Here are the key steps in the treatment plan: 1. Use RME to correct the posterior crossbite and expand the maxilla. 2. Use orthodontic treatment to align the teeth and correct the midline shift. Extraction of the displaced canine may be needed. 3. Monitor jaw growth and consider orthognathic surgery if the class 3 skeletal relationship does not improve with growth. 4. Address any residual speech or functional issues. 5. Continue follow up into adulthood to ensure stability of the treatment results. The multidisciplinary treatment aims to improve occlusion, function and facial esthetics for the patient. Close monitoring of jaw growth is important given his age.

1. Cleft lip and palate from
embryological development till
maturity.
By
Dr. Khaled Wafaie
Master of science in orthodontics
University of Dundee
Orthodontic specialist at Smile Train and Operation
Smile

2. Classification of cleft lip and palate?
• Clefts of the lip and palate are generally divided into two groups
isolated cleft palate and cleft lip with or without cleft palate,
representing a heterogeneous group of disorders affecting the lips
and oral cavity.
• These defects arise in about 1·7 per 1000 live born babies with ethnic
and geographic variation.
• Cleft lip with or without cleft palate is most frequent in males, and
isolated cleft palate is most typical in females

3. (A) Cleft lip and alveolus. (B) Cleft palate. (C) Incomplete unilateral cleft lip and
palate. (D) Complete unilateral cleft lip and palate. (E) Complete bilateral cleft lip
and palate. Shaw WC. Orthodontics and occlusal management. Oxford: Butterworth-Heinemann, 1993.

4. • Effects on speech, hearing, appearance, and psychology can lead to
long lasting adverse outcomes for health and social integration.
• Evidence show that cleft patients have higher morbidity and mortality
throughout life than do unaffected individuals. Findings of studies
have shown an increased frequency of structural brain abnormalities
• Typically, children with these disorders need multidisciplinary care
from birth to adulthood nursing, plastic surgery, maxillofacial surgery,
otolaryngology, speech therapy, audiology, counselling, psychology,
genetics, orthodontics, and dentistry.

5. 4th week-> paired maxillary and mandibular processes
6th week-> merging of medial nasal processes with maxillary processes to form upper lip and primary palate
7th week-> the palatal shelves rise to a horizontal position above the tongue and come into contact and fuse
10th week-> In addition to fusing in the midline, the secondary palate fuses with the primary palate and the nasal septum

6. • Since the lip and primary palate have distinct developmental origins
from the secondary palate, clefts of these areas can be subdivided
into cleft lip with or without cleft palate and isolated cleft palate in
which the lip is not affected.
• This subdivision is validated by the finding that, under most
circumstances, cleft lip with or without cleft palate and isolated cleft
palate do not segregate in the same family.
• Genes responsible for cleft Osr2, Lhx8, Msx1, Fgf10, Fgfr2b, Tgfb2,
and Tgfbr2.
Any familiar gene?

7. Lifestyle and environmental risk factors
• Environmental risk factors might be important in cleft lip and palate,
and maternal exposure to tobacco smoke (increase risk by 20%),
alcohol (fetal alcohol Syndrome), poor nutrition (not enough
evidence), viral infection, medicinal drugs, and teratogens in the
workplace and at home in early pregnancy have all been investigated.
-Little J, Cardy A, Munger RG. Tobacco smoking and oral clefts:
a meta-analysis. Bull World Health Organ 2004; 82: 213–18.
-Honein MA, Rasmussen SA, Reefhuis J, et al. Maternal smoking and
environmental tobacco smoke exposure and the risk of orofacial
clefts. Epidemiology 2007; 18: 226–33.

8. • In most studies, maternal use of multivitamin supplements in early
pregnancy has been linked to decreased risk of orofacial clefts; in a
meta-analysis, multivitamin use was associated with a 25% reduction
in birth prevalence of orofacial clefts.
• Johnson CY, Little J. Folate intake, markers of folate status and oral clefts: is the evidence
converging? Int J Epidemiol 2008; 37: 1041–58.

9. • Folate deficiency increased risk of orofacial clefts in people. In North
America, where fortification of grains with folic acid has been
mandatory since the late 1990s, some evidence suggests a decline in
prevalence at birth of cleft lip with or without cleft palate.
• Hernández-Diaz S, Werler MM, Walker AM, Mitchell AA. Folic acid antagonists during pregnancy
and the risk of birth defects. N Engl J Med 2000; 343: 1608–14.

10. • Zinc is important in fetal development, and deficiency of this nutrient
causes isolated cleft palate and other malformations. In the
Philippines, zinc deficiency is widespread, and high maternal amounts
of zinc in plasma were associated with low risk of orofacial clefts with
a dose-response relation.
• Warkany J, Petering HG. Congenital malformations of the central nervous system in rats produced
by maternal zinc defi ciency. Teratology 1972; 5: 319–34.
• Tamura T, Munger RG, Corcoran C, et al. Plasma zinc concentrations of mothers and the risk of
nonsyndromic oral clefts in their children in the Philippines.

11. • Maternal occupational exposure to organic solvents and parental
exposure to agricultural chemicals have been associated
inconsistently with cleft lip, cleft lip and palate, and cleft palate alone.
• Gordon JE, Shy CM. Agricultural chemical use and congenital cleft lip and/or palate. Arch Environ
Health 1981; 36: 213–21. 101
• García AM. Occupational exposure to pesticides and congenital malformations: a review of
mechanisms, methods, and results. Am J Ind Med 1998; 33: 232–40.

12. • Interferon regulatory transcription factors are activated after viral
infection. Association of IRF6 with clefts raises the possibility that viral
infection in the first trimester of pregnancy might enhance risk of a
cleft.
• Acs NA, Bánhidy F, Puhó E, Czeizel AE. Maternal influenza during pregnancy and risk of congenital
abnormalities in off spring. Birth Defects Res A Clin Mol Teratol 2005; 73: 989–96.

13. • Foetal moulding: decreased level of amniotic fluid can lead to the
head being flexed against the chest preventing growth of the
mandible.
• May cause a cleft palate as the tongue is forced upwards preventing
normal closure of the palatal shelves.

14. Genetic factors
• Cleft lip with or without cleft palate is listed as a feature of more than
200 specific genetic syndromes, and isolated cleft palate is recorded
as a component of more than 400 such disorders.
• The proportion of orofacial clefts associated with specific syndromes
is between 5% and 7%.
• Tolarova MM, Cervenka J. Classifi cation and birth prevalence of orofacial clefts. Am J Med Genet
1998; 75: 126–37.

15. Clinical management
1) Identification of modifiable risk factors for oral clefts is the first step towards
primary prevention.
2) Birth to six weeks – feeding assistance, support for parents, hearing tests and
paediatric assessment.
3) 3-6 months – surgery to repair a cleft lip
4) 6-12 months – surgery to repair a cleft palate
5) 18 months – speech assessment.
6) Three years – speech assessment.
7) Five years – speech assessment
8) 8-12 years – bone graft to a palatal cleft and RME to correct posterior crossbite
caused by palatal closure scar
9) 12-15 years – orthodontic treatment and monitoring jaw growth (Orthognathic
surgery)
10) These will usually be recommended until they're around 21 years of age, when
they're likely to have stopped growing.

16. Surgery for cleft lip
• The operation usually takes one to two
hours.
• A slight scar may remain, but the
surgeon will attempt to line up the scar
with the natural lines of the lip to make
it less noticeable. It should fade and
become less obvious over time.

17. Palate repair surgery
• The operation usually takes about two hours

18. Additional surgery (Bone graft)
Alveolar bone grafting between the ages (9 and 11)  it encourages dental development and
subsequent treatment at the area of cleft. There is moderate evidence that it improves nasolabial
esthetics.

19. Feeding help and advice
• Many babies with a cleft palate have problems with breastfeeding because of the gap
in the roof of their mouth.
• They may struggle to form a seal with their mouth – so they may take in a lot of air and
milk may come out of their nose. They may also struggle to put on weight during their
first few months.
• A specialist cleft nurse can advise on positioning, alternative feeding methods and
weaning if necessary.
• If breastfeeding isn't possible, they may suggest expressing your breast milk into a
flexible bottle that is specially designed for babies with a cleft palate.
• Very occasionally, it may be necessary for your baby to be fed through a tube placed
into their nose until surgery is carried out.

20. Treating hearing problems
• Children with a cleft palate are more likely to develop problems
because of fluids builds up in the ear.
• This is because the muscles in the palate are connected to the middle
ear. If the muscles aren't working properly because of the cleft, sticky
secretions may build up within the middle ear and may reduce
hearing.

21. Speech and language therapy
• Repairing a cleft palate will significantly reduce the chance of future
speech problems, but in some cases, children with a repaired cleft
palate still need some form of speech therapy.
• A speech and language therapist (SLT) will carry out several
assessments of your child's speech as they get older.

22. Role of Orthodontics in cleft patients
• Orthopedic appliances to improve surgical results (Pre-maxillary
alignment), but according to recent evidence it is non significant to
use it.
NAM

23. What’s NAM appliance?
• First invented in 1950 as an adjunctive to correct cleft lip and palate, its
indication is to reduces the severity of the initial cleft alveolar and nasal
deformity.
• Initial impression of the cleft lip and palate infant is obtained within the
first week of birth. A heavy-bodied silicone impression material is used to
take the initial impression. The infant is held upside down by the surgeon
and the impression tray is inserted into the oral cavity. Air way must be
under supervision.
• The mouth is examined for residual impression material.

26. Taking impression
must be fast with
caution to prevent
any blockage of
airway.

27. Start initial treatment
with passive NAM
appliance.

28. Then transfer after 2-
3 months for active
NAM appliance.

29. • The plate is made of hard, clear self-cure acrylic with 2-3mm
thickness.
• A retention button is fabricated and positioned anteriorly at an angle
of 40° to the plate. The vertical position of the retention arm should
be at the junction of the upper and lower lip. Its position is
determined in clinic.
• It is used to secure the molding plate in the mouth with the help of
orthodontic elastics and tapes.
• A small opening measuring 6–8 mm in diameter is made on the
palatal surface of the molding plate to provide an airway in the event
that the plate drops down posteriorly.
• The nasal stent is not fabricated at this time. Instead its construction
is delayed until the cleft of the alveolus is reduced to about 5–6 mm
in width.

31. • Check for any sharp edges or rough surfaces that may irritate the soft
tissue. The appliance is then secured extra-orally to the cheeks and
bilaterally by surgical tapes that have orthodontic elastic bands at one
end.
• The use of skin barrier tapes on the cheeks.
• The horizontal surgical tapes are a quarter inch in width and about 3–
4 inches in length.
• Parents are instructed to keep the plate in the mouth full time and to
remove it for daily cleaning. The infant may require time to adjust to
feeding with the NAM appliance in the first few days.
• The baby is seen weekly to make adjustments to the moulding plate
to bring the alveolar segments together.

33. Make sure that the
mother is educated
enough to deal with any
situation.

34. Nasal stent
• The nasal stent component of the NAM appliance is incorporated
when the width of the alveolar gap is reduced to about 5 mm. (WHY?)
• The rationale for delaying the addition of the nasal stent is that as the
alveolar gap is reduced, the base of the nose and the lip segment
alignment is also improved.
• The stent is made up of 0.36 inch, round stainless steel wire and takes
the shape of a ‘Swan Neck’, entering 3-4 mm of the nose.

35. Long-Term Effects of Presurgical Infant Orthopedics in Patients With
Cleft Lip and Palate: A Systematic Review (Aslihan Uzel and Nazan Alparslan)
• Based on the results of this study, treatment with passive IO
appliances have no positive effects on the seven treatment outcomes
(motherhood satisfaction, feeding, speech, facial growth, maxillary
arch dimension, occlusion, nasolabial appearance) in patients with
UCLP until the age of 6 years.
• Active appliances have no positive effects on feeding in patients with
UCLP.
• There is evidence on the improvement of nasal symmetry in patients
with UCLP using NAM appliances.

36. At the age of 9
• Bone graft placement at the bony defect, to help in canines eruption
and start orthodontic movements.
• Start to correct class skeletal relation by using facemask (for 12 hours
a day) with expansion to correct posterior cross-bite found in most
cases because of the scar of the palatal surgery.

37. Case scenario 1
• A.H is a 10 years old Egyptian female presented with a unilateral left
cleft lip and palate with class 3 incisor on class 3 skeletal base with
decreased vertical proportion. The overjet is -5mm with increased
incomplete overbite. Canine is unclassified and molar is class 3, She is
presented with bilateral transposition of upper canines and first
premolars and 2 supernumerary teeth with hypodontia in upper right
lateral incisor. Severe crowding upper arch and mild lower. She
performed first surgery when she was 6 months for the cleft lip then
she performed the first surgery for the palate when she was 1.5 years
old then second surgery for the palate when she was 2.5 years.

38. Pre-treatment - Extra Oral views
ProfileFull face
Smile

39. Pre-treatment - Intra oral views
Labial view

40. Pre-treatmentDPT

42. Pre-treatment
Lateral
Cephalogram

43. Variable Pre-treatment Normal
value
SNA 83 82° ± 3
SNB 85 79° ± 3
ANB -2 E= -3 3° ± 1
SN to Maxillary Plane 10 8° ± 3
Wits appraisal 6mm 0mm
Upper incisor to maxillary plane 117 108° ± 5
Lower incisor to mandibular plane 94 92° ± 5
Macnamara N perpendicular to Pog 3mm
Macnamara N perpendicular to A -1mm
Maxillary mandibular planes angle 20 27° ± 5
Upper anterior face height 43
Lower anterior face height 50
Anterior face height ratio 53.7 55%
Lower incisor to Apo 5mm 0-2mm
Lower lip to E plane 2mm -2mm
Lower incisor edge to upper incisor
root centroid
11mm 0-2mm
Interincisal angle 127 133° ± 10
Pre-treatment
Cephalometric
analysis

44. Treatment sequence

45. Additional surgery (Bone graft)
Alveolar bone grafting between the ages (9 and 11)  it encourages dental development and
subsequent treatment at the area of cleft. There is moderate evidence that it improves nasolabial
esthetics.

46. Mid-treatment - Extra Oral views
Profile
Smile
Cleft patients have late growth, facemask can be used till 12
years of age. Facemask is used for shorter periods in cleft
patients (10-12hours). (Delaire et al)

47. Treatment to be
continued

48. Case scenario 2
• M.A is a 18 years old Egyptian male presented with class 1 incisor
relation on class 3 skeletal base with bilateral posterior crossbite. This
was complicated with increased complete overbite with cross-bite in
lower left central with upper right central. Hypodontia of upper left
lateral and extracted upper right displaced canine. Upper midline
shifted to the left by 5mm. Lip surgery performed at 6 months of age.
First palatal surgery performed at 1.6 years. Second surgery at 3
years. Third palatal surgery performed at 9 years. Grade 3 bone defect
at the palate.

49. Extra-oral pre-treatment

51. Quadhelix
was placed
and
treatment
to be
continued

52. Every one can
make a difference
to add one more
smile

53. References
• Mossey, Peter A., et al. "Cleft lip and palate." The Lancet 374.9703
(2009): 1773-1785.
• Uzel, Aslihan, and Z. Nazan Alparslan. "Long-term effects of
presurgical infant orthopedics in patients with cleft lip and palate: a
systematic review." The Cleft Palate-Craniofacial Journal 48.5 (2011):
587-595.