Management of cleft lip and palate 2. /certified fixed orthodontic courses by Indian dental academy

MANAGEMENT OF CLEFT LIP AND
PALATE-II

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INDIAN DENTAL ACADEMY
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• Primary Repair of Cleft Lip
• Primary Repair of Cleft Palate
• Comprehensive orthodontic treatment of the cleft
lip and palate patient (including secondary
alveolar bone grafting)
• Orthognathic surgery for the cleft patient.
• Dental anomalies associated with cleft lip and
palate
• The GOSLON Yardstick

Primary repair of unilateral cleft lip:
Anatomic Considerations:
• The superficial muscles of the face are arranged
schematically in 3 interdependent rings.
• These muscles include the transverse nasal muscle,
levator labii superioris alaeque nasi, levator labii
superioris, depressor septi, orbicularis oris.
• In patients with clefts, these muscles do not insert on
their corresponding elements on the medial side of
the cleft.
• As a result they are prolapsed laterally, and cannot
solicit stimulation and normal growth.

• The nasal septum is pulled by muscles on the non
cleft side, displacing it with the anterior nasal
spine in that direction.
• On the cleft side the labial commisure is deviated
latero-inferiorly, which in turn favors lateral
deviation of the chin to the cleft side.
• This accentuates the nasal asymmetry and the
entire anterior part of the face is distorted and
malformed.

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Some characteristic muco-cutaneous
abnormalities are also seen associated with
the cleft lip.
Malposition of nostril skin on upper part of
lip.
Retraction of labial skin
Alteration of white roll of lip
Presence of a special mucosa neighboring
the muco-cutaneous junction on the sides of
the cleft.

The goal of primary closure is not
only to re-establish normal
insertions of all the naso-labial
muscles but also to restore the
normal position of all the other soft
tissues, including the mucocutaneous elements.


Timing of repair
• There is still some controversy about ideal
time for cleft lip repair.
• Most surgeons abide by the rule of 10s.
• General anesthesia is usually necessary for
surgery and is safe when the infant is 10
weeks of age, 10 lbs in weight and has a Hb
level of 10g.
• Recently there has been discussion of early
repair in the first 1-2 weeks of life: not
common yet.

Lip Adhesion:
• Some surgeons prefer to perform a
preliminary lip adhesion before definitive
lip repair.
• Particularly done in extremely wide
complete clefts with marked maxillary and
nasal distortion.
• Reduces the actual deformity by helping to
mold the maxillary segments closer together
• May make formal lip repair less difficult.

• Technique involves paring of cleft margins
and a 3 layer repair including mucosa,
muscle and skin.
• This converts the complete cleft into an
incomplete one.
• Non-surgical lip adhesion with tape has also
been reported to be of benefit.
• However, current opinion among some
authors is that lip adhesion is an unnecesary
procedure.

• According to Salyer et al (Clinics in Plastic Surgery,
April 2004):
• Lip adhesion may contribute to additional scarring or
abnormal tethering of the lip or nasal elements.
• Using a lip adhesion treats the abnormal skeletal
base, making it easier for the surgeon to close the lip
at the expense of overall esthetics of nose and lip.
• May cause fixation or scarring of the alar base or
associated adjacent structures in an abnormal
position, making definitive normal contour of nose
more difficult.
• The utility of naso-alveolar molding in early
treatment of unilateral cleft lip and palate has also
been challenged www.indiandentalacademy.com
recently.

Techniques of lip repair
• Early lip repairs involved paring the lip margins
and repair of skin and mucosa without muscle
realignment.
• The orbicularis oris muscle therefore maintained
its abnormal attachments resulting in an
orbicularis bulge in the lateral lip segment.
• Nowadays it is standard practice to detach the
muscle from its abnormal skin and mucosal
attachments and reorient it in a proper fashion.

1. Straight line technique
(Rose-Thompson)
• Used in case of an
incomplete cleft lip that
requires minimal
lengthening.
• Slightly curved or angled
incisions of equal length are
made on either side of the
cleft , which, after suturing,
create a philtral scar line
symmetric with normal
philtral column.
• Formal muscle repair is also
done.

2. Triangular Flap technique
(Tennison-Randall)
• Used in situations where
maximal lengthening of the
lip is required.
• Precise reproducible
mathematical markings as
described by Randall are
used, allowing excellent
results even by relatively
inexperienced surgeons.
• Scar line crosses the philtrum
in lower portion of lip, which
may be unesthetic.

3. Millard’s Rotation
Advancement Technique:
• One of the most popular cleft
lip repair techniques in the
USA.
• Described by Millard as a cut
as you go technique and is
not easy to master.
• Rotation and advancement
flaps are marked and
adjusted during the
procedure to provide
adequate lip length.
• Scar line crosses upper
philtrum column. www.indiandentalacademy.com

4. Modified Rotation Advancement Flap
(Mohler, 1986):
• Produces a scar line that more closely
mimics the normal philtral column, than
original Millards technique.
• Achieved by extending the rotation incision
into the columella and making a back-cut.
• Muscle repair is also performed.
• Lengthening of columella occurs.
• Scar line is more vertical and lateral in the
upper lip, which appears more natural.

5.


Primary Repair of Cleft Palate:
• Primary cleft palate repair is indicated in nearly all
affected children to facilitate speech and
swallowing.
• Earlier, primary repair was performed at 18-24
months of age, but recent advances in anesthesia
and surgery allow early cleft palate repair at 9-12
months of age.
• An infant is generally ready for repair when able
to drink from a capped cup without a nipple.

Advantages of early repair of cleft palate:
1. Encourages normal speech patterns.
2. Permit normal swallowing patterns.
3. Allow eustachian tube to function against
a repaired palate.
4. Trauma of surgery completed early before
patient is a toddler.
5. Help parents lead the child through tasks
of development with less difficulty.

Contra-indications to early repair:
1. Children with upper airway obstruction
2. Severe retrognathia
3. Persistent glossoptosis as occurs in Robin
sequence.
4. Children at risk of excessive blood loss,
delayed wound healing
5. Increased anesthetic risk.

Goal of cleft palate repair:
To create normal function in the hard palate
and soft palate.
Simple obturation of the cleft never permits
normal function.
It requires realignment of all the associated
tissues (mucosa, submucosa, muscle, nerve,
vessel, and bone) to create a functional
structural unit.

Pathologic anatomy of the cleft palate:
• Four muscles with various degrees of fusion
compose the soft palate and produce its
primary functions of elevation, obturation
of the nasal pharyngeal opening, and
traction on the eustachian tube during
swallowing.
• These are the tensor veli palatini, the
levator veli palatini, the uvulus, and the
palatopharyngeus.

In cleft palate patients, the attachments of these
muscles in the soft palate are defective
The muscles that normally join at the midline of
the soft palate, course anteriorly and insert on or
near the posterior edge of the hard palate.
Result in defective function of the soft palate.
Lead to compromised sphincter function,
velopharyngeal insufficiency, problems in speech,
chronic otitis media, risk of permanent hearing
loss.


Surgical repair of cleft palate
• The French dentist LeMonnier performed the first
surgical repair of a congenital cleft palate in the
1760’s.
• The 3 stage operation consisted of passing sutures
through the cleft borders, cauterizing the cleft
edges, and realigning the fresh edges.
• By the early 20th century, goals included
lengthening of the palate to improve speech in the
cleft patient.
• In the past few decades, attention has shifted to
achieving optimal speech development and
avoiding abnormal growth after repair.

Surgical preparation of patient:
• General anesthesia.
• Head of table lowered.
• Use of mouth prop, cheek retractor, throat
pack
• Occlusal mouth mirror for indirect
visualization of the hard palate, nasal
mucosa.
• Magnification, headlights.

Techniques of surgical repair:
Incomplete clefts of soft palate:
1. Side-to side veloplasty:
Veau, in the early 20th century repaired
clefts of soft palate by bringing together
the cleft edges,without suturing together
the muscle bundles.


2. Kriens Intravelar Veloplasty:
• Proposed by Kriens in 1969
• Restores the levator sling and the palatal
musculature at the midline where they normally
meet.
• Accomplished by dissecting anteriorly
malpositioned bundles from posterior edge of hard
palate and repositioning them in the midline.
• The effectiveness of Krien’s technique over
conventional veloplasty has not yet been
demonstrated in randomized, prospective,
controlled studies.

3. Furlow double opposing Z-plasty
• Has become the veloplasty of choice for
many surgeons, over the past decade.
• Uses two reversed Z plasties based upon the
cleft midline, both of which draw in soft
palate tissue from the sides to close the cleft
defect and restore the musculature to its
anatomic position.


Incomplete clefts of hard and soft palate
1. Von Langenbeck’s technique (1859)
• This technique depends on paring the edges of the
cleft and separating the oral and nasal mucosa.
• Releasing incisions are made, hard palate is
elevated bilaterally to allow mucosal closure.
• The nasal mucosa and oral mucosa are sutured
side to side to form a 2 layered closure.
• Generally used for cases of incomplete clefts of
hard and soft palate.

2. Veau-Wardill-Kilner
(VWK) palatoplasty
• Modification of von
Langenbeck technique
• Involves medial and
posterior movement of
left and right palate.
• Purpose is to increase
palatal length to
improve
velopharyngeal
function.
• Accomplished via a VY lengthening done at
the anterior hard palate.

Concerns with the VWK palatoplasty:
Denudation of palatal bone anteriorly, which may
adversely affect midfacial growth in cleft palate
patients. (La Rossa D. Cleft Palate Craniofac J
2000)
A recent retrospective study (Pigott et al. Cleft Pal
Craniofac J 2002) comparing the von Langenbeck
and VWK techniques, found that over a 5 year
period, maxillary growth was less affected with
the von Langenbeck Technique with releasing
incisions.

Complete bilateral cleft palate:
• Presents a unique challenge because of cleft width and
continuity of the palatal cleft with clefts of the lip and
alveolus.
• Technique for repair: two flap palatoplasty,which is
similar to the VWK repair but involves more
extensive dissection anteriorly to encompass the cleft
edges at the alveolus.
• May be combined with a vomer flap, for closure of
nasal mucosa: four flap palatoplasty.
• In addition, buccal flaps can been used to cover
denuded areas of the palate.
• Mann and Fisher (Plast Reconstr Surg 1997) have
documented the use of bilateral buccal flaps in
conjunction with a modified Furlow repair to cover
denuded areas on www.indiandentalacademy.com palate.
the posterior hard

Post-operative care:
• Average blood loss for the procedure is 50-60 ml
and the length of procedure is 12 hours.
• Post-op. monitoring with pulse oximetry;
observation for hemostasis and respiratory
distress.
• Adhesive arm restraints for 10 days to prevent
patient from placing objects in the mouth.
• Diet of clear fluids initiated on 1st post-operative
morning.
• A patient who has adequate oral intake, is in no
distress and meets usual discharge criteria may be
sent home on the 1st post-operative afternoon.

Comprehensive orthodontic treatment:
Aims :
1. To prevent gross deformity of dental arches.
2. Restore normal overall contour of upper arch
3. Relate the upper and lower dental arches, by
expanding the upper arch as required, and
extracting in the lower arch if necessary.
4. To encourage proper functional exchange
between the arches.


6. To create more room for tongue, facilitating
articulation.
7. Prepare the dentition for secondary bone
grafting, prosthetic rehabilitation, orthognathic
surgery.
8. To improve the appearance of the profile and
facial contours.
The orthodontist’s knowledge of craniofacial
growth and cephalometry qualifies him/her to
monitor closely the craniofacial growth, dental
development of the patient, as well as treatment
results.

Timing and sequence of treatment
(4 periods)
I. Neonate and infant (Birth to Two Years)
Presurgical orthodontics, maxillary
orthopedics.
Feeding plates, Passive molding plates,
Elastic straps.
Nasal Stents.


II. Primary Dentition (2-6 years of age)
• Establishment of primary dentition permits
classification of the type of developing
malocclusion, which is an important part of
diagnostic regimen.
• Anterior crossbite may be seen unilateral/
bilateral, with or without mandibular shift.
• Orthodontic treatment may be required to remove
interfering contacts in order to eliminate
mandibular shift.
• If the dental crossbite relationship is a continuing
problem, it may reflect an underlying skeletal
discrepancy. This may require growth
modification with face mask.

• According to Vig and Mercado, contemporary
opinion recognizes a need for orthodontic
treatment in the early mixed and permanent
dentitions.
• No strong evidence supports a benefit from
routinely treating dental malocclusions in the
primary dentition.
• Treatment may be deferred till it can be combined
with other treatment goals.

III. Mixed dentition Stage (7-12 years of age)
Goals of treatment at this stage include:
1. Lateral expansion of the posterior segments if
required, using palatal expanders incorporating
screw, or quad helix.
Puneet Batra, Ritu Duggal and Hari Parkash (JIOS
2003) reported on the use of a Nickel Titanium
Palatal Expander which is temperature activated
and produces light continuous pressure (230-300
gms) on the mid palatal suture. They documented
three cases of CL/P which were treated with this
modality to correct crossbite and molar relation.

• The maxillary arch should not be over-expanded ,
or else the alveolar defect would be widened. It
should be sufficient to improve arch form and
correlate it with lower arch.
(Note: If grafting is done prior to expansion of the
maxilla, a 3 month period must elapse before
attempting expansion.)
2. Correction of incisor malalignment and displaced
teeth.
3. Resolution of anterior crossbite.


4. Growth modification:
Children treated for cleft lip and palate often
develop midfacial retrusion.
In order to avoid the need for later surgery, growth
modification by protraction of the maxilla and
restraint of mandibular growth may be attempted.
Facemask and reverse headgear have been used to
achieve correction of skeletal discreopancy.
Buschang et al (Angle 1994) evaluated 20 children
with UCLP, treated at 7.3 years of age, with a
combination of maxillary expansion and facemask
therapy. Their results showed that although
skeletal changes are limited, they do produce
marked improvements in the soft tissue profile.

• Lisa So (AJODO 1996) evaluated 10 consecutive
Southern Chinese girls born with unilateral
complete cleft lip and cleft palate who were
treated with the reverse headgear for a period of
9.7 + 1.6 months with a standard deviation of
months.
• The pretreatment age ranged from 9 to 12 years
and none of the subjects had reached maximal
pubertal growth.
• 10 patients with UCLP who were matched for age
and sex and were not treated, served as controls.

Skeletal and dental effects of reverse headgear


Use of implants for maxillary protraction
• Use of conventional face mask therapy using the
maxillary dentition as anchorage may be
associated with anchorage loss in the form of
maxillary dental protrusion.
• Osseointegrated implants can be used to provide
unlimited anchorage for protraction.
• Singer et al (Angle Orthod 2000) reported a case
in which Branemark Implants were placed in the
zygomatic buttresses of the maxilla in a 12-year
old female patient with a Class III malocclusion
associated with unilateral cleft lip and palate
defect.

• The implants were left to integrate for 6 months
followed by placement of customized abutments that
projected into the buccal sulcus
• Elastic traction (400 g per side) was applied from a
facemask to the implants at 30 degrees to the
occlusal plane for 14 hours / day for 8 months. The
maxilla moved downward and forward 4 mm rotating
anteriorly as it was displaced.
• Clinically, this resulted in an increase in fullness of
the infraorbital region and correction of the
pretreatment mandibular prognathism.
• There was an increase in nasal prominence as the
maxilla advanced. This contributed to the increase in
facial convexity.

The secondary dental change frequently seen in
standard facemask therapy was avoided.

• In the future, new protraction devices may
use short-duration dynamic forces rather
than continuous forces as currently
delivered.
• Current research on the mechanobiology of
the sutures is exploring the response of cells
to oscillating mechanical signals. ( Mao, J
Dent Res 2002)

Alveolar bone grafting

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Purpose: Not simply to close a hole in the
alveolus but also to accomplish certain
esthetic and functional goals.
These goals are:
Closure of oronasal fistula
Stabilization of the lesser segment
Adequate bone support for teeth adjacent to
the cleft.
Allow for eruption of teeth in the cleft area
(lateral incisor or canine) with good bony
support.

• Augmentation of piriform region.
• Establish good soft tissue contours with
adequate keratinized gingiva for periodontal
health.
• Minimize growth disturbances


Historical aspects:
• The first reports of maxillary alveolar bone
grafting appeared in the German literature in the
early 20th century with reports by Lexer and
Drachter.
• Boyne and Sands in 1972, desribed a successful
protocol for secondary alveolar bone grafting,
using the ilium as the donor site, which has
become the standard technique, the world over.


Timing of repair:
• Timing of repair has been controversial.
• From a chronologic viewpoint it may be primary
or secondary.
• Primary repair occurs between birth and the age of
2 years, and is typically performed at the same
time as lip repair, or as a later operation before
palate repair.
• Long term studies in the 1970s and 1980s showed
it to be associated with higher incidence of
detrimental growth effects such as midface
retrusion and anterior crossbite.

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Early secondary repair is done if the patient
appears to have a functional lateral incisor that can
erupt into the grafted cleft site.
This is performed when the lateral incisor root is
2/3rds – 3/4th formed.(age 6-7 years)
Morphology of the lateral incisor is an important
consideration.
Conventional secondary repair as described by
Boyne and Sands is performed generally at the age
of 9-11 years just before the eruption of the canine
tooth.
Done in cases where early repair is not warranted.
Vast majority of patients fall into this category.

• This age is believed to be appropriate because
sagittal and transverse growth of the maxilla is
essentially complete by the age of 8 years, and
remaining vertical growth is from eruption of
permanent teeth.
Tertiary repair: Done after the eruption of the
permanent dentition (usually the 2nd permanent
molars)
• Shown to have a lower success rate compared to
conventional secondary grafting.
• Gradual loss of bone along the distal surface of
central incisor root and mesial surface of canine
root limits the bone graft “take”.

Role of the orthodontist in alveolar cleft
grafting:
• Orthodontist plays an essential role.
• In infancy, maxillary orthopedics is carried
out to expand the collapsed lesser segment,
mold the anterior maxillary arch and reduce
the alveolar gap.
• Prior to secondary bone grafting, further
orthodontic treatment is required.

This includes:
• Placement of fixed appliance on the maxillary
arch.
• Expansion of the anterior and posterior maxilla to
develop favorable arch form, partially or
completely eliminate crossbites.
• Alignment or derotation of malpositioned incisors.
• Improvement of dental function and esthetics.
Approximately 4-6 months of orthodontic
treatment should be anticipated in preparation for
alveolar bone grafting.

• Bone grafting of the alveolar cleft without
proper orthodontic preparation will lead to
poor results with malposition of the lesser
segment, a stabilized maxillary arch
constriction, and posterior crossbite.
• Correction of these will necessitate
additional surgical procedures.

Bone graft donor sites:
• The gold standard site in alveolar cleft repair is he
iliac crest, typically harvested as a a particulate
cancellous bone and marrow (PCBM) graft.
• Provides the greatest volume of cancellous bone
available among commonly used sites.
• Success rates using cancellous iliac bone have
been reported to be usually greater than 80%.
• Limited dissection of muscle and periosteum,
along with use of percutaneous trephine method
have reduced postoperative pain substantially.

• Bergland et al of the Oslo study group reported
high rates (85%) of spontaneous eruption of the
canine following bone grafting. Another 15%
required forced eruption.
• Da Silva Finho et al (Angle Orthod 2000)
reviewed the literature pertaining to successful
eruption of permanent canine following secondary
alveolar bone grafting and found it to vary from
27% to 95%.
• In their own sample of 50 patients treated with
secondary alveolar bone grafting, the authors
reported spontaneous eruption of the canine
through the graft in 72% of cases, while in another
6%, orthodontic traction succeeeded in erupting
them.

• Other sites which have been investigated are the
tibia, the calvarial bone and mandibular
symphysis.
• Tibial bone provides sufficient cancellous bone,
but disadvantages are a visible scar and possibility
of damage to epiphyseal growth plate.
• Calvarial bone and mandibular symphysis bone
have the advantage of being located in the facial
skeleton and arise from membranous bone. This
gives the theoretical advantage of less overall
resorption.
• Disadvantage: Provide much smaller quantity of
cancellous bone, making them inappropriate for
larger clefts.

Procedures involved in alveolar bone
grafting:
• Layered closure of the oro-nasal fistula is
achieved.
• The oro-nasal fistula is incised and two sets of
flaps are created: nasal and oral mucosal layer.
• Nasal closure is performed before placing the
bone graft and the oral closure.
• Buccal and palatal flaps need to be raised for
proper closure of the alveolar cleft.
• After closure of the nasal and palatal flaps, the
bone graft is placed over the inferolateral pyriform
rim, to augment the alar base.
• Following this, the buccal flaps are closed.

Innovations in repair of cleft sites:
• Platelet rich plasma is an autologous source of
growth factors that has been shown to accelerate
the rate and degree of bone formation in a bone
graft.
• Obtained by centrifuging autologous blood into its
basic components.
• Rich source of growth factors such as PDGF,
TGF, which have been shown to play important
roles in bone regeneration and repair.
• Approximately 60-100 cc of whole blood is
recommended to provide an adequate amount of
PRP.

Composite intramenbranous bone grafts:
• In an effort to augment the healing of
autogenous EC bone, Rabie and Lie (Int J Oral
and Maxillofac Surg 1996) mixed the
autogenous EC bone with demineralized
endochondral bone matrix (DBMEC). This
composite endochondral bone graft (ECDBMEC) produced 47% more bone than
autogenous EC bone alone.
• Similar results were obtained when autogenous
IM bone mixed with DBM, prepared from IM
bone in origin, produced 204% more bone than
the IM bone alone.

• Rabie and Chay (AJODO 2000) reported a
case of cleft lip and palate with a large
alveolar defect in which bone harvested
from the chin mixed with DBM was used
successfully.


• Distraction osteogenesis has also been used
by Liu et al (Plastic Reconstr Surg 2000) to
close large alveolar clefts that would
otherwise have been difficult to close using
conventional methods.
• Yen et al (JOMS 2001) have also reported
the use of a modified distraction device for
closure of cleft spaces.

3. Permanent dentition stage treatment
• The permanent dentition is associated with the
adolescent growth spurt and onset of puberty,
during which time the skeletal discrepancy
becomes more accentuated and occlusal
relationships deteriorate.
• Sagittal maxillary deficiency coupled with vertical
maxillary deficiency may result in overclosure of
mandible accentuating the Class III tendency.
• Transverse discrepancies may be accentuated by
the Class III sagittal relation and lead to posterior
crossbites.
• As the patient matures, a decision has to be made
whether the patient can be treated by orthodontics
alone or in combination with orthonathic surgery.

This requires full face and profile assessment as well
as cephalometric analysis and prediction tracings.
If the skeletal discrepancy is mild and esthetic
concerns are minimal, dental compensation by
orthodontic treatment alone may be recommended.
This would involve full banded/ bonded appliances
with use facemask therapy upto the beginning of
adolescent growth spurt.
Extractions may be required for corection of
crowding.
Use of Class III elastics in patients with vertical and
sagittal discrepancies.
• Caution must be exercised, as the patient may
outgrow the dental correction, ultimately requiring
surgery.

• In case orthognathic surgery is required, the
orthodontist must perform necessary presurgical
orthodontics to decompensate the dentition, for
maximal skeletal correction.
• 12-18 months of pre-surgical orthodontics are
usually necessary to align the teeth, correct axial
inclinations, dental midline discrepancy, coordinate arches and localize space for prosthetic
replacement of teeth.
• Placement of full-size archwires with lugs
provides a means for rigid intermaxillary fixation
at time of surgery.
• After surgery, post-surgical orthodontic detailing
of occlusion is achieved in 4-6 months.

Orthognathic surgery for the cleft patient
Timing of orthognathic surgery
• Orthognathic surgery should be delayed till skeletal
maturity has been achieved as documented by hand
wrist radiographs or sequential cephalometric
radiographs taken at 6 month intervals.
• Usually at 17 years for girls and 18-20 years for
boys.
• Velopharyngeal function must be evaluated prior to
surgery as it may be disturbed by Le Fort I
advancement of maxilla leading to velopharyngeal
incompetence.
• The LeFort I osteotomy is the most favored
technique by authors for correction of sagittal
maxillary deficiency.

• Two jaw surgery i.e combination of maxillary
advancement and mandibular setback is indicated
when there is a true mandibular prognathism, or if
there is maxillary retrognathia of more than 10-12
mm.
• Segmental osteotomy: Is done if the greater
maxillary segment is in a good position, but the
lesser segment is medially and posteriorly
displaced.
• LeFort II osteotomy: Indicated in patients with
severe paranasal hypoplasia extending to the infraorbital rims.
• Premaxillary osteotomy: Done in patients with
repaired BCLP who have protruded and rotated
premaxilla. Generally done in children above 11
years of age.

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Some co-existing conditions which may need
repair at the time of osteotomy include:
Palatal fistulae
Soft tissue abnormalities
Bone asymmetry
Soft tissue scars of palate and lip, nose.

• Some authors are of the opinion that esthetic and
functional correction of the lip, nose or both is
best performed at a separate procedure, when the
soft-tissue and skeletal changes from osteotomies
have stabilized.

Relapse following LeFort I maxillary
advancement
• Relapse is more likely in cleft patients with
maxillary hypoplasia.
• This relapse is related to the factors that originally
contributed to the deformity:
• Scarring, muscle pull, tension in the soft tissues,
instability of bone segments.(Hochban et al 1993)
• Functional harmony, good occlusal adjustment,
rigid fixation with plates and bone grafting are
recommended to promote stability.

Dental anomalies associated with cleft
lip and palate
• Congenital developmental dental anomalies have
frequently been reported to occur in individuals born
with cleft lip, cleft palate, or both.
• These include anomalies in number of teeth (missing or
supernumerary), their shape, size, time of formation
and/or eruption, as well as the formation and
mineralization of their enamel.
• Both the deciduous and permanent dentitions are
affected, but the occurrence of these anomalies appears
in a considerably higher rate in the permanent dentition.
• The maxillary arch has been reported to have a higher
incidence of tooth abnormalities than the mandibular
arch.

• In addition, the extent or “penetration” of the
anomalies in the dentition depends on the severity
of the cleft.
• The teeth that are most frequently missing,
excluding the third molars, are the maxillary
permanent lateral incisor in the cleft area and the
second premolars outside the cleft region.
• Shapira (AJODO 1999) found an incidence of
74% for missing maxillary lateral incisors and
18% for missing second premolars in children
with cleft lip, cleft palate, or both.
• Hypodontia was found to occur approximately
three times as frequently on the cleft side as on the
non-cleft side in the maxilla (Ranta 1972)

• Hypodontia outside the cleft region was also much
higher in cleft-affected children than in others.
(Ranta AJO 1986) found the frequency of missing
teeth outside the cleft site for children with cleft
lip and palate, as follows:
7.5% to 32.3% for the maxillary 2nd premolars,
3.1% to 10.4% for the maxillary lateral incisors,
and
0.4 to 10.8% for the mandibular second premolars.
• Shapira et al (Angle Orthod 2000) in a study of
278 patients with cleft lip, cleft palate, or both age
5 to 18 years found an overall hypodontia
prevalence of 77% (excluding third molars) for the
sample.

• In addition, supernumerary teeth may be seen
adjacent to the cleft site.
• Lateral incisors with peg shape, crown-root
malformations and enamel hypoplasia are also
seen.
• The teeth adjacent to the cleft site may be rotated,
palatally erupted, poorly inclined, or periodontally
compromised.
• These dental anomalies are thought to be caused
by a combination of genetic and exogenous
factors.

The Goslon Yardstick (Mars et al
Cleft Pal J 1987)
• Mars et al have devised a method of categorizing
malocclusions in patients with unilateral clefts of
lip and palate in such a way as to represent the
severity of the malocclusion and the difficulty of
correcting it.
• This is known as the Goslon Yardstick and is
based on the assessment of
Antero-posterior arch relationships.
Vertical labial segment relationships
Transverse relationships.
This method has been successfully used to
compare treatment results in multi center studies.

Prosthetic Management of Cleft Lip and
Palate Patients.
• When a lateral incisor is present and is viable,
every effort should be made to preserve it.
• If it is missing, orthodontic space closure may be
carried ou or space may be preserved for a future
prosthesis.
• According to Figueroa et al (Clins in Plast Surg
1993) there are certain specific indications for
prosthetic replacement of the lateral incisor.

1. Canine on cleft side in ideal Class I relation with
lower canine.
2. Distal/ posterior eruption of the canine
3. Lack of suitable bone for tooth movement.(Give
FPD)
4. Long span of movement for canine.
5. Need for excessive palatal contouring of canine.
6. Abnormal shape of maxillary central incisors
7. Unfavorable shape/size/ color of canine.
8. When there is sufficient bone for a single osseointegrated implant prosthesis.

Thank you
Leader in continuing dental education


Management of cleft lip and palate 2. /certified fixed orthodontic courses by Indian dental academy

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