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Cleft lip and palate slideshare

CLEFT LIP AND PALATE

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Cleft lip and palate slideshare

  1. 1. CLEFT LIP AND PALATE Presented by: Khushbu Agrawal Dept of Orthodontics
  2. 2. CONTENTS  Introduction  Incidence  Embryology  Aetiology  Predisposing factors  Classification  Diagnosis  Problems associated with clefts  Syndromes associated with clefts 2
  3. 3. 3  Management of Cleft lip and palate • Timing of treatment sequence • Presurgical Orthopedic treatment • Nasoalveolar molding • Alveolar Bone grafting • Role of Orthodontist • Orthognathic surgery • Prosthetic rehabilitation • Recent advances • Other specialities  Conclusion  References
  4. 4. • Cleft lip and palate is the second most common congenital anamoly after clubfoot • Amoung the 15 types of orofacial clefting, cleft lip and palate is the most common one. 4 INTRODUCTION
  5. 5. • Hippocrates (400 BC) and Galen (150 AD) mention cleft lip, but not cleft palate in their writings • Cleft palate – Fanco (1556) • Repair of cleft lip – as early as 255-206 BC in China • The first successful closure of a soft palate defect was reported in 1764 by LeMonnier, a French dentist. 5
  6. 6. Kingsley (1880) - oral deformities as a branch of mechanical surgery Calvin case (1921) - a practical treatise on technique and principles of dental orthopaedic and prosthetic correction of cleft palate H.K.Cooper,Sr (1930’s) - Introduced the integrated team concept and formed the Lanchester cleft palate clinic - True integration starts with a meeting of the minds of the individuals who first examine the patient together and then agree on a program together 6
  7. 7. INCIDENCE
  8. 8. INCIDENCE • Worldwide one in 600 (1:600) • cleft lip with or without the cleft palate 9.92/10,000 • cleft lip 3.28/10,000, and cleft lip and palate 6.64/10,000 • Birth prevalence of clefts between 27,000 and 33,000 clefts per year A child is born with a cleft somewhere in the world every 2 minutes according to a WHO study published in 2001 Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189. 8
  9. 9. • Caucasian population, the prevalence of CL was 25%, CLP 50%, and CP 25% • In India meta-analysis of 25 early studies from 1960 to 1979 showed incidence of CLP 1.08 and CL 0.23 in 100 live births • In India alone the number of infants born every year with CLP is 28,600 78 affected infants are born every day, or 3 infants with clefts born every hour Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189. 9
  10. 10. • More common clefts are – • Unilateral clefts • Males female ratio is 2:1 • Left sided • Males more affected by cleft lip • Females more affected by cleft palate 10 Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–189.
  11. 11. EMBRYOLOGY
  12. 12. EMBRYOLOGY • Development of facial structures starts at the end of 4th week • 5 facial prominences around stomatodeum 1. Unpaired frontonasal process 2. Paireed maxillary prominences 3. Paired mandibular prominences 12 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  13. 13. • In following 2 weeks – • The 2 medial nasal processes fuse in midline – upper lip • Mandibular processes fuse in midline – lower lip 13 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  14. 14. • The maxillary and lateral nasal process separated by nasolacrimal groove/duct • Frontonasal process – bridge of the nose • Medial nasal process – tip of nose and philtrum of upper lip • Lateral nasal process – ala of the nose 14 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  15. 15. • Primary palate – maxillary and medial nasal process merge • Formation of intermaxillary segment from merged medial nasal prominences 15 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  16. 16. 16 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  17. 17. • Secondary palate – formed from 2 outgrowths from maxillary prominences – palatine shelves • Fuse in midline at 7th week • Incisive foramen – midline landmark between primary and secondary palate 17 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  18. 18. Formation of clefts • Failure of fusion of maxillary and medial nasal processes – anterior to incisive foramen • Failure of fusion of palatine shelves – posterior to incisive foramen • Cleft lip – failure of proliferation of mesodermal cells in midline 18 Thronton JB, Nimer S and Howrd P. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  19. 19. Formation of clefts 19
  20. 20. 20
  21. 21. ETIOLOGY
  22. 22. AETIOLOGY Ancient Folk explanations • Aztecs – eclipses occurred because a bite had been taken out of the moon • Prevented with an obsidian knife above the pregnant abdomen • Modern Mexico prevented with keys and safety pins 22
  23. 23. Early Chinese • Eating rabbit “hare lip” • Bad karma or wrong doings Philippines • Force to the fetal face Familial or “In the blood” 23
  24. 24. Multi factorial Environ mental Genetic 24
  25. 25. 1] Genetic • Genetic disorders are classified into 4 groups 1. Chromosomal 2. Single gene 3. Multifactorial – oral clefts 4. Mitochondrial 25 John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  26. 26. 2] Multifactorial because: 1) Chances increases if more than one family member if affected 2) More the severity, greater the chances of recurrence in sibling 3) Higher risk if affected individual is of less affected sex 4) Risk decreases in remotely related individuals 5) Consanguinity increases the rate because of sharing of genes 26 John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
  27. 27. 2 unaffected parents with 1 child affected  Risk for future children:  4.4% for CL+/-palate  2.5% for CP only 1 parent affected  Risk for future children  3.2% for CL+/-palate  6.8% for CP only 1 parent affected with 1 child affected  Risk for future children  15.8% for CL+/-palate  14.9% for CP only 27
  28. 28. 3] Environmental factors • Maternal smoking or tobacco exposure • Viral infections • Poor nutrition • Certain Medicinal drugs • Teratogens like:  Rubella virus, Cortisone/ steroids, Mercaptopurine, Methotrexate, Valium, Dilantin 28 Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85
  29. 29. PREDISPOSING FACTORS  High maternal age  Diabetes  Toxemia  Reduced blood supply  Folic acid deficiency  Racial – mongoloids  Radiations 29 Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85
  30. 30. CLASSIFICATION
  31. 31. CLASSIFICATION Bixler divided oral clefts into three groups 1. Syndromic / single-gene / chromosomal or environmental  1% of CLP AND 8% of isolated cleft palate 2. Familial  25% of CLP and 12% of isolated cleft palate 3. Isolated / non-familial  75% of CLP and 80% of isolated cleft palate 31 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  32. 32. Davis and Ritchie’s classification (1922) Group I: Prealveolar process cleft (clefts affecting the lip) 1. Unilateral (right/left: complete/incomplete) 2. Bilateral (right: complete/incomplete; left: complete/incomplete) 3. Median (complete/incomplete) Group II: Postalveolar process cleft (clefts affecting the palate) 1. Soft palate 2. Hard palate 32 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  33. 33. Group III: Alveolar process cleft (any cleft involving the alveolar process) 1. Unilateral (right/left: complete/incomplete) 2. Bilateral (right: complete/incomplete; left: complete/incomplete) 3. Median (complete/incomplete) 33 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  34. 34. Victor Veau’s classification (1931) A] Cleft lip Class I : U/L notching of vermillion border, not extending into the lip. Class II : cleft extending into the lip, but not including the floor of the nose. Class III: extending into the floor of the nose. Class IV: any b/l cleft of the lip, whether incomplete or complete. 34 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  35. 35. 35 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  36. 36. B] Cleft palate Class I : soft palate Class II : soft/hard palate extending no further than incisive foramen. Class III: complete unilateral cleft, extending from uvula to incisive foramen, then deviating to one side Class IV: two clefts extending forward from the incisive foramen into the alveolus. 36 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  37. 37. 37 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  38. 38. Fogh-Andersen’s classification (1942) 1. H arelip (single or double) 2. H arelip with cleft palate 3. Isolated cleft palate 4. R are atypical clefts, e.g., median cleft lip 38 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  39. 39. Kernahan and Stark’s classification (1958) 1. Clefts of structures anterior to the incisive foramen 2. Clefts of structures posterior to the incisive foramen 3. Clefts affecting structures anterior and posterior to the incisive foramen 39 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  40. 40. American Cleft Palate–Craniofacial Association (ACPA) classification (1962) 1. Clefts of the prepalate (cleft of lip and embryologic primary palate) a. Cleft lip (cheiloschisis) b. Cleft alveolus (alveoloschisis) c. Cleft lip, alveolus, and primary palate (cheiloalveoloschisis) 2. Clefts of the palate (cleft of the embryologic secondary palate) a. Cleft of the hard palate (uranoschisis) b. Cleft of the soft palate (staphyloschisis or veloschisis) c. Cleft of the hard and soft palate (uranostaphyloschisis) 40 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  41. 41. 3. Clefts of the prepalate and palate (alveolocheilopalatoschisis) 4. Facial clefts other than prepalatal and palatal a. Cleft of the mandibular process b. Naso-ocular clefts c. Oro-ocular clefts d. Oroaural clefts 41 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  42. 42. Kernahan and Stark’s stripped Y classification (1971) 42 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  43. 43. Spina’s classification (1973) Group I: Preincisive foramen clefts a. Unilateral b. Bilateral c. Medial Group II: Transincisive foramen clefts a. Unilateral b. Bilateral Group III: Post incisive foramen clefts a. Total b. Partial Group IV: Rare facial clefts 43 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  44. 44. Kernahan and Stark’s stripped-Y: Modification by Ehlsaky (1973) and Millard (1976) 44
  45. 45. Schuchardt and Pfeifer’s symbolic classification left Right Lip Alveolus Hard palate Soft palate Total cleft Partial 45 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  46. 46. LAHSHAL classification by Okriens (1987)  Lahshal is a paraphrase of the anatomic areas affected by the cleft. L – lip A – alveolus H – hard palate S – soft palate H – hard palate A – alveolus L – lip 46 Allori AC et al. Classification of Cleft Lip/Palate: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1)
  47. 47. DIAGNOSIS
  48. 48. DIAGNOSIS • Prenatal ultrasound – 2D or 3D • Prenatal counselling • 22% to 33% rates for detecting facial clefts • 73% - fetal cleft lip • 1.4% - isolated cleft palate • Color Doppler ultrasonography can also be used 48 Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
  49. 49. Ultrasound technique - Non-invasive diagnostic tool - Confirm fetal viability - Determine gestational age - Establish number of fetuses and their growth - Check placental location - Examine fetal anatomy for detecting malformations 49 Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
  50. 50. Transabdominal US - Not reliable till gestational age of 15 weeks - Done at 20 or more weeks of gestation Transvaginal USG - Earlier visualization (12 weeks) - Better image resolution - Greater specificity and sensitivity 50 Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
  51. 51. Babcock and McGahan (1997) - Starts with coronal plane - Assessment continues in axial view - Bilateral clefts: sagittal view - Isolated clefts: axial view 51 Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
  52. 52. Advantages of prenatal cleft diagnosis - Psychological preparation for parents to have realistic expectations - Parent education for cleft management - Preparation for neonatal care and feeding - Opportunity to investigate other abnormalities - Possibility of fetal surgery 52 Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
  53. 53. Disadvantages of prenatal cleft diagnosis - Emotional disturbance - High maternal anxiety and dysfunction - Termination of pregnancy 53 Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012
  54. 54. PROBLEMS ASSOCIATED WITH CLEFT LIP & PALATE
  55. 55. 55 Dental Skeletal Nasal Feeding Ear problems Speech Associated anomalies *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
  56. 56. DENTAL  Tooth agenesis, hypodontia (most common)  Supernumerary teeth (2nd most common)  Enamel hypoplasia (CI)  Crossbites  Ectopic eruption, transposition  Taurodontism, dilacerations 56 *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
  57. 57. 57 SKELETAL  Maxillary deficiency  Mandibular prognathism  Class III malocclusion  Concave profile *Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara, Dental Anomalies of Number in The Permanent Dentition of Patients With Bilateral Cleft Lip: Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476.
  58. 58. 58 FEEDING PROBLEMS  Oronasal fistulas  Draining of oral fluids in nasal cavity and vice versa  Bottle, cup and spoon, tube feeding  Infant held at 30-450 angle to aid swallowing
  59. 59. SYNDROMES ASSOCIATED WITH CLEFT LIP & PALATE
  60. 60. SYNDROMES  Around 400 syndromes  Chromosomal anomalies • Trisomy 13 (Patau) • Trisomy 18 (Edward) • Trisomy 21 (Down’s) • Velocardiofacial syndrome (22q11 deletion) 60 *Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
  61. 61.  Inherited syndrome • Sticklers (Autosomal dominant) • Treacher Collins (AD) • Van der Woude (AD)  Non-inherited syndrome • Pierre Robin Syndrome – triad of cleft palate, glossoptosis, retrognathia • Goldenhar syndrome 61 *Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
  62. 62.  Teratogenic • Fetal alcohol syndrome • Fetal phenytoin syndrome • Fetal valproate syndrome 62 *Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
  63. 63. MANAGEMENT OF CLEFT LIP & PALATE
  64. 64. 64 MULTIDISCIPLINARY MANAGEMENT CLEFT TEAM Dentist Surgeon Nursing Genecists Social worker Ophthalmol ogist Psychologi st Paediatrician Speech therapist ENT/ audiologist
  65. 65. 65 TIMING AND SEQUENCING OF CONSERVATIVE SURGICAL-ORTHODONTIC TREATMENT (1980s) *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
  66. 66. 66 *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
  67. 67. Philadelphia Centre for research in Child growth- Wilton Krogman (1947-71) Divided the treatment into 8 phases: • First stage – Prenatal phase Complete history of gestation and maternal health, counseling of the parents Genetisist and other Social workers 67
  68. 68. • Second stage – at birth Pediatrician discusses the condition with the parents, Surgeon advises about the operative plan, Dental specialists appraises the arch relationships • Third stage – birth to 1 year Pediatrican - advises about the feeding Surgeon - carries out the lip closure (rule of 10) Dental specialist - secures the models and radiographs Speech therapist - discusses about the insufficiency and incompetence of the pharyngeal seal 68
  69. 69. • Fourth stage – 1-2yrs Pediatrican - takes care of the health and nutrition. Surgeon carries out the closure of the hard palate 1:2 soft palate 1:6 Speech therapist - monitors the vocabulary and option of a prosthetic replacement ENT - monitors the ear condition. • Fifth stage – 2-6 years Orthodontist – arch relations, crossbites, developing malocclusion 69
  70. 70. • Sixth stage – 6-12 years Surgical corrections - secondary closure /repair of palate, lip and the nose • Seventh stage – 12-18 years Surgical follow up on the lip and nose correction, orthodontic treatment is continued • Eighth stage – 12 years onwards Regular patient follow-up 70
  71. 71. 1. No preoperative orthopedics. 2. Closure of Cleft lip in infancy – Millard procedure -3 months 3. Closure of the remaining isolated cleft – Von Langenbeck -18 months. 4. Secondary operations 18-30 yrs of age. 71 Cleft Lip and Palate Patients Management in OSLO- Norway (1948)
  72. 72. 1. Pre dental treatment-1-18 months of age. 2. Deciduous dentition 3-6 yrs of age-full eruption of primary dentition. 3. Early mixed dentition 7-9 yrs- after or during the eruption of permanent maxillary incisors. 4. Late mixed and early permanent dentition 9 ½ yrs onwards 72 FISHMAN
  73. 73. 1. Infancy – before the initial surgical repair of the lips. 2. During late primary and early mixed dentition. 3. Late mixed and early permanent dentition. 4. Late teens (after completion of facial growth in conjunction with orthognathic surgery). 73 PROFITT
  74. 74. 74 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  75. 75. Neonatal • Birth to 1 year Deciduous dentition • 1 to 6 years Mixed deentition • 6 to 12 years Permanent dentition 75 • 12 years and adult
  76. 76. • Hoffman (1678) – extraoral devices to retract protruding premaxilla • McNeil (1950s) – presurgical orthopaedic • Hotz – premaxilla is normally placed, by age 10, face grows downward and forward into balance with premaxilla 76 NASOALVEOLAR MOULDING *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  77. 77. • Grayson (1993) – first technique to correct the alveolus, lip and nose in cleft infants • Matsuo (1988) - Research for cartilage moulding - high maternal level of estrogen at the time of birth correlates with an increase in hyaluronic acid, which inhibits the linking of the cartilage intercellular matrix 77 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  78. 78. • Matsuo used a stent, silicone tubes to shape the nostrils • Grayson (1999) adapted his nasal stent to extend from the anterior flange of an intraoral molding plate. • This new technique was named – “ Nasoalveolar molding” 78 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  79. 79. 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. 79 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  80. 80. 80 Procedure: • A heavy-bodied impression material is used to take the initial impression as soon after birth as possible. • Grayson and Maull (1999) held infant in upside down position to keep the tongue forward which permitted fluids to draw off the oral cavity when impression tray is placed • Yang (2003) took the impression using a pre-trimmed customized pediatric tray with the baby being held in the erect position, by one of the parents *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  81. 81. • Prashanth (2013), Mishra (2010) obtained impression when the infant was awake in a prone position on the dental chair, the child is held on the lap of their parents with no anesthesia. • Dubey (2011) made impression of the cleft region upper arch using ice cream stick and impression compound. 81 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  82. 82. • Plate – clear self-cure acrylic, trimmed with a denture soft material • 2–3 mm in thickness • The retention arm – 40 degrees to get appropriate activation and to avoid dislodgement of the NAM plate from palate 82 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  83. 83. • The nasal stent is added to the intraoral molding plate when the cleft alveolar gap is reduced to 5mm or less • Stent – 0.036-in gauge round stainless steel wire • The intranasal portion is formed from hard acrylic, covered with a thin layer of soft spongy acrylic denture liner 83 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  84. 84. • Elastics used are 0.25 inch and it should be stretched about two times the diameter for activation force of about 2 Oz 84 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  85. 85. 85 *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  86. 86. 86 Complications and disadvantages: • Irritation of the oral mucosal or gingival tissue • Ulceration of intraoral tissues • The intranasal lining of the nasal tip can become inflamed • Skin irritation due to tape usage • Parent compliance required • Moulding plate may get dislodged and obstruct the airway *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  87. 87. 87 Benefits: • Short-term: the tissues are well aligned prior to primary lip and nose repair • Long-term: • change in nasal shape is stable • Reduced number of surgical revisions • Reduction of treatment cost • Shetty V et al (2017) - improves arch symmetry and stability, and thus may prevent arch collapse in the long term *Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
  88. 88. CLEFT LIP REPAIR 88 • Goal: improve facial aesthetics by restoring nasal and lip contour • Timing: 3 to 6 months • Millards “RULE OF TEN” [term coined by Wilhelmmesen and Musgrave in 1969] • 10 weeks (age) • 10 pounds (weight) • 10 gm/dl (Hb)
  89. 89. 89 Techniques: 1. Tennison – Randall (Z-Plasty) 2. Millards rotation advancement repair 3. Rose – Thompson straight line repair
  90. 90. PRESURGICAL ORTHOPEDIC TREATMENT 90 Presurgical orthopedic treatment (PSOT) ?????  Many authors – many minds  PSOT beneficial or not ?? *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
  91. 91.  1920s -1930s – repair the defect by establishing an anatomical continuity  Priority of treatment - Improve speech ability - Dental function - Facial aesthetics  Importance of growth not recognized 91 *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
  92. 92.  1950s – Two schools of thoughts 92 • McNeil and Burston • Align palatal segments • Delay palatal closure till 5-9 years of age Presurgical Orthopedics • Led by Pruzansky • Did not favour PSOT • Palatal closure at 2-4 years of age Immediate surgery *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
  93. 93. A Millard-Latham Procedure 93  Latham manipulated the palatally pinned presurgical orthopaedic appliance – mechanical expansion of the lateral palatal segments is followed by the retraction of the protruding premaxilla into position within the arch  Floor of nose is surgically closed  Gingivoperiosteoplasty – migration of alveolar bone cells – close alveolar gap *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
  94. 94. 94  Modified appliance – a premaxillary stainless steel pin 7/10 mm in diameter is inserted through the posterior stem of the premaxilla.  3 Oz force per side for premaxilla retraction  Premaxilla retraction and expansion  8-14 days – premaxilla is positioned within the palatal segments *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
  95. 95. 95 CHANGING SURGICAL CONCEPT FROM 1920S TO 1950S • Graber (1950s) – surgery performed early, caused severe midfacial deformity later • Brophy, first proponent of surgical technique – steel-clamp and silver-wire bony closure technique • von Langenback soft tissue procedure alone to approximate lateral halves of maxilla and reduce intermaxillary width *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
  96. 96. • Graber, Slaughter and Brodie (1950s-1960s) – negative reports on surgical procedure done at an early age • “No palatal surgery at an early age” (before 12 months) • James Scott (1956) – Sutural growth theory • McNeil and Burston – adopted his theory – functional paediatric prosthesis – palatal closure between 5 to 9 years of age 96 *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
  97. 97. • Melvin Moss (1968) – functional matric theory – septal cartilage grows as a secondary response • McNeil – Father of presurgical orthopaedics – supported Scott’s theory • Burston – premaxilla was normal and lateral palatal segments were retruded in face • Presurgical orthopaedics + primary bone grafting within first year of life • Prusanky – opposed the same 97 *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
  98. 98. 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 98 *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
  99. 99. • Berkowitz (1978) – “State of art” • Primary bone grafting – deleterious effects on midface • No evidence that PSOT normalize feeding, tongue posture, swallowing or growth 99 *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
  100. 100. CONSERVATIVE TREATMENT – THE BEST APPROACH • Same surgery performed can cause in different results at different ages: 1. The cleft defect 2. The facial growth pattern 3. The surgical procedure 100 *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
  101. 101. 101 CLEFT PALATE SURGERY TIMING AND SPEECH OUTCOME 1970s • Mid to late 1970’s – 18 to 24 months surgical palate repair • General trend of better speech results with earlier ages at surgery • Jolleys (1954) – approximately 90% of children who underwent surgery before the age of 2 years had good or excellent speech • General age range for surgery – 6-9 months, before 8 months, 1 year range, between 2 to 3 years *Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191
  102. 102. 1980 – 1990s • Kaplan (1981) – palatal closure between age of 3 to 6 months • Dorf and Curtin (1982,1990) – importance for phonemic development or articulation age • Greater discrepancy in speech performance between the "12 months and younger group" and the children operated on over the age of 12 months • Ross (1987) – slightly better facial growth if surgery done in the first year of life 102 *Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191
  103. 103. SURGERIES FOR CLEFT PALATE 1. Von Langenback 2. V-Y palatoplasty by Veau 3. Furlow’s technique 4. Wardill Kilner’s push back 103
  104. 104. 104 BONE GRAFTING FOR ALVEOLAR CLEFT DEFECTS BONE GRAFTING Primary bone grafting First 2 years of life Secondary bone grafting Early – 2 to 5 years of life Late – 11 to 14 years of life *Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
  105. 105. OBJEVTIVES FOR SURGICAL GRAFTING: • Stabilization of segments • Improved oral hygiene • Nasal secretions prevented from draining into the mouth • Unites maxilla to better withstand occlusal forces • Bony base for teeth eruption • Improves nasal symmetry • Provide feeling of normalcy and improve social acceptance 105 *Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
  106. 106. BONE GRAFTING AND ORTHODONTIC TOOTH MOVEMENT • A general rule – “orthodontic tooth movement performed with improved outcomes after the bone graft has been completed” • Tooth movement initiated 1 to 3 months after grafting into the grafted area 106 *Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
  107. 107. SURGICAL MANAGEMNT OF ALVEOLAR CLEFT • Ideal timing: - 9 to 11 years of age - Before canine eruption, canine root is 1/3rd formed (Bergland et al) • Best source of bone graft: (autologous cancellous bone) - Anterior portion of iliac crest - The rib, tibia - The cranium - The mandible 107 *Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192-196
  108. 108. 108
  109. 109. 109 ROLE OF ORTHODONTIST *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  110. 110. A] NEONATAL MAXILLARY ORTHOPAEDICS • McNeil (1950)s – Father of presurgical orthopaedics • Rationale – realignment of collapsed segments • Active or passive orthopaedic appliances 110 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  111. 111. B] ORTHODONTIC-ORTHOPAEDIC TREATMENT IN DECIDUOUS DENTITION • Problems in deciduous dentition: - Delay in eruption in vicinity of cleft - Malformed or congenitally missing lateral incisor - Anterior or posterior buccal crossbite - Functional shift 111 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204
  112. 112. • Turvey (1982) believe that orthodontic treatment in the deciduous dentition, although possible, is contraindicated • Rygh and Tindlund (1988) – Growth modification at this stage has been proposed • They recommend utilization of a quad-helix appliance soldered to bands on the primary second molar teeth and canines to expand the upper arch • Alongwith protraction face mask to modify and redirect growth 112 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  113. 113. C] ORTHODONTIC TREATMENT DURING THE MIXED DENTITION • Bone grafting: • 5 to 6 years of age • After 8 to 9 years of age • Radiographically, after root of unerupted canine is half or one-third developed. 113 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204
  114. 114. • Orthodontics – 6 months before grafting • Fixed appliance in upper arch • Objectives at this stage: - Expansion of maxilla, - elimination of crossbites, derotations of malposed teeth, - improve dental and aesthetic function • Spontaneous canine eruption (27%), surgical uncovering (17%), combined surgical and orthodontic traction (56%) • Orthodontics resumed 3 months after graft placement 114 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  115. 115. Expansion appliances for cleft palate patients: 1. Telescopic maxillary expander 2. Fan shaped maxillary expander 3. Butterfly maxillary expander 4. Spring jet for slow expansion 5. Banded / bonded rapid palatal expansion 6. Modified hyrax appliance 7. Quad helix 115
  116. 116. Protraction Facemask Therapy: • Can be used before bone grafting in mild midfacial deficiency • Increased growth at circumaxillary sutures • Orthopaedic force – 350 to 500 gram/side • 10-12 hours a day • 12-15 months 116
  117. 117. D] ORTHODONTIC TREATMENT DURING THE PERMANENT DENTITION • Decision – orthodontics alone OR orthodontic combined with orthognathic surgery • Ross (1987) – 25% require surgery • 3 consecutive cephalogram, 6 months apart showing no change in length of mandible can be used 117 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  118. 118. TREATMENT BY ORTHODONTICS ALONE 1. Tooth alignment 2. Establishment of a continuous maxillary arch with favourable archform 3. Correction of anterior and/or posterior crossbites 4. Stability of occlusion in the presence of dental compensations 5. Favourable dentofacial esthetics 118 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  119. 119. TREATMENT BY ORTHODONTICS COMBINED WITH ORTHOGNATHIC SURGERY • Severe skeletal discrepancy, oronasal fistulas, speech deformity • Maxillary surgery – multiple segment Le Fort I osteotomy with down- grafting • Presurgical orthodontic treatment – 12 months • AP discrepancy – more than 8mm – bijaw surgery needs to be planned 119 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  120. 120. • Unilateral clefts – 2 piece Le Fort I osteotomy 120 *Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14
  121. 121. • Bilateral clefts – 3 piece Le Fort I osteotomy 121 *Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14
  122. 122. • Post-surgical orthodontic – 4 to 6 months • Transverse maxillary stabilization by transpalatal arch or piggy-back overlay arches • Immediate retainers – Hawley’s type • Cemented lingual arch in maxilla • Vaccum formed retainers not indicated 122 *Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-204.
  123. 123. • Ambrose Pare (1565) – prosthesis to obturate palate • Obturators using sponges, wax, and silver to more modern materials • Latham appliance (1980) – unilateral or bilateral clefts 123 PROSTHETIC REHABILITATION FOR CLEFT PALATE PATIENTS *Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19
  124. 124. Restorative treatment options in permanent dentition • Partial overdenture • Removable partial dentures • Fixed prosthetic rehabilitation • Implant prosthodontics • Restoration – laminates and veneers 124 *Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19
  125. 125.  Velopharyngeal impairment – insufficient contact between the velum and the posterior and lateral pharyngeal walls  Velopharyngeal insufficiency – deficiency  Velopharyngeal incompetence – neuromuscular 125 VELOPHARYNGEAL IMPAIRMENT *Dalston R. Velopharyngeal Impairment in the orthodontic patients. Semin Orthod 1996;2:220-7.
  126. 126. Treatment 1. Speech therapy 2. Non-surgical or speech aid prosthesis • Obturators • Transitional appliance in growing patients 3. Surgical • Palatoplasty, Sphincter pharyngeoplasty 126 *Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19
  127. 127. • Fetal surgery – done in intrauterine life (prior to 20 weeks) • Non-life threatening defects like cleft lip, cleft palate, Pierre Robin syndrome, Treacher-Collins syndrome, craniofacial microsomia • Open fetal surgery • Feto-endoscopic approach 127 RECENT ADVANCES *Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607
  128. 128. ADVANTAGES 1. Provide a scarless repair, “ripple effect” is eliminated 2. Correct the primary deformity, 3. Prevent secondary deformities, and 4. Give the parents a "normal“ - appearing child at birth 128 *Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607
  129. 129. CONCLUSION • Oral clefts are the second most common congenital anamoly, having multifactorial origin • A considerable knowledge about the etiology and embryology is required for proper diagnosis and treatment planning of such patients • Treatment begins soon after birth and continues till adulthood requiring a team approach. 129
  130. 130. CONCLUSION • Multiple problems and syndromes with clefts • Multidisciplinary approach for management, patient-centered • Variations in treatment sequence • Role of orthodontists 130
  131. 131. REFERENCES • Reddy S et al. Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Indian J Plast Surg. 2010 Jul-Dec; 43(2): 184–9. • Allori AC et al. Cleft lip and palate classification: Then and Now. Cleft Palate–Craniofacial Journal 2016;53(1) • Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012. • John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification, etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168 • Inderbir Singh. Human embryology. Macmillan India. Seventh edition 2001. • Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85 131
  132. 132. REFERENCES 1. Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques. Elsevier 2012 2. 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 3. Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara, Dental Anomalies of Number in The Permanent Dentition of Patients With Bilateral Cleft Lip: Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476. 4. Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994 5. 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 6. Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod 1996;2:185-191 132
  133. 133. 7. Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8. 8. Waite P, Waite D. Bone Grafting for the Alveolar Cleft Defect. Semin Orthod 1996;2:192- 196 9. Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197- 204 10. Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient. Semin Orthod 1996;2:205-14 11. Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod 1996;2:215-19 12. Dalston R. Velopharyngeal Impairment in the orthodontic patients. Semin Orthod 1996;2:220-7. 13. Papadopulos NA. Foetal surgery and cleft lip and palate: current status and new perspectives. Br J Plast Surg. 2005 Jul;58(5):593-607 14. Chang J. Fetal plastic surgery: a review and preview. © Chang www.thefetus.net/ 133
  134. 134. THANK YOU 134 THANK YOU

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