dr. Sunil (2).pptxManagement of Orofacial Cleft Dr. Sunil (2).pptxManagement of Orofacial Cleft Dr. Sunil (2).pptxManagement of Orofacial Cleft Dr. Sunil (2).pptx

1. Dr Suneel Kumar, FCPS
03/11/2015

2. Embryology
Causative Factors
Problems of Individuals with
Cleft
 A-Dental Problem
 B-Malocculsion
 C-Nasal deformity
 D-Feeding
 E-Ear Problem
 Speech difficulties
 Associated Anomalies
Treatment of Cleft Lip & Palate
 A-Timing of Surgical Repair
 B-Cheilorrahy
 C-Palatorrhapy
 D-Alveolar Cleft Graft
Correction of Maxillomandibular
Disharmonies
 Sceondary Surgical
Procedures
Dental needs of Individuals with
Cleft
 Prostheric Speech aid
Applainces

3. A Cleft is a congenital abnormal space or gap
in the upper lip, alveolus or palate.

4.  Cleft lip.
 Cleft Palate.
 Cleft lip and palate.

5.  Most common serious congenital anomalies
to effect the orofacial region.
 Initial appearances is groustique ( can be
seen, felt and heard ).
 Need dental care throughout course of
treatment.
 Source of shock to parents of an afflicted
baby.

6. Treatment must address patient appearances,
speech, hearing, mastication and degulation.

7.  General or pediatric dentist
 Orthodontist
 Prosthodontist
 Oral & Maxillofacial Surgeon
 Plastic surgeon
 Audiologist
 Otorhinolarynologist
 Pediatrician
 Speech pathologist
 Psychologist or psychistrist
 Social worker

8. GENERAL FEATURE
 The rate of occurrence 1in 700 ( USA ).
 More common in Asian, less in black.
 Boys are affected more often than girls, by ratio
of 3:2
 Cleft lip and palate (together) occurs about
twice in boy, whereas isolated cleft more often
in girls.
 ¾ are unilateral, ¼ are bilateral.
 Left side involve more frequently than right
when defect is unilateral.
 May be complete or incomplete.

9.  Primary Palate.
Lip, Alveolus
 Secondary Palate.
Hard and Soft Palate

13.  Unilateral
( complete )
cleft lip
extending into
the nose.

14.  Unilateral
( incomplete ) cleft
lip

15.  Unilateral cleft
involving lip and
alveolus.

16.  Bilateral cleft
involving lip and
alveolus.

17.  Isolated cleft palate

18. Cleft palate
combined with
unilateral cleft of
alveolus.

19.  Bilateral complete
cleft of lip and
palate.

20. Soft palate cleft shows variation
 Bifid uvula (Only Uvula)
 Submucosal cleft or Occult Cleft (Muscles of
soft palate not unite, not seen on Cursory
(rapid) Examination when pts says “ah” then
appear )
 On plapation Absent of Posterior nasal spine
characteristic feature of submucosal cleft

21.  Entire process take place b/w the 5th and
10th weeks of fetal life.

24.  Exact cause is unknown.
 No single factors can be identified as
cause of clefts.
 Syndrome account 15% of the total no: of
the causes.
 Environmental factors play contributory
role at the time of embryological
development when lip and palate fusing.

25. Non Syndromic:
1-Radiation(pregnancy)
2-Smoking (pregnancy)
3-Durgs (Antiepletic, Phyeniton,
Thalidomide) (Pregnancy)
4-Alcohol (Pregnancy)
5-Viruses (Toga virus, Rubella virus)
6-Nutritional deficiency
7-Excess or Deficiency of vitamins
8-Chemicals
9-Hypoxia

26. Syndromic: Heridarty:Genetic
1-Treacher Collins Syndrome
2-Van der Woude Syndrome
3-Apert's syndrome
4-Stickler's syndrome
5-Velocardiofacial syndrome
6-carpenter syndrome

28.  1-Dental
 2-Malocculsion
 3-Ear
 4-Speech difficulties
 5-Nasal Deformity
 6-Feeding
 7-Associated Anomalies

29. 1-DENTAL
 Primary, permanent teeth and jaw may be
affected by cleft.
 Supernumerary and congenitally absence
of teeth.
 Cleft commonly extend b/w the lateral
incisor and canine may displace or
absences of these teeth.
 Supernumerary frequently present around
the cleft margin.

30. 2-MALOCCULASION
 Skeletal discrepancy commonly found
specially in cleft palate.
 Class III malocclusion seen in most cases
( pseudoprognathism).
 Unilateral palatal cleft show narrow
dental arches.
 Bilateral heaving constricted posterior
segments and protusive anterior segment.

31. 3-FEEDING
 Babies with cleft palate, swallow normally once
material being reaches the hypopharynx.
 Have extreme difficulty to produce the
negative pressure in the mouth to allow
sucking.
 Problem easily overcome through the specially
design elongated nipple which extend further
into the baby mouth.
 May be use eye droppers or large syringe for
feeding.

32. 4-NASAL DEFORMITY
 Commonly seen in cleft lip.
 Alar cartilage flared on cleft side and
coulumella of nose pulled toward the
noncleft side.
 Surgical correction of nasal deformity should
be differed until all cleft and associated
problem have been corrected.

33. 5-EAR PROBLEM
 Predispose to middle ear infection.
 Leveter veli palatine and tensor veli
palatine remain unattached due to soft
palate cleft.
 Muscle allow the opening of the ostium,
disruption may close the space, serous
fluid accumulate and result in serous
ostitis media.

34. 6-SPEECH PROBLEM
 Retardation of consonant sound.
( i, e, p, b, t, d, k, g )
 Hyper nasal speech.
 Dental malformation & abnormal tongue
placement.
 Hearing problem.

35.  7-Associated Anomalies
20 times more likely to another problems
Culb foot
Neurologic problems
Cardiac problems

37. Dr Suneel Kumar, FCPS
05/11/2015

38. Embryology
Causative Factors
Problems of Individuals with
Cleft
 A-Dental Problem
 B-Malocculsion
 C-Nasal deformity
 D-Feeding
 E-Ear Problem
 Speech difficulties
 Associated Anomalies
Treatment of Cleft Lip & Palate
 A-Timing of Surgical Repair
 B-Cheilorrahy
 C-Palatorrhapy
 D-Alveolar Cleft Graft
Correction of Maxillomandibular
Disharmonies
 Secondary Surgical
Procedures
Dental needs of Individuals with
Cleft
 Prosthetic Speech aid
Appliances

40.  The aim of treatment is to correct the cleft and
associated problems, thus hide the anomaly so
that patient can lead normal life.

41.  Neo-natal
 Referred to cleft lip and
palate team
 Diagnosis and genetic
counseling
 Address psycho-social issues
 Provide feeding instructions
 Make feeding plan

42.  Birth-1 month
 Referred to cleft lip
and palate team
 Diagnosis and genetic
counseling
 Address psychosocial
issues
 Provide feeding
instructions and check
growth

43.  1-4 months
 Check feeding and
growth
 Repair cleft lip
 make sure ears and
hearing

44.  5-15 months
 Check feeding, growth,
development
 Check ears and
hearing; consider ear
tubes
 Repair cleft palate
 Provide oral hygiene
instructions

45. 16-24 months
 Assess ears and hearing
 Assess speech and
language
 Check development

46.  2-5 years
 Assess speech and
language;
manage velopharyngeal
insufficiency
 Check ears and hearing
 Consider lip/nose
revision before school
 Assess development and
psychosocial adjustment

47.  6-11 years
 Assess speech and
language;
manage velopharyngeal
insufficiency
 Orthodontic interventions
 Alveolar bone graft
 Assess
school/psychosocial
adjustment

48.  12-21 years
 Jaw surgery,
rhinoplasty as needed
 Orthodontic, bridges,
implants as needed
 Genetic counseling
 Assess
school/psychosocial
adjustment

49.  Rule of 10:
10 week of age
10 lb weight
10 g/dl hemoglobin
 Surgery may be postponed if heaving medical
problem.

50.  1-Better palatal and pharyngeal muscle
development once repaired.
 2-Ease of feeding.
 3-Better development of phonation skills.
 4-Better auditory tube function.
 5-Better hygiene when the oral and nasal
partition is competent.
 6-Improve psychological state for parents
and baby.

51.  1-Surgical closer is more difficult in younger
children with small structure.
 2-Scar formation resulting from surgery cause
maxillary growth restriction.

52.  The lip corrected as soon as possible.
 Soft palate is closed b/w 8 and 18 months of
age.
 Hard palate repaired in the last.

53.  It is the surgical correction of the cleft lip
deformity.
 Earliest operative procedure used to correct
cleft deformity and is undertaken as soon as
medically possible.

54. OBJECTIVE
 Functional:
Should restore the functional
arrangement of the orbicularis oris to
reestablish the normal function of upper
lip.
 Esthetic:
Produce a lip that display normal
anatomical structure.

55. Options Available
1-Millard
Conventional
Modified (Type-1 Type-2)
2-Noordroffs
3-Skoong
4-Melek
5-Tennisson
6-Randoll
7-Le-Mesurer
8-Wynn
9-Delaire
10-Trauner

56.  Le Mesurier technique

57.  Milard operation

58.  it’s a surgical correction of cleft palate.
 May be perform in one or two operation.
 Two operation:
First soft palate closure (stylorrahphy )
Second Hard palate closure
(uranorraphy)

59. OBJECTIVE
To create a mechanism capable of speech
and degulation without significant interfering
the maxillary growth.

60. Options Available
Hard Plate
Soft Plate
1-Vomer flap
2-W-Y Push back
3-U-shaped Push Back
4-Vom-lagenback
5-Intravelarveloplasty
6-Furlows Z plasty
7-Layered Closured

61. Hard palate closure
Von Langenbeck operation using lateral
releasing incision.

62. Vomar flap technique for bilateral hard
palate cleft

63. Wardil operation for
palatal lengthening
on closer.

64. Soft palate closure
 Always close in three layers:
Nasal mucosa
Muscle
Oral mucosa

65.  Triple layer soft
palate closure.

66.  Alveolar cleft usually not corrected without
graft.
 As a result afflicted may have oronasal
fistula.
 Maxillary alveolus not continuous because of
cleft.

67. Common problem due to residual alveolar
cleft.
 1-Oral fluids escape into the nasal cavity.
 2-Nasal secretion drain into the oral cavity.
 3-Teeth erupt into the alveolar cleft.
 4-The alveolar segment collapse.
 5-Speech adversely affected

68. ADVANTAGES
 1-Closure of oronasal fistula
 2-To Establish the bony continuity between cleft
segements
 3-To Establish the alveolar contour of the ridge
 4-To help the eruption of lateral incisor and
canine
 5-Fot orthodontic tooth movement
 6-For implant placement
 7-To give the support at base of nose
 8-PDL health of adjacent teeth
 9-To prevent the exposure of cementum of the
adjacent teeth

69. Timing of graft procedure
 Perform at age of 7- 10 years.
 Graft is place before the eruption of canine
 Graft is placed when ½ or 2/3 roots of
unerupted canine formed
 When the maxillary cental incisors are
erupted

70. Timing of graft procedure
 1-Primary at the time of lip closure or within
2years of age
 2-early Secondary at the time of eruption of
centals incisors
 3-Secondary at the age of 8 to 11 years
 4-Late secondary after the eruption of canine

71.  1-Autogenous graft
 2-Allogenic graft
 3-Xenogenic graft
Ideal
 Autogenous graft (Illiac crest, Cranium,
Symphysis region, Rib graft, 3rdmolar area of
mandible, tibia)
 In other types of graft tooth will not
Grow/Erupt and take 6 to 9 months for
complete healing

72. Orthognathetic surgery
 Total maxillary osteotomy in advance cases.
 Alveolar graft may be inserted at the time.

73.  Perform after the initial repair of the cleft.
 Improve the speech or correct the residual
defect.
 Improve Velophyarengal competent.

74.  Dentist must aware the treatment plane of
cleft team.
Avoid the bridge before the
treatment.
Avoid supernumerary extractions
 Teeth may be malformed or absent

75.  Missing teeth should be replace.
 Speech aid appliance (failed second surgery)

76. Speech bulb
Palatal lift.