Dr MUHAMMED RAHEESH

SENIOR LECTURER

DEPT OF ORTHODONTICS

CONTENTS:

1. INTRODUCTION
2. EPIDEMIOLOGY
3. ETIOLOGY
4. EMBRYOLOGY
5. CLASIFICATION OF CLEFTS
6. TRRREATMENT OF CLEFT LIP AND PALATE:

- INFANT ORTHOPEDICS

- TREATMENT IN MIXED DENTITION

- TREATMENT IN PERMANENT DENTITION

- SURGICAL ORTHODONTICS

- DISTRACTION OSTEOGENESIS

7. CONCLUSION

8. REFERENCES

INTRODUCTION:

cleft means a crack, fissure split or gap

Orofacial clefts are among the most common congenital anomalies requiring multidisciplinary care. Such anomalies include several handicaps such as impaired suckling, defective speech, deafness, malocclusion, gross facial deformity and severe psychological problems.

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cleft lip and palate is a congenital birth defect which is characterized by complete or partial cleft of lip and or palate

• Cleft of lip and the palate is one such condition, that occurs at such a strategic place in the orofacial region and at such a crucial time that it becomes a complex congenital deformity.
• Management of CLCP involves a multi disciplinary approach requiring the services of an orthodontist, oral surgeon, prosthodontist, otolaryngologist, audiologist, speech therapist, paediatrician.

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EPIDEMIOLOGY:

Cleft lip and palate is a global problem.(0.28-3.74/1000 live births globally)

Least incidence in negroids(0.4%) and maximum in afghans(4.9%)

Among Indians it seen maximum in Agrawal community and Brahmins(1.7%).

The incidence of oral clefts is seen more in males than in females.

Cleft lip alone- more in males than female

Cleft palate- more in females than males

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EMBRYOLOGY

• The first pharyngeal arch (mandibular arch), develops two prominences:
• The maxillary prominence
• The mandibular prominence

• As the medial nasal prominences merge with the maxillary prominence, they form an intermaxillary segment.

The intermaxillary segment gives rise to :-

1. philtrum of the upper lip.
2. The premaxillary part of the maxilla
3. The primary palate.

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ETIOLOGY:

1.) Heredity:

Transmitted through a male as sex linked recessive gene. Predisposition for cleft lip is 40% while only 18-20% for cleft palate.

It is transferred as:

1. Monogenic/ single gene disorder-conform to mendelian inheritance
2. Polygenic/ multifactorial inheritance- show familial tendency but not mendelian inheritance
3. Chromosomal abnormalities:

- Down’s Syndrome

- Edwards Syndrome (trisomy 18)

- Trisomy D and E

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SYNDROMES WITH CLEFT LIP AND PALATE

Van der woude Syndrome

Treacher Collins Syndrome Autosomal Dominant

Cleidocranial Syndrome

Ectodermal Dysplasia

Stickler’s Syndrome

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Roberts Syndrome

Appelt Syndrome

Christian Syndrome Autosomal Recessive

Meckel Syndrome

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2.) Environmental Factors:

Usually occurs due to various influences during Ist trimester.

• Environmental teratogens:
• Ethyl Alcohol- causes FAS (fetal alcohol Syndrome).

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• Cigarette smoking- 30% increase in cleft lip and palate and 20% increase in cleft palate in smoking during pregnancy. Nicotine acts synergistically with TGF.

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• Anti seizure drugs.eg: diphenyl hydantion and trimethadione.also causes growth retardation, craniofacial dysmorphism, mental deficiency

MALNUTRITION:

Hypervitaminosis A: acute maternal exposure to 13-cis retinoic acid during first trimester causes cell death in the pharygeal arch leading to facial clefting. Vit A analogue used as an anti-acne drug. Also proved by animal experiments.

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Folic Acid: Deficiency of folic acid affects virtually every organ system. It affect the neural tube- neural crest cell migration and differentiation.

Anaemia and anorexia

INFECTION DURING PREGNANCY:

Rubella infection during the first 3 months associated with clefting.

PARENTAL AGE:

Shaw etal presented evidence that women above the age of 35 had a doubled risk of having a child with CLCP.above 39- tripled risk.

Consanguineous marriages- increased risk of CLCP in child.

Local Factors:

• Failure of the head to elevate and become erect at around the 7-9^th week
• Failure of the tongue to descend downwards, thus causing a mechanical interference to fusion of the palatine shelves.
• Deficiency of Oxygen
• Shift of Blood Supply of Face-During the 6^th week, most of the midface is supplied by the Stapedial artery which is the branch of the Internal Carotid artery.

At around the 7th week, stapedial artery severs from the internal carotid and its terminal branches join the external carotid artery. Delay in this vital step can lead to cleft palate.

DAVIS AND RITCHIE CLASSIFICATION (1922):

They classified congenital clefts based on the position of the cleft in relation to the alveolar process.

Group I-Pre alveolar clefts Lip clefts only with subdivisions for unilateral, median, bilateral.

Group II-Post alveolar clefts degrees of involvement of soft and hard palate to be specified till the alveolar ridge, submucous clefts included.

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Group III-Alveolar clefts is complete clefts of palate, alveolus ridge and lip with subdivisions for unilateral, median, bilateral.

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II VEAU’S CLASSIFICATION (1931):�

• Group I - Cleft of soft palate only

• Group II - Cleft of hard and soft palate, extending no further than the incisive foramen thus involving the secondary palate alone.

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• Group III - Complete unilateral cleft of soft and hard palate, lip and alveolar ridge

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• Group IV - Complete bilateral cleft of soft and hard palate, lip and alveolar ridge on both sides.

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III KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971):�

• In this classification the incisive foramen is taken as the reference point
• “Y” logo are each divided into three sections, representing the lip, the alveolus and the hard palate as far back as the incisive foramen. The stem of the “Y” is also divided into three parts, representing varying degrees of clefting of the hard and soft palates.

V MILLARD’S CLASSIFICATION (1977):�

• A modification of Kernahan’s striped “Y” classification.
• The inverted triangles represent the nasal arch the upright triangles represent the nasal floor.

LAHSHAL CLASSIFICATION: okriens

• L- lip
• A- Alveolus
• H- hard palate
• S– soft palate

MULTIDISCIPLINARY CLEFT LIP � AND PALATE TEAM

• Pt coordinator
• Pediatrician
• Maxillofacial surgeon
• Orthodontist
• Pedodontist
• Prosthodontist
• Genetic counselor
• Plastic & reconstructive surgeon
• Social worker
• Psychiatrist & psychologist
• Speech pathologist
• Audiologist
• Nurse

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PATIENT COORDINATOR

• Arranges appointments
• Maintain records
• Monitors interaction b/w parents & team members

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PEDIATRICAN:

• maintainance of pt’s overall health
• Assess pt physiological status, developmental milestones

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PEDODONTIST :

• Routine prophylaxis
• Fluoride supplements rinses, dentifrices
• Close communication b/ n other team members.
• Pre & post orthopedic phase , obturator

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ORTHODONTIST :

• Obtains records, OPG ,study models diagnostic photographs .
• Provides comprehensive ortho care
• Works closely with surgeon to plan most app procedure

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GENETIC COUNSELLOR :

• Examines- syndromes associated with CLP
• Assess risk factor for future offspring

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SOCIAL WORKER :

• Acts as pt`s advocate
• Aids in psychological assessment
• Guidance regarding financial resources for medical care

PLASTIC SURGEON:

• Time of surgery
• Responsible for obtaining alv bone grafts
• Nasopharyngeal examination of speech
• pharyngoplasty - improve velopharngeal function, correct internal nasal deformities

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PSYCHATRIST & PSYCHOLOGIST:

• Evaluate pt – strength, weakness in cognitive interpersonal, emotional behavioral & social development.
• Emphasis – cope with emotional, physical stress

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SPEECH PATHOLOGIST:

• monitor speech output
• Offers therapeutic option to enhance maturation of speech

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• AUDILOGIST :
• Performs test- hearing difficulties
• Perform - middle ear surgery if needed

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• ROLE OF NURSE :
• Advisor , support family during time of anxiety
• Daily care of infant
• Teaches mother- care of nose, facial skin, cleaning of splints at each feeding time
• Actively communicate with team members.
• Emphasis total family involvement not just treatment of pt

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Multidisciplinary sequence of treatment

• STAGE I – Maxillary Orthopedic stage

( birth- 18 months)

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• STAGE II – Primary Dentition stage

( 18 months- 5 years)

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• STAGE III - Late primary/ mixed dentition

( 6 - 11 years)

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• STAGE IV - Permanent dentition stage

(12 - 18 years)

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STAGE I – Maxillary Orthopedic stage�( birth- 18 months)

• Immediate attention to the needs of new born
• Feeding problems- difficult to maintain adequate nutrition
• Mc Neil (1950) devised - Intra oral maxillary obturator.

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• Advantages:

1) provides a false palate, reducing incidence of feeding difficulties in newborns

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2) Maxillary cross arch stability preventing arch collapse after definitive cheiloplasty

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3) Molding the cleft segments into approximation before primary alveolar bone grafting.

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4) Facilitate infants ability to create sufficient –ve pr, which allow adequate sucking of milk.

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• Impression – Alginate -Infant held upright- to prevent aspiration of excess material

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• Appropriate emergency kit- oxygen suction , standard airway management equipment.

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• Impression – good anatomic detail with coverage of entire maxillary arch.

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• Appliance- self cure acrylic, excessive areas trimmed & polished.

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Instructions to parents:

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• Recall the pt after 2 days.
• Appliance – approximate 3 months until the time of initial lip closure

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• Premaxillary orthopedics (birth-4/5 months) :
• In some cases BCLP ,premaxillary segment is anteriorly placed or displaced laterally to one side .

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• Hofman (1686):
• Head cap & premaxillary strap

to reposition premaxilla.

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• Useful in antero posterior

& vertical repositioning.

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Appliance construction :

• 1week after delivering the

Obturator

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• A baby bonnet - head gear anchorage

for pre maxillary retraction strap

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• Elastic strap is placed over protruding premaxilla & is anchored to infants head with bonnet.

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• Sequential application of increasing equal forces - retroposition of premaxilla

• Bonnet & strap appliance – 24 hours, removed during feeding.

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• Desired movement - 6 – 8 weeks.

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• Surgeons have for a long time disagreed on the timing of cleft lip surgery.
• Some prefer early surgery soon after birth while others recommend a late lip surgery.
• The early school suggests that surgery should be performed within 45 days of birth. According to them, the early surgery improves the facial appearance
• The late school suggests that surgery should be postponed till the completion of dentition. reasoned that the tissues would be able to grow andmature thereby giving the surgeon more muscle massto work on.

Surgical palate closure

• The palatal repair should be attempted between 12- 24 months of age. This facilitates normal speech, hearing and improves swallowing.
• The palatal repair can be accomplished by using bone transplants that are taken from rib, iliac bone, mandibular symphysis,tibial bone or outer table of parietal bone.

STAGE II – Primary Dentition stage� ( 18 months- 5 years)�

• Initially focused- maintaining oral health

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• Meticulous daily oral hygiene

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• Special care - ectopically erupted teeth

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• In extensive cases of uni & Bilateral CCLP – surgical closure postponed 18-24 months.

Maxillary prosthetic appliance

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• Periodic recall check up – every 3-4 months.

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STAGE III - Late primary/ mixed dentition� ( 6 - 11 years)�

• Correction of developing traumatic occlusion & post segmental alignment

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• Interceptive correction of traumatic occlusion to prevent destruction of enamel & dentin

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• Maxillary expansion – palatal expansion methods

in pts who have not undergone primary alv bone grafting

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STAGE IV - Permanent dentition stage� (12 - 18 years)�

• Comprehensive orthodontic / surgical management of permanent dentition

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• Surgical procedures involving maxilla, mandible are completed

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• Cleft with severely retrusive maxilla - LeFort I maxillary advancement .

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SURGICAL TREATMENT OF CLEFTS

• TIMING OF SURGICAL PROCEDURE:

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RULE OF TEN:

• 10 weeks age.
• 10 pounds of body weight.
• 10 g Hb \dl of blood.

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ADVANTAGES :

• Better palatal & pharyngeal muscle attachment.
• Ease of feeding
• Better development of phonation skills
• Better auditory tube function
• Better hygiene when the oral & nasal partition is competent
• Improved psychological state for parents & child
• DISADVANTAGES :
• Surgical correction - difficult in younger children with small structures
• Scar formation – maxillary growth restriction

surgical procedures

• Lip correction – as early as possible
• Soft palate correction –18-24 months
• Hard palate correction – 4-5 years of age

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• CHEILORRHAPY :(Surgical repair of lip)

Objectives : 2 fold

• functional
• esthetic

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• key point- break up lines of scar to minimize

fibrosis & contracture deformity

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• If closed in linear fashion - scar contracture, characteristic notching of upper lip.

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Few techniques :

• Le Mesuirier technique (UCL)
• Tennison operation
• Wynn operation
• Millard operation (rotation advancement technique)

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Treatment of CLCP: A brief Overview