pathophysiology of clefting....embryological basis management of cleft lip and cleft palate- orthodontic consideration timing and sequencing of treatment primary verses secondary alveolar grafting

1. Principles of Orthodontic
Management 0f Cleft Lip and
Palate
Presenter: Dr Kiprop, Jonathan.
8th July 2019

2. Outline
 Introduction
 Epidemiology
 Embryology
 Etiology
 Classification of clefts
 Management of cleft lip and palate
• Orthodontic considerations
 Conclusion
 References

3.  Cleft lip and palate is a congenital birth defect which
is characterized by complete or partial cleft of lip
and/or palate
 Not life threatening unless associated with a
syndrome
Definition

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.
 Complex congenital deformity - multidisciplinary
team approach in its management.

5.  Cleft lip and palate- global problem-(0.28- 3.74/1000
live births.
 Least incidence in negroids (0.021 to 0.41/1,000 live
births), maximum in mongoloids and Afghans(0.49%)
 Oral clefts is seen more in males than in females. 2:1
 Cleft lip alone- more in males than female
 Cleft palate- more in females than males
 Clefts mostly unilateral and left sided
Epidemiology

6. Local Statistics

7. Case in KNH

8. Aetiology- Multifactorial
 Genetics
 Syndromic-
 Van der woude
 Apert
 Treacher Collins
 Cleidocranial dyplasia,
 Ectodermal Dysplasia,
 Others- Stickler’s Syndrome, Oro-facial digital
syndrome, Pierre Robin, and Christian Syndrome

9.  Teratogenic Drugs- Diazepam and other
benzodiazepines, Steroids (0.07% to 1.9%),
amphetamines phenytoin, thalidomide,
Mercaptopurine, Methotrexate
 Ethyl Alcohol- causes FAS (fetal alcohol Syndrome).
 Hypervitaminosis A
 Malnutrition -Folic Acid def, anaemia and anorexia
 Maternal smoking or tobacco exposure
 Intrauterine infection-Rubella infection
Environmental Factors:

10.  High maternal age (shaw et al)
 Diabetes
 Toxemia
 Reduced blood supply - ischemia
 Racial – mongoloids
 Radiations
Predisposing Factors

11. Pathogenesis:Embryological basis
 Development of facial
structures starts at the
end of 4th weeks
 5 facial prominences
around stomodeum
1. Unpaired frontonasal
process
2. Paired maxillary
prominences
3. Paired mandibular
prominences

12. Descent of tongue influenced by the growth of
mandible
Elevation of palatine 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. Intrinsic shelf-elevating force-chiefly generated by
accumulation and hydration of hyaluronic acid
Mechanisms Elevation of Palate

13. Cleft of palate occurs in number of ways:
 Defective growth of palatal shelves
 Delayed or total failure of shelves to elevate and
attain a horizontal position
 Lack of contact between shelves
 Post fusion rupture of shelves
 Failure of mesenchyme consolidation.
Cleft Palate

15. Cont…

17. Prenatal Diagnosis
Advantages
 Psychological preparation of
parents and caregivers.
 Patient education
 Preparation for neonatal
care and feeding
 Opportunity to investigate
for other structural or
chromosomal abnormalities
 Possibility for fetal surgery
 Customized surgical
treatment plan by the
plastic surgeon.
Disadvantages
 Emotional disturbance and
high maternal anxiety
 Choice to terminate the
pregnancy even in the
absence of other
malformations due to
1. Perceived burden,
2. Expectation of recurrence,
3. Religious and cultural
beliefs,

18.  Dental, skeletal, nasal, feeding, ear problems, speech
 DENTAL -tooth agenesis, hypodontia (most common)
,supernumerary teeth (2nd most common), enamel
hypoplasia , crossbites, ectopic eruption,
transposition, taurodontism, dilacerations
 SKELETAL -maxillary deficiency, mandibular
prognathism, class III malocclusion, concave profile
Jamal et al
Problems associated with CL/P

19.  FEEDING PROBLEMS- Oronasal fistulas, draining of
oral fluids in nasal cavity and vice versa - Bottle, cup
and spoon, tube feeding, infant held at 30-45 degrees
angle to aid swallowing
Cont…

20.  The Northwestern University CLP team introduced
the concept of co-ordinated and integrated treatment
plans in a team approach around a conference table
 Team approach- optimizes outcome, reduced hospital
admissions, Need for GA and overall cost.
 Comprehensive care approach- collaboration to
determine timing and sequence of treatment
Team Approach

21. Team Approach

22. Treatment Cycle

23.  The timing and sequencing of orthodontic treatment
are not carried out in isolation from other members
of the team but as a result of collaborative decisions
made in a coordinated, patient-centered manner
sensitive to the patient’s and family’s needs
 The orthodontist should consider additional priorities
other than malocclusion.
Cont…

24. Schedule of Treatment

25. Sequencing of Treatment

26. Cont…

27. *Samuel Berkowitz. Celft Lip and Palate.2006. 2nd edition Page number 451-8.

28.  Divided into four distinct developmental periods.
• Infancy- birth to 2yrs
• Deciduous dentition- 2-6yrs
• Mixed dentition 7-12 yrs
• Permanent dentition.
 These periods are defined by age and dental
development and considered as time frames in which
to accomplish specific objectives.
Timing and sequencing of
orthodontic care

29.  Presurgical orthodontics/neonatal maxillary
orthopedics
 Initiated during the first or second week of life unless
complications arise from other congenital anomalies or
medical problems.
 Carried out by the orthodontist, the pediatric dentist,
or the prosthodontist.
Neonate and Infant (≤ 2 Yrs)

30. Naso-Alveolar Moulding
Objectives:
• Reduce severity of initial cleft deformity
• Columella – Nonsurgical lengthening (in bilateral
clefts) and uprighting (in unilateral clefts)
• Reduction in the width of the alveolar cleft segments
until passive contact of the gingival tissues is
achieved

31. CLAIMED BENEFITS OF PSOT
• Control and modify postnatal development of maxilla
• Early alignment for better occlusion and function –
swallowing and speech
• Reduce middle ear infections
Disadvantages
Primary bone grafting – deleterious effects on midface
• No evidence that PSOT normalize feeding, tongue
posture, swallowing or growth
Berkowitz 1996
Presurgical Orthopedics

32.  Early or primary bone grafting associated with
maxillary orthopedics at the time of primary lip repair
may have compromised the long-term follow-up of
treated patients.
 Results suggested that neonatal maxillary
orthopedics produced little effect on the developing
malocclusions if assessed when the child was 10 years
old.
Cont…

33.  Adjunctive procedure to primary definitive lip repair.
 These appliances adjust the position of the cleft
segments into a more ideal relationship before
definitive surgical repair of the lip. Results
comparable with lip adhesion.
 Increased burden of care- many clinic visits necessary
to adjust the appliance during the first year of life.
 It has a potential of wound dehiscence and the need
for an additional surgery.
Cont…

34.  At 2 to 3 years of age the establishment of the
primary dentition permits classification of the type of
developing malocclusion- skeletal vs dental
 The facial soft tissues may mask the underlying
skeletal deficiency of the midface in young children.
 The dentition often reflects the skeletal relationship
in absence of compensation.
Primary Dentition Stage (2-6yrs)

35.  To eliminate mandibular shifts, orthodontic treatment
may be indicated to remove the interfering contact by
tooth movement.
 This process may involve the maxillary incisors if an
anterior crossbite exists or expansion of the posterior
segments to eliminate a posterior crossbite.
 Severe skeletal discrepancies may be managed by
growth modification and redirection e.g with a
protraction face mask which modifies circum-
maxillary sutures.
Cont…

36.  Factors to consider in determining when to initiate
orthodontic treatment during the primary dentition
stage. These factors include
 Child cooperation,
 The severity of the malocclusion
 Timing of secondary bone grafts
 Need for future orthodontic treatment in the early
mixed or permanent dentitions.
Cont…

37.  Contemporary opinion recognizes a need for
orthodontic treatment in the early mixed and
permanent dentitions.
 Orthodontic treatment may be best delayed until it
can be combined with other treatment goals and thus
shorten the overall duration of treatment.
 Early treatment procedures require a long-term
follow-up period to evaluate the outcome of
treatment when the child reaches adolescence.
Cont…

38.  Starts at 6- 7 yrs of age with the eruption of the first
permanent molars and incisors.
 Growth of the craniofacial complex often accentuates
a previously mild skeletal discrepancy
 Permanent incisors erupting adjacent to the cleft site,
typically are rotated, misplaced,malformed, or
hypoplastic. They may be supernumerary, absent, or
peg shaped.
Mixed Dentition Stage (7-12 yrs)

39.  Constricted V-shaped maxillary arch form contributes
to the posterior crossbite seen in the mixed dentition.
 Maxillary expansion appliances can be used to correct.
 Tissue deficiency in facial clefting, lead to
compromised supporting alveolar bone at the cleft
site.
Cont…

40.  Bone grafting allows restoration of an uninterrupted,
continuous alveolar ridge that allows for eruption of
teeth into the graft and orthodontic movement of
teeth into the cleft site
 Placement of osseo-integrated implants is now
possible with prosthetic replacement of missing
teeth.
Cont…

41.  Done before 2 yrs.
 Primary alveolar bone grafting rarely done in the
neonate- retards maxillary growth.
 However, the case for early bone grafting has been
defended and, although controversial, continues to
be practiced by several institutions and craniofacial
teams.
Pruzansky (1964), Jolleys and Robertson (1972)
Primary Alveolar Bone Grafting

42.  By definition secondary or delayed alveolar bone
grafting is performed after primary lip repair.
 Classified into-
 Early (2 to 5 yrs.)
 Intermediate (6 to 15 yrs.)
 Late (adolescence to adulthood ≥ 16 yrs).
Secondary Alveolar Bone Grafting

43. Benefits of secondary alveolar bone grafting
1. Provision of bone/periodontal support for un-erupted
teeth and those teeth adjacent to the cleft.
2. Closure of oro-nasal fistulae by using a three-layered
closure technique-graft sandwiched in soft tissue planes.
3. Support and elevation of the alar base on the cleft
side. This helps to achieve nasal and lip symmetry and
provides a stable platform for nasal structures
Intermediate Secondary Bone Grafting

44. 4. Construction of a continuous arch form and alveolar
ridge.
 Allows for moving teeth bodily and for uprighting roots
into the cleft site.
 Enabling a more aesthetic and hygienic prosthesis in
preparation for implants to be placed when teeth are
missing.
5. Achieve stabilization and some repositioning of the
premaxilla in those patients with a bilateral cleft.
Cont…

45.  The timing of surgery depends more on dental
development than on chronologic age.
 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.
Timing.

46.  Graft may be placed at an earlier age to improve the
prognosis of a lateral incisor- if it is distal to the cleft.
 Minimal adverse effect on maxillary growth and
development which is almost complete by 10yrs.
 Once teeth have erupted into the cleft site, their
periodontal support will not improve with a bone
graft.
Early Grafting

47.  Bone grafting in the intermediate period has the
greatest benefits and least risk for interfering with
mid-facial and skeleto-dental growth and
development.
 The sequencing of procedures surrounding alveolar
bone grafting requires interdisciplinary
communication and cooperation resulting in better
and more predictable patient care.
Bergland et al
Sequencing.

48.  The general or pediatric dentist-restoration of any
carious tooth adjacent to the cleft before the grafting
procedure.
 Patient/parents - good oral hygiene practices
 orthodontic treatment may be required presurgically
to reposition maxillary teeth that are in traumatic
occlusion or to expand a severely constricted maxilla.
Cont…

49.  Any erupted teeth adjacent to the cleft that have
poor periodontal or endodontic prognosis should be
extracted at least 2 months in advance to allow
healing of mucosal tissues before surgery.
Cont…

50.  The grafting procedure uses tissue lining the cleft
defect to construct a nasal floor and close the nasal
side of the oral-nasal fistula.
 The cleft lining is elevated in a sub-periosteal plane
that leaves bare the osseous margins of the cleft.
 Cancellous bone taken from the ilium, cranium, ribs,
tibia or mandibular symphysis is then packed into the
cleft defect.
Surgical Technique

51.  Cancellous bone is preferred over cortical bone
because it vascularizes more rapidly and is less likely
to become infected.
 Once the cleft defect is packed with bone and the
margins are overpacked, soft tissue coverage of the
graft is required.
Cont...

52. Orthodontic concerns regarding secondary bone
grafting relate to the
• Transverse dimension
• Incisor alignment
• Eruption of the maxillary canines.
Orthodontic Considerations
Associated with Bone Grafting

53.  Expansion of the posterior segments preoperatively
may improve the occlusion widen an existing fistula.
 The expansion
 Provides better surgical access for incision and elevation
of flaps with closure of the palatal and vestibular
oronasal fistulae following the alveolar bone graft.
 Improves the buccolingual orientation of the collapsed
posterior segment with the anterior segment, restoring
arch symmetry.
The Transverse Dimension.

54.  Alignment of incisors adjacent to the cleft, which
typically are rotated, displaced, or tipped, is limited by
the available bone into which the roots of the teeth
may be moved.
 If appliances have been placed presurgically,
individual orthodontic tooth movements should be
delayed until 2 to 6 months following placement of
bone graft
Incisor Alignment

55.  The early movement of the roots into the grafted
bone appears clinically to consolidate the alveolar
bone and improve the crestal alveolar height.
 In bilateral cleft lip and palate cases, a vertically
extruded premaxilla can be repositioned upward with
the use of a labial intrusion archwire, moving the
incisors en masse with the bone in vertical alignment
with the posterior segments prior to bone grafting
Cont…

56.  Maxillary canine erupts through the grafted bone
 With orthodontic movement of teeth, sufficient space
is created in the arch to allow the canines to erupt.
 Removal of unerupted supernumerary teeth is
performed during bone grafting to create an
unobstructed path of eruption for the canine.
Eruption of the Maxillary Canine.

57.  Often the canine will erupt rapidly following the bone
graft.
 If the lateral incisors are malformed or absent,
especially in patients with bilateral clefts, the canine is
encouraged to erupt adjacent to the central incisors.
 Closing the edentulous space is an advantage, thus
avoiding the need for a prosthetic replacement of the
absent lateral incisors.
Cont…

58.  With the eruption of the canines and premolars, the
permanent dentition is established.
 During this time, the adolescent growth spurt and
onset of puberty occur.
 The skeletal discrepancy becomes accentuated, and
facial appearance and occlusal relationships
deteriorate.
 Heightened self-consciousness about body image and
facial appearance.
Permanent Dentition Stage

59.  Cosmetic concerns from facial scars and derogatory
comments by peers may have a profound
psychological effect.
 Involution of the adenoidal lymphoid tissue occurs,
often with impairment of speech from the resulting
hypernasality.
 Above reasons may need for early intervention by the
surgeons, orthodontists, speech therapists, and
psychologists.
Cont…

60.  orthodontics alone ± orthognathic surgery
 Ross (1987) – 25% require surgery
 Orthodontic treatment
• Tooth alignment
• Establishment of a continuous maxillary arch with favourable
archform
• Correction of anterior and/or posterior crossbites.
• Stability of occlusion in the presence of dental compensations
• Favourable dentofacial esthetics
Rx in Permanent Dentition

61.  Patients with unilateral complete CL/P typically
become more maxillary deficient and mandibular
prognathic due of sagittal maxillary deficiency.
 Vertical maxillary deficiency may result in overclosure
of the mandible to achieve occlusion of the teeth,
thus accentuating the Class III tendency.
Growth Considerations.

62.  Management of CL/P is complex and needs
multidisciplinary approach.
 Orthodontist plays a central role in management at all
stages
 Best done in specialized centres
Conclusion

63. References
1. Graber Vanarsdall and Vig. Orthodontics: Current Principles and
Techniques. Elsevier 2012.
2. Bishara SE, Staley RN. Maxillary expansion: clinical implications.
Am J Orthod Dentofacial Orthop 1987 Jan;91(1): 3-14.
3. Jamal GA et al. Prevalence of Dental Anomalies in a Population
of Cleft Lip and Palate Patients. Cleft Palate–Craniofacial
Journal, 2010;47(4):413-20
4. Berkowitz S. A Comparison of Treatment Results in Complete
Bilateral Cleft Lip and Palate Using a Conservative Approach
Versus Millard-Latham PSOT Procedure. Semin Orthod
1996;2:169-184

64. Thank you.