Cleft lip palate

Ohm Moogambika namaha
Angalaparameswari namaha
1
GOOD MORNING

CLEFT LIP AND
PALATE
Presented by:
Dr. Anil Kumar Godara
2

Contents
• Introduction
• Why called rehabilitation and not treatment
• Embryology
▫ Normal lip and palate
▫ Etiology of cleft lip and palate
▫ Prenatal growth of cleft lip and palate
▫ Prenatal diagnosis
• Post natal growth
• Classification of cleft lip and palate
3

Contents
• Rehabilitation
▫ Formation of cleft lip and palate team
▫ Schedule of treatment
• Role of orthodontist
• Presurgical orthopedics
• Primary lip repair
• Primary palatal repair
• Orthodontic treatment in primary dentition
• Orthodontic treatment in mixed dentition
• Treatment of skeletal discrepancy
▫ In growing patients
4

Contents
▫ In adult patients
 Orthognathic surgery
 Orthognathic vs. distraction osteogenesis
• Treatment of velopharyngeal insufficiency
▫ Normal velopharyngeal sphincter
▫ Defects
▫ Surgical correction
▫ Prosthetic enhancement
• Future directions in CLP rehabilitation
• Varied treatment requirements
• Conclusion
• References
5

• The incidence of cleft lip and/or palate has been
reported in early studies to be as low as 1 in 2000 in
Negroids to as high as 4.9/1000 live births in Afghans.
• Studies done in India among such communities reveal
an incidence of 1 in every 600-1000 births.
Incidence of Cleft Lip & Palate
6

• The incidence of CLP is highest among the Mongoloids.
• Cleft lip is common among males while cleft palate is
more common among females.
• Unilateral clefts account for 80% of the incidence while
bilateral clefts account for the remaining 20%.
• Unilateral clefts involving the left side are seen in 70% of
the cases.
7

Rehabilitation
• WHO - Rehabilitation of people with disabilities is a
process aimed at enabling them to reach and maintain
their optimal physical, sensory, intellectual, psychological
and social functional levels.
• Cooper said “few congenital deformities can lead to such
a great varieties of disabilities like pitiable looks, dental
caries, poor dental occlusion, poor speech, middle ear
infection, psychological aberrations, economic burdens,
fear of hereditary transmission…”
8

Embryology of Human face
• At four week
▫ Five prominences
 2- Mandibular
 2 - Maxillary
 Frontonasal process
• At fifth week
▫ Nasal placodes –
nasal pits
▫ Median nasal
process(MNP)
▫ Lateral nasal
process(LNP)
10
MaxMax
MandMand
Frontonasal

For next two weeks
• Maxillary process
continues to
grow.
• MNP are pushed
towards the
midline
11
MaxMax
MandMand
Frontonasal

• At seventh week
▫ LNP is pushed cranially
▫ MNP fuses with
Maxillary process, and
with each other.
▫ A thin layer of
epithelium is formed at
the junction called
‘nasal fin.’
12
MaxMax
Mand
Frontonasal

13
• The entire upper lip
is formed by
▫ Maxillary process
▫ MNP – philtrum of
the upper lip.MNP

Completed face of a
human embryo at
three months in
utero
14

Palatal formation
• The primary palate is
derived from the
Intermaxillary segment.
• Deﬁnitive palate is
formed by two shelﬂike
outgrowths -palatine
shelves
• Appears in the sixth
week of development -
obliquely downward on
each side of the tongue
15

• The elevation of the
palatal shelves are not
equal, anterior two thirds
lift first followed by rest.
• The elevation happens
earlier in males than in
females
• At around 7 - 71/2 weeks,
these vertically oriented
palatal shelves elevates
into a horizontal position,
such that the epithelial
surfaces meet each other
• EXTRINSIC
▫ Downward movement of
tongue due to mandibular
growth sprut and cranial end
extension
▫ Tongue physically pushes the
shelves upward
▫ Lowering of tongue due to
fetal mouth opening reflex
• INTRINSIC
• Hydration of the ECM
especially, hyaluronic
acid
• Contraction of the
myofilaments actin,
myosin
• Differential rate of
Palatal formation
16

Palatal formation
• The fusion of the palatal epithelium happens first in
the center and then proceeds anteriorly and
posteriorly, fusion occurs with the nasal septum as
well.
• The epithelia lining the palatal shelves fuses and are
called the Medial Edge Epithelia (MEE)
• Complete fusion of the palate takes till 10 weeks in-
utero.
• Ossification of the palate starts at about 10 weeks In
utero.
• Ossifies by four ossification centers
▫ Two premaxillary
▫ Two palatine
17
Craniofacial development By Geoffrey H. Sperber

• Several theories have been proposed to explain
how these 2 epithelium-covered palatal shelves
fuse into one continuous structure:
▫ All of the epithelial cells died.
▫ Epithelial cells migrated to the oral or nasal epithelium
▫ Epithelial cells transformed into mesenchymal cells
(EMT) thus creating continuity.
18
Palatal formation
Epithelial-Mesenchymal Transformation during Craniofacial Development J DENT RES 2005;
84; 678

Etiology of CLP
• The etiology of CLP is multifactorial, which can be
broadly classified into
▫ Genetic
 Syndromic
 Non-syndromic
▫ Environment
19

Genetic etiology
Syndromic causes
• Chromosomal
▫ Trisomy 13
▫ Trisomy 18
▫ Velocardiofacial syndrome
• Non-Mendelian
▫ Pierre Robin sequence
▫ Goldenhar syndrome
• Mendelian disorders
▫ Van der Woude syndrome
▫ Stickler syndrome
▫ Oral-facial-digital syndrome
▫ Treacher Collins syndrome
20
Management of children with cleft lip and Palate: a review describing the application. Fetal and Maternal Medicine Review 2005
▫ Ectodactyly-ectodermal
dysplasia-clefting syndrome
▫ Gorlin syndrome
▫ Smith-Lemli-Opitz syndrome

Genetic etiology
• Non syndromic causes
▫ Over 90% of isolated cleft palate cases are nonsyndromic.
▫ Localization of contributory genetic sequences is ongoing
program,
 Transforming growth factor - Alpha (TGF-A)
 MSX -1 gene.
 Barx – 1 gene
 Several other genes involvement is also suspected like
 MSX2, RARA, TGFA, TGFB3, TGFB2, MTHFR, GABRB3, FOXE1,
GLI2, JAG2, LHX8, PHF8, SATB2, SKI, SPRY2, and TBX10.
21
Current concepts in genetics of nonsyndromic clefts. Indian J Plast Surg 2009

• Dioxin, organic solvents,
plant toxins, food
contaminants
Environmental Agents
• Teratogens
▫ Viral infections
22
Environmental etiologies of orofacial clefting and craniosynostosis. Vandana shashi
 German measles
 Toxoplasmosis
 Cytomegalo inclusion
diseases
 Anticonvulsants
 Thalidomide
 Alkylating agent
 Chlorambucil
 Selenium
 Salicylic acid
 Boric acid
▫ Prescription drugs
 Vitamin A
 Folic acid
 Riboflavin
 Magnesium
 Pantothetic acid
▫ Nutritional deﬁciencies
 Steriod hormones
 Sex steriod
 Maternal diabetes
 Maternal adrenalectomy
▫ Endocrine abnormalities
▫ Hypoxia
▫ Radiation
• Intrauterine factors
▫ Toxins
▫ Recreational drugs
• Maternal factors
 Alcohol,
 Cigarette smoke
 Thyriod
 Maternal thyroidectomy
 Propylthiouracil
 Iodine compounds
▫ Fetal constraint
▫ Amniotic bands

Prenatal formation of Cleft lip
• Cleft lip is formed by non fusion of MNP with
maxillary process
23
MaxMax
Frontonasal
MaxMax
Frontonasal

Prenatal growth of cleft lip
• Development of musculature
▫ The myoblast infiltrating the upper
lip are derived from the hyoid arch.
▫ Unilateral
 Orbicularis oris – encounters the cleft
turns upwards gaining insertion in the
anterior nasal spine and the alar
wings.
 Occasionally the muscle fibers may
run horizontally ending abruptly at
the cleft edge.
24
▫ Bilateral
 The muscle fibers gets
attached to the alar bases.
 The central prolabium is
isolated from both the
lateral muculature.
 They are felt like
collagenous, very cellular
with fibroblast.
Cleft lip and palate . R. B. Ross, M. C. Johnston.

Prenatal growth of cleft lip
• Development of blood vessels &
nerve
▫ The upper lip is supplied by superior
labial branch of facial artery.
▫ Unilateral
 The artery encountering the cleft
turns upward, crosses the midline and
supply.
 The nerves follows it.
25
▫ Bilateral
 The arteries turns upwards.
 The central prolabium is
supplied by the artery
supplying the tip of the
nose
 The nerves the follows it.

Prenatal growth of cleft palate
• Development of musculature
▫ The myoblast infilterating the soft
palate is derived from varied
arches
▫ On encountering the cleft margin
the stream turns either
 Turns forward – posterior margin of
hard palate
 End abruptly at the margin
 Turns backwards – uvula
▫ Disrupts the muscular pattern and
results in diminished muscular
activity.
26

Pre-natal diagnosis
• The first antenatal ultrasound diagnosis of cleft lip
and palate was reported in 1981 .
• Fetal facial imaging.
Indications
▫ Parents at the risk of carrying child with cleft lip and
palate.
▫ Any congenital malformation noticed during routine
scanning
▫ As a part of routine scanning procedure
28
Cleft lip and palate: Diagnosis & management. Samuel Berkowitz

• Timing of scan
▫ 57% success before 20 weeks of gestation
▫ 80% success after 20 weeks of gestation
▫ Confirmed - second scan after 20 weeks.
• Procedure
▫ Two types of ultrasound
 Trans abdominal
 Trans vaginal – accurate –
before 12 weeks
▫ Two planes of view
▫ Frontal
▫ Coronal
Pre-natal diagnosis
29
▫ Disruption of the normal
midfacial architecture
▫ Absence of the maxillary ridge
normally seen slightly anterior
and inferior to the orbits
▫ Broadening of the nasal cavity
▫ Coronal
▫ soft tissue mass projecting
anteriorly fromthe midline
nasal septum below the nose

Pre-natal diagnosis
• Importance
▫ Alert us of 205 syndromes associated with CLP
▫ Aminocentesis should be done to confirm potentially
lethal chromosomal abnormality before planning for
elective termination of pergnancy.
▫ Prepare the parents and setup a CLP team for
evaluation at birth.
30

Post natal growth
Post natal growth of cleft lip and palate depends on
• Intrinsic factors
▫ Circumstances leading to the formation of the cleft in
the early embryonic period.
• Adaptive factors
▫ Once the cleft is there, subsequent growth will
continue to be affected by it.
• Induced factors
▫ Sequelae of cleft treatment, with surgery as the
dominant factor.
31

The Classification Dilemma
Many systems have been offered but none
has been universally accepted because of language
differences, inaccuracies, omissions and lack of
simplicity.
32

THE DAVIS AND RITCHIE
CLASSIFICATION - 1922
• Davis and Ritchie proposed
their system of classification
of clefts at the American
Medical Association meeting
in St. Louis in 1922.
• Based on the location of the
cleft relative to the alveolar
process.
33

• Uses three major groups with some subdivisions under
each.
Group I – cleft lip (pre-alveolar)
Group II – cleft palate (post-alveolar)
Group III – cleft of both lip and palate (Alveolar)
Unilateral, median and bilateral
variants of these three main groups were indicated by
further numbers.
34

Group I:
- a cleft of the lip unilateral
would be group I, 1
- a cleft of the lip median
would be group I, 2
- a cleft of the lip bilateral
would be group I, 3.
35

Group II:
Clefts of palate alone were
subdivided into:
Subgroup II,1 - uvula and soft
palate.
Subgroup II,2 – hard palate.
Each of these two
subgroups was further divided
into 1/3, 2/3 and 3/3 cleft.
36

Group III:
Clefts of lip, alveolus, hard
palate and soft palate were
subdivided into:
Subgroup III,1 – unilateral.
Subgroup III,2 – median.
Subgroup III,3 – bilateral.
37

VEAU'S CLASSIFICATION - 1931
Group I - Cleft of the soft
palate only.
Group II - Cleft of the hard
and soft palate to the
incisive foramen.
38

Group III - Complete
unilateral cleft of the soft
and hard palate, and the
lip and alveolar ridge on
one side.
Group IV - Complete
bilateral cleft of the soft
and hard palate, and the
lip and alveolar ridge on
both sides.
39

FOGH-ANDERSEN'S CLASSIFICATION - 1942
In his 1942 monograph,
Inheritance of Harelip and Cleft
Palate, Poul Fogh-Andersen of
Copenhagen described his
morphological classification of
cleft lip and palate based on
embryology and genetics.
40

• He divided clefts into three main groups:
1. Harelip (single or double) - including all degrees from a
small notch in the prolabium to a complete cleft of the
lip extending "as far as the incisive foramen." When the
cleft was bilateral through lip and alveolus, he noted,
"There is prominence of the premaxiIla."
2. Harelip and cleft palate - which is the largest group. He
noted complete clefts from nostril to uvula and others
broken by osseous and skin bridges. This group
included single and double clefts.
41

3. Cleft palate - This group included isolated cleft palate
which he noted may involve the soft palate or the soft
and hard palate and "is always median and it never
reaches further than the incisive foramen."
Fogh-Andersen also included the submucous cleft
presenting as a cleft in the soft palate but only a bony
cleft of the hard palate with intact oral and nasal mucous
membrane.
4. A group of rare atypical clefts was optional.
42

PRUZANSKY’S CLASSIFICATION - 1953
• Samuel Pruzansky’s classification (AJO 1953)
describes four classes of clefts:
1. Clefts of lip alone.
2. Clefts of lip and palate.
3. Clefts of palate alone.
4. Congenital insufficiency of the palate.
43

KERNAHAN AND STARK CLASSIFICATION - 1958
• Kernahan and Stark's 1958 classification emphasized
the embryological basis of the incisive foramen's being
set as the boundary marker.
• Clefts of the lip and premaxilla, occurring at 4 to 7 weeks
of embryonic life, were termed clefts of the primary
palate.
• Clefts of the hard and soft palate posterior to the incisive
foramen, occurring at 7 to 12 weeks, were termed clefts
of the secondary palate.
44

I. CLEFTS OF PRIMARY
PALATE ONLY.
• Unilateral clefts (right or
left).
-Total
-Subtotal
• Median clefts.
-Total (premaxilla absent)
-Subtotal (premaxilla
rudimentary)
• Bilateral clefts.
-Total
- Subtotal
45

II. CLEFTS OF
SECONDARY PALATE
ONLY.
• Total
• Subtotal
• Submucous
46

III. CLEFTS OF PRIMARY AND SECONDARY
PALATES
• Unilateral clefts (right or left).
-Total
-Subtotal
• Median clefts.
-Total
-Subtotal
• Bilateral clefts.
-Total
-Subtotal
47

VILAR-SANCHO CLASSIFICATION - 1962
The Spanish plastic surgeon, Vilar-Sancho, in 1962
classified all clefts (SK) as incomplete (small letter) or
complete (capital) using the appropriate letter of the
Greek word for the area involved:
• K for kilos (lip),
• G for gnato (maxilla),
• U for urano (hard palate) and
• S for stafilos (velum).
After the letter of the location and cleft extent,
the side affected is indicated with d for right, I for left and
s for bilateral.
48

Vilar - Sancho classification
KI – cleft lip, left.
GI – premaxilla, left
UIS – hard & soft
palate
SK – complete cleft.
49

INTERNATIONAL CONFEDERATION FOR
PLASTIC AND RECONSTRUCTIVE SURGERY
CLASSIFICATION - 1968
In 1968, the Subcommittee on Cleft Lip and Palate
Nomenclature of the International Confederation for
Plastic and Reconstructive Surgery submitted a
classification based on the embryological basis of cleft
lip and palate.
50

• Clefts of the Lip, Alveolus, and Palate
(Classification based on embryological principles.)
Group 1: Clefts of anterior (primary) palate.
a. Lip: right and/or left
b. Alveolus: right and/or left
Group 2: Clefts of anterior and posterior (primary and secondary)
palate.
a. Lip: right and/or left
b. Alveolus: right and/or left
c. Hard palate: right and/or left
Group 3: Clefts of posterior (secondary) palate.
a. Hard palate: right and/or left
b. Soft palate: median
(For further subdivision the terms "total" and "partial" should be
used.)
51

• Rare Facial Clefts
(Classification based on topographical findings.)
a. Median clefts of upper lip with or without hypoplasia or
aplasia of premaxilla.
b. Oblique clefts (oro-orbital).
c. Transverse clefts (oroauricular).
d. Clefts of lower lip, nose, and other very rare clefts.
This classification was a combination of the
Fogh-Andersen and Kernahan & Stark systems.
52

THE STRIPED ‘Y’ CLASSIFICATION - 1971
• Desmond Kernahan, at
the University of
Manitoba in Winnipeg, in
1971 simplified the cleft
record-taking, from the
least to the greatest
defects, in one of the
most practical method
yet.
53

Kernahan striped Y classification
• Block 1 &4 – lip.
• Block 2 & 5 – alveolus.
• Block 3 & 6 –hard palate anterior to
incisive foramen.
• Block 7& 8 – hard palate posterior to
the incisive foramen.
• Block 9 – soft palate.
• The area affected by the cleft is shaded
on the symbolic Y shape.
54
The striped Y-A symbolic classiﬁcation for cleft lips and palates K ernahan Plastic & Reconst Surgery May 1971

Kernahan’s striped ‘Y’
Lip Lip
Alveolus Alveolus
Hard palate (anterior to
to incisive foramen)
Hard palate (anterior to
incisive foramen)
Hard palate (posterior
to incisive foramen)
Soft palate
Incisive foramen
55

• Cleft areas are indicated by stippling the respective
segments.
• Submucous clefts of the palate are indicated by
horizontal lines where a true cleft is not present.
• A Simonart's band at the threshold of the nostril is
indicated by horizontal lines across the most anterior
portion of the respective limb of the ‘Y' .
56

• For median clefts, a straight line is drawn centrally
between 1 and 4 on the striped "Y“.
• For true central lip clefts and in cases where the whole
primitive palate is absent (eg. trisomy and
arhinencephaly) the entire area between the two limbs
of the "Y" is blocked.
57

58
Simonart's band
Submucous clefts

• Inverted triangle – nose
• Triangles 1 & 5 – nasal floor
• Block 2 & 6– lip.
incisive foramen.
• Block 9 & 10 – hard palate posterior to
• The area affected by the cleft is shaded
on the symbolic Y shape.
Millard’s modification Kernahan classification
59
1
2
3
4
5
6
7
8
9
10
11
• Block 1 &4 – lip.
incisive foramen.
• Block 7& 8 – hard palate posterior to
TERMINOLOGY AND CLASSIFICATION OF FACIAL CLEFTING. ROBERT J. SHPRINTZEN.

ELSAHY’S STRETCHED ‘Y’ - 1972
• In 1972, the Egyptian Nabil
Elsahy, also from Winnipeg,
Manitoba, modified the
Kernahan’s ‘Y’ classification.
60

• He added triangular peaks (1
and 5) to the ends of the
prongs to represent the nasal
floor in case of incomplete
clefts of the lip.
• This modification caused a
shifting of the numbers in the
squares:
• 2 & 6 - lip
• 3 & 7 - alveolus
• 4 & 8 - hard palate anterior to
the incisive foramen
• 9 & 10 - hard palate
• 11 - soft palate.
61

• To indicate a vermilion notch on the left, a narrow band
of stippling is placed in the lower portion of square 6
while an alveolar notch on the same side has a band of
stippling in the upper portion of square 7.
• Collapse of the maxillary segments is indicated by filling
in or stippling 3 & 4 or 7 & 8.
62

• Elsahy double-lined the squares (9
and 10) in the hard palate area
and used arrows to indicate
direction of deflection in complete
clefts.
• He placed a circle (12) under the
stem of the Y to represent the
pharynx. Then with a dotted line
from the Y to the O reflecting
velopharyngeal competence, any
break in continuity of this dotted
line could be interpreted as the
amount of incompetence.
63

• Elsahy also added circle
13 to represent the
premaxilla, and the
amount of its protrusion
is indicated by the dotted
line with an arrow and the
position of circle 13.
64

• The Y will be capped with
triangular peaks for the
nasal floor, and these will
be topped with similar
triangular peaks turned
upside down to represent
the nasal arch.
65

HARKINS CLASSIFICATION - 1962
In 1962 Harkins et al, for the American Cleft Palate
Association, proposed three main cleft groups:
1. Prepalate - included unilateral, bilateral and medial lip
clefts as well as congenital scars and all variations of
alveolar clefts.
2. Palate - included all forms of cleft palate forward as far
as the incisive foramen.
66

3. Prepalate and palate - included unilateral and bilateral
complete clefts but also the combination of incomplete
clefts of lip and palate.
They then added a group 4 of rare clefts other than
prepalate or palate types. These included the various
facial clefts and lower lip clefts, which were charted in a
diagram.
67
Harkins’ diagrammatic
classification

68
INDIAN CLASSIFICATION
• Proposed by Dr. C. Balakrishnan in1975
• Cleft lip only (GP.I)
• Cleft lip and alveolus (gp. 1-a)
• Cleft palate only (gp.2)
• Cleft lip and palate (gp.3)

LAHSHAL CLASSIFICATION (1987)
• This is one of the simplest classifications and was
formulated by Kriens o.
• LAHSHAL is a paraphrase of the anatomic areas
affected by the cleft.
69

72
Schuchardt & Pfeifer’s classification
• Graphic representation
• Three pairs of rectangles are
arranged vertically each
representing lip, alveolus and
palate.
• Inverted triangle represents
the soft palate.
• Shade full for complete cleft,
partial if incomplete.
TERMINOLOGY AND CLASSIFICATION OF FACIAL CLEFTING. ROBERT J. SHPRINTZEN.
LEFT RIGHT
LIP
ALVEOLUS
PALATE
SOFT PALATE

Goslon Yardstick
• Developed in Great Ormond Street, London and
Oslo.
• Classification of dental arch relationship in mixed
and early permanent dentition into five discrete
groups
• Provides treatment guidelines for orthodontic
treatment.
73
Goslon Yardstick- a new system Classification of dental arch relationship. Micheal Mars. Cleft Palate J 1987

Goslon Yardstick
• Assessment done in all three planes, graded based on
severity
▫ Anteroposterior relationship
 Malocclusion
 Class III > class II div 1, more preferred occlusion
 Overjet
 Reverse overjet > increased overjet
▫ Vertical relationship
 Open bite > shallow bite > deep over bite
▫ Transverse relationship
 Anterior crossbite > posterior crossbite
 Degree more important than number of teeth
74

Goslon Yardstick
• Based on the severity of malocclusion, it is grouped into
▫ Group 1 – excellent
▫ Group 2 – good
▫ Group 3 – fair
▫ Group 4 – poor
▫ Group 5 – very poor
• Group 1 & 2 – straight forward orthodontic treatment
or none at all
• Group 3 – complex orthodontic treatment
• Group 4 & 5 – orthodontics with orthognathic surgery
with increasing severity
75

Health care teams
• Health care teams are established and operative
group of health professionals joined together for any
specialized condition requiring more than one
specialty expertise.
• Basically three types of health care teams
▫ Intra disciplinary team
▫ Multi disciplinary team
▫ Inter disciplinary team
76

Cleft lip and palate team
• Defined as a team of professionals who provide
coordinated & inter disciplinary evaluation and
treatment to patients with cleft lip and palate.
• The core members, very essential for forming a CLP team
are
▫ Surgeon – expertise on orthopedic surgery
▫ Orthodontist
▫ Primary care physician
▫ Speech pathologist
77

Treatment Timeline
Time Unilateral cleft lip and
palate
Bilateral cleft lip and palate
78
Infancy
(1 – 4 weeks)
Presurgical orthopedics Presurgical orthopedics
8 – 12 weeks Primary lip repair Primary lip repair
Primary palatal repairPrimary palatal repair
5 Years
18 – 24 months
Surgical repositioning of
premaxilla with bone graft
6 – 10 years Alveolar bone grafting Alveolar bone grafting
Comprehensive orthodonticsComprehensive orthodontics11- 14 years
17 – 19 years Orthognathic – revisional
surgeries
Orthognathic – revisional
surgeries

Feeding a cleft child
• The primary goals concerned with feeding are
▫ Maintaining adequate nutrition.
▫ Finding a technique as close as possible to normal
▫ Technique that maximizes the oral stimulation for
motor development
▫ Mother- child intimacy should be preserved as far as
possible.
79
Feeding infants with cleft lip and palate- an overview. Cleft Palate J 1987

Feeding a cleft child
80
Assessment of feeding
Condition Technique
Cleft lip and
palate
Breast feeding unlikely
Deliver milk directly into mouth
Breast feeding may succeed
Soft nipple with large opening
Breast feeding or bottle
feeding works well
Breast feeding or bottle
feeding works well
Nipple with large base should be used
Cleft palate
Cleft soft
palate
Cleft lip
Feeding infants with cleft lip and palate- an overview. Cleft Palate J 1987

Cleft Lip & Cleft Palate
81
A cephalometric analysis of the developmental pattern
and facial morphology in cleft individuals
• A study done by T.M. Graber & published in AJO
1949.
• A total of 33 cleft patients were selected, which
included both operated and un-operated cleft cases.
• It was a cephalometric study.

82
Results of the study
• The maxilla on cleft lip/palate was deficient not only in its
antero-posterior & lateral growth but also in its vertical
growth.
• There was a high negative angle of convexity demonstrating
the lack of antero-posterior development.
• There was a markedly large intermaxillary/freeway space.
• Mandibular growth appeared to be normal .
• There was an excessive lingual axial inclination of the lower
incisors to the mandibular plane.

83
Treatment of cleft lip & palate
• There are six major fields of interest that seems to
be in current debate as far as treatment of cleft
patients are concerned. They are :
1. Prevention
2. Pre-term diagnosis
- genome analysis
- amniotic enzyme analysis
- pre-natal ultrasound screening

84
3. Early repair
- surgery of clefts in utero
- neo-natal cleft lip/palate repair
- one stage closure
- early nose correction
4. Perfection of surgical techniques
- scar free repair
- pre-surgical orthopedics
- use of Bone Morphogenetic Protein
- use of implants

85
5. Better psychological support
- emotional support and professional advice to
patients and parents
6. Improvement of analytic armamentarium
- development of internationally acceptable
yardsticks/ standards for objective evaluation,
diagnosis and treatment planning.

86
General management overview
( Center for Craniofacial anomalies, Univ. of
California, San Francisco)
• Immediately after birth : pediatric consultation,
evaluation by geneticist.
• Within first few weeks : team evaluation.
• 10 – 12 weeks : surgical repair of cleft lip.
• Before 1 year : surgical repair of cleft palate.
• 3 months after palate repair : team evaluation,
speech & language assessment.

87
• Between 2 to 5 years : medical & behavioral
intervention if needed.
• At 5 to 6 years : lip & nose revision if necessary.
• At 7 years : start orthopedic/orthodontics (phase I).
• Between 9 & 11 years : bone grafting of alveolar
bony defects.
• At 12 years or later : phase II orthodontics.
• At the end of orthodontic treatment : replacement
of missing teeth.
• When most growth is completed : orthognathic
surgical procedures.

88
Surgical management
• Surgical correction of cleft lip & palate.
• Alveolar bone grafting
• Oronasal fistulas.
• Later- Orthognathic surgery if required

89
Orthodontist in cleft team
• Treatment can involve orthodontic, orthopedic or
combined orthodontic & surgical procedure.
• Prior to instituting treatment at any particular
stage , the orthodontist should consider.
1. Whether there is a problem ?
2. If the problem is likely to worsen
3. Whether treatment will minimize/prevent further
problem ?
4. Whether the degree of improvement warrants
treatment at this stage ?

90
Orthodontic diagnosis
• A major part of all orthodontics is diagnosis –
determining the nature of the problem, the
essential basis for deciding what to do about it and
when to do it.
• Because of the complicated factors involved in cleft,
diagnosis becomes an even more complex
undertaking with these individuals.
• A thorough organized approach is very critical. The
Ackerman & Proffit system constitutes a convenient
framework for describing the orthodontic problems
in three planes of space- anterioposterior,
transverse and vertical.

91
Orthodontic diagnosis (patient history)
• Medical-dental history : an accurate description of
the type & extent of cleft present at birth and a
record of timing and type of surgery performed till
date.
• Frequent upper respiratory infections, enlarged
tonsils/adenoids or other forms of nasal
obstructions are known to be common in cleft
patients.
• Social & behavioral : whether the patient/parents
are appreciative of their dental problems.

92
• Somatic growth & maturation : on the average it
has been found that children with cleft do not differ
significantly from non-cleft children in their height
& weight.
• Genetic & family history : to assess the possible
genetic role in clefting. Family history to rule out
consanguineous marriage.
• Habits : as the dentoalveolar region is already
compromised, oral habits may more severely
aggravate the situation. E.g tongue thrusting.

93
Orthodontic diagnosis (radiographs)
• Apart from the normal radiographs, the occlusal radiograph of
the maxilla is of importance in cleft cases, which helps in
determining :
- the extent & severity of the cleft
- presence of supernumerary/impacted teeth
- amount of periodontal support

94
Orthodontic diagnosis ( lateral cephalogram)
• The most commonly used cephalometric analyses are the
Steiner’s & McNamara analysis.
• To determine the antero-posterior location of the maxilla
these two analyses use point A as the reference landmark.
• But the location of point A will be difficult in cleft individuals
because of the presence of cleft.
• This can be overcome in atleast certain cases of cleft patients
by making use of a method given by Jacobson in the article
“Point A re-visited”.(AJO-1980)

95
Orthodontic diagnosis (lateral cephalogram )
Normal Cleft
?

96
Point A re-visited
• X – point at root apex.
• Y – point between upper
1/3rd and lower 2/3rd of
root length.
• Z – midpoint of root length.

97
• From these points , lines
were dropped
perpendicular to the NA
line.
• X1, Y1 & Z1 were identified.
• Statistical analyses were
done to determine which of
the landmarks could be
used as a guide for the
determination of NA line.

98
• In the event of point A
being difficult to locate an
estimated NA line could be
drawn through point Ae .
• This could be located by
plotting a point 3mm ahead
of a point between upper
third & lower two-thirds of
the root axis of maxillary
central incisor.

99
Orthodontic diagnosis ( additional
diagnostics)
Occlusal radiograph
C.T scan

100
Orthodontic diagnosis (additional
diagnostics)
• Radiovisiograph : a new intra-oral imaging system, which
utilizes a microprocessor based image receptor system rather
than the conventional silver halide crystal films.
• Improves the image quality & reduces radiation exposure by
80%
Conventional Radiovisiograph

101
Orthodontic diagnosis (problem list)
• Intra-arch alignment &
symmetry:
• Crowding of the dentition is
common problem.
• Missing teeth.

102
• Profile / esthetics.
• Concave profile with
retrusive maxilla & normal
mandible.

103
• Transverse problems :
• Because of the constricted
maxillary arch crossbites of
varying severity are the
common problem in the
transverse dimension.

104
• Antero-posterior problems.
• The retrusive maxilla along
with a normal mandible
superimposed on the
transverse problem results
in a class III tendency.

105
Orthodontic diagnosis ( problem list)
• Vertical problems.
• The position of the mandible varies in rest position
and in occlusion.
• This may generate excessively long or short lower
face heights.
• The functional shift of the mandible results in
pseudoprognathism.

106
Orthodontic treatment
• Orthodontic treatment for these patients may
involve long periods of time at various ages.
• The treatment should be planned in stages. The
orthodontic treatment can be instituted :
• i) Infancy
• ii) Primary dentition
• iii) Mixed dentition
• iv) Permanent dentition

Pre-surgical orthopedics
• Kerr McNeil, a prosthodontist from Scotland
advocated pre-surgical neonatal maxillary
orthopedics in 1950s.
• Retarded mid-facial growth is the result of traumatic
surgery
• But, he based on James Scott - ‘cartilaginous theory’
• Suggested that, ‘cleft palatal segments detached
from the downward- and forward-growing nasal
septum were deprived of their growth impetus,
remaining small and deficient in mass and retruded
within the face.
107
Cleft Lip and Palate diagnosis and management - Samuel Berkowitz

• Reposition the maxillary segments by a series of
orthopedic appliances , to align the palatal segments
into an ideal relationship while reducing the cleft
space
• Soon after birth, correct the bony deficiency by
stimulating palatal growth – stimulatory plates.
• Stimulatory pads - pressed gently on the palatal
mucosa a short distance away from the margins of the
palatal cleft, stimulate growth of the underlying bone,
thus reducing the width of the hard palate defect.
108

• But over the years, the appliance evolved into
several types
▫ Passive appliance
▫ Semi active appliance
▫ Active appliance
109

Passive appliance
110
Impression – elastomeric
materials
Combination of hard & soft
acrylics
Extent – obturate whole cleft from left to right vestibule
alveolar cleft to uvula
• Passive appliance with delayed closure was introduced in
Zurich in 1960s.
• Procedure
▫ Patient is recalled every 3 weeks
▫ Adjustments are made by grinding the plate to guide the
segments during growth.
▫ The direction and total amount of growth are used to
indicate when a new plate is necessary.
▫ A new plate is inserted just after lip surgery at 5-6 months
time.
▫ To prevent rotations of alveolar segments common after lip
surgery
▫ Palate is closed in two stages
▫ 1 – soft palate closure at 12 – 18 months
▫ 2 - hard palate at 6-9 yrs.
▫ Plate is continued till soft palate closure.

Passive appliance
• Advantages
▫ Plate keeps the tongue out of the cleft.
▫ The oral and nasal cavities are separated and nasal
breathing is restored.
▫ It aids in feeding
▫ It maintains the width of the maxilla and lets the palate
increase spontaneously in all three dimensions without
impeding its growth potential
▫ It permits the soft palate to grow to its maximum length
prior to surgery.
111

Active appliance
112
Pins Slot former 25 mm screw
with nut
• Introduced by Georgiade in 1970, modified by
Latham and Millard in 1980.
• Principle – normal alveolar segment - anchorage -
force to cleft segment.
• Procedure
Orthopedic advancement of cleft segment. Latham. cleft palate J. 1980

Primary bone graft
• Second step after aligning the palatal segments with
pre-surgical orthopedics is to stabilize it.
• Segments must be in close proximity with good arch
form, an onlay rib graft is placed across the labial
surface of the cleft in a subperiosteal tunnel that is
developed by limited dissection.
113
• Objectives
▫ To fix the alveolar segments together and
equalize the growth
▫ To prevent collapse of the maxillary
segments
▫ To stabilize the premaxilla in complete
bilateral clefts
▫ To provide more bone for teeth adjacent to
the cleft
▫ To better support the ala and improve the
contour of the cheek

Source of graft materials
114
• Cancellous bone from
illiac crest. The gold
standard.
• Cranium
• Ribs
• Tibia
• Mandibular symphysis
• Third molar region
• Alloplastic materials.
e.g hydoxyapatite.

Drawbacks
• At annual meeting of the American Cleft Palate-
Craniofacial Association held in St. Louis in 1990, the
thesis “Presurgical orthopedics is by and large a waste
of time”
• The opponents of neonatal maxillary orthopedics
stated that it is a complex and expensive therapy that is
ineffective and unnecessary
• Even restricts maxillary development and influences
speech negatively due to delayed surgery of the hard
palate
115
• Especially procedure that involves the primary bone
grafting restricts the growth of the maxilla
• Vertical direction – primarily
• Anteroposterior direction – minimally
• Resulting in more horizontal columellar plane and a
reduced nasolabial angle.

Nasoalveolar molding
• Barry Grayson in 1993 described a technique to
correct the alveolus, lip, and nose in infants, based
on research on molding cartilage by Matsuo.
116
• Alar base width is
significantly increased
• Flattened nasal tip
• Deficient or absent
columella
• Alar cartilages are flared
and concave
• Wide nostril base
• Lower lateral nasal cartilage
is displaced laterally and
inferiorly
• Increased alar rim
• Oblique columella
• Overhanging nostril apex

• 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.
117
• Relax ligaments, cartilage, and
connective tissue, enabling the fetus
to pass through the birth canal.
• Thus, molding of nose, alveolus is
possible in infants.

• Molding plate made of hard clear
acrylic and lined with a thin coat of
soft denture material.
• A 5-mm diameter hole is made in the
center of the acrylic palatal vault to
provide an airway.
• The appliance is secured extraorally to
the cheeks, bilaterally by surgical
tapes.
• A retention arm is positioned
approximately 40º down from the
horizontal plane to prevent unseating
of the appliance from the palate.
118

• Made of .036
gauge round
stainless steel
wire
• Shape of a
“swan neck”
119
• Nasal stent
• The intranasal
portion
consists of a
hard acrylic
• shaped into a
bi-lobed form
resembling a
kidney
• A layer of soft
denture liner is
added to the
hard acrylic for
comfort.
• The upper lobe
enters the nose
and gently lifts
the dome
• The lower lobe
of the nasal stent
lifts the nostril
apex and defines
the top of the
columella

Advantages
• Improved long-term nasal esthetics
• Reduced number of nasal surgical procedures,
• Reduced need for secondary bone grafts if
gingivoperiosteoplasty is applied
• No larger growth disturbance is found than with
other well-established procedures
• Savings in cost.
120

Primary lip repair
• A cleft lip produces distortions in all tissue layers,
including skin, muscle, cartilage, mucous membranes,
teeth, and bone.
• Timing
▫ Generally carried out when the child is 2 to 3 months of age,
▫ Rule of 10, proposed by Thompson in 1912,
 approximately 10 weeks of age,
 10 pounds of weight,
 10 mg/dl of serum hemoglobin.
121

Primary lip repair
• Advantages
▫ Child at reduced anesthetic risk
▫ Ensure successful wound healing
▫ Allow enough time to determine if other
malformations are present
▫ Establish comfortable feeding and airway routines for
the child and parents.
122

Primary lip repair
• Other school of thought
▫ Immediate lip repair, just after birth and prior to
discharge from the newborn nursery
• Advantages
123
Utilizing benefits of fetal-like wound
healing
Avoiding any psychosocial trauma to
parents, baby with an unrepaired CL
Neonatal lip repair with reduced scarring
have not been realized
Studies have failed to show improved
bonding between the child and mother
Increased anesthetic and surgical
risks of neonatal surgery

Primary lip repair
Types of surgery
• Unilateral cleft lip
▫ Millard rotational
advancement
▫ Tennyson-randall repairs
▫ Triangular flap repair
▫ Nakajima
▫ Straight line repair
124
• Bilateral cleft lip
▫ Straight line- veau III
▫ Millard
▫ Manschester, modified as
broadbent and wolf repair
▫ Mulliken
▫ Black
▫ Noordhof

Primary palatal repair
• Objectives
▫ To reconstruct the hard and soft palate with closure of
all existing oronasal communication from the incisal
foramen back through the uvula.
▫ Creation of a dynamic soft palate, capable of
interfacing with the lateral and posterior pharyngeal
walls to achieve sufficient velopharyngeal (VP) closure
and, thus normal speech.
125

• Two factors governing timing of palatal repair
126
Phonemic or
articulation age
Facial growth
•Child starts to babble at 6-9 months
of age and first full word by 13 months
of age.
•Develop significantly fewer
compensatory articulations and
maladaptive speech patterns if the
palate is repaired before 2 years of age
•Earlier the repair more the potential for
growth restriction of the upper jaw

Minimizes the development of
• Irreversible pathologic compensatory speech
patterns
• Surgical risks
• Growth restriction of the upper jaw
Single stage lip and palate repair
Advantage
oReducing the number of operation
oVelopharyngeal sphincters early at age
• Different protocols
127
One stage Two stage
Early repair
Delayed repair
Late repair
3-6 months
12-24 months
2-5years
 Correct soft palate aid speech at early age,
delaying the hard palate, thus allowing
unhindered growth.
 Especially with presurgical orthopedics with
periosteoplasty.
 Disadvantages
 Poor speech result, even with obturators
 No significant improvement of facial growth.
One stage
Disadvantage
oLonger surgery
oFacial growth is negatively
hindered
Two stage

• Types of repair
• Hard palate
• Von langenback/bipedicled flaps
• Pushback-veau-wardill-kilner, unipedicled flap
• Vomers flap
• Soft tissue
• Layered closure
• Intravelar veloplasty
• Furlow
128

Primary dentition
• Permits classification of the type of developing
malocclusion.
• The facial soft tissues may mask the underlying skeletal
deficiency of the midface in infants.
129
• With growth & redistribution, the
facial soft tissue changes, as the
chubby face of infancy takes on the
more mature and defined
proportions of the child.
• Reveals the skeletal discrepancy
more accurately than in the
younger child.
• The dentition often reflects the
skeletal discrepancy, if not
compensated.

Primary dentition
• Crossbite will be major orthodontic problem in the
primary dentition, which can be
▫ Single or segmental
▫ Unilateral or bilateral
▫ Anterior or posterior
130

Primary dentition
• Factors governing
▫ Age of the patient.
131
▫ Position of teeth.
▫ Amount of resorption of primary teeth.
▫ Stability and retention.

Bone graft
• Rationale for Grafting
▫ Grafting achieves stability of the arch and prevents collapse of the
alveolar segments.
▫ Grafting preserves the health of the dentition. Grafting provides
room for the canine and lateral incisors to erupt into the arch into
stable alveolar bone.
▫ Grafting restores continuity not only of the alveolus, but also of the
maxilla at the piriform rim.
▫ Palatal and nasolabial fistulas are often present even following
palatoplasty. Grafting of the alveolar defect provides an opportunity
for the surgeon to address the residual oronasal fistula.
132

Timing of the Graft
133
< 2 Years of Age: Primary
Grafting
• After lip repair
• Before palate repair
• 2–5: Early secondary
• 6–12: Mixed dentition
secondary
• 6–8: Early mixed dentition
• 9–12: Late mixed dentition
• > 12: Late secondary grafting
≥ 2 Years of Age: Secondary
Grafting

Secondary Grafting
134
During the Mixed Dentition
Early Late
• Grafting done
between the ages of
6 and 8 yrs .
• Before eruption of
lateral incisors.
• Preserves both
lateral incisors and
canine
• Grafting done
between the ages
of 8 and 12 years
• Maxillary canine
root is one-half to
two-thirds
developed.
• provides bone
support for eruption
of canine

• Factors determining the ideal time
▫ Dental age vs. chronologic age
▫ Presence of the lateral incisor
▫ Position of the lateral incisor
▫ Degree of rotation/angulation of the central incisor
▫ Size of the patient and of the cleft
▫ Need for adjunctive procedures
Secondary Grafting
135

• Two important procedures are
▫ Expansion
▫ Tooth alignmentPresurgical expansion
• Easier expansion -less resistance,
• Improved access to the cleft for closure
of the nasal floor
• Better postoperative hygiene
• Less chance of reopening the oronasal
fistula.
• Presurgical expansion may also allow
orthopedic movement of the
premaxillary segment into alignment.
Postsurgical expansion
• Improved bone consolidation
• when the graft is placed under a
dynamic load during healing
• A smaller soft tissue defect to
close
• Less difficulty procuring an
adequate volume of bone
• A narrower defect, which will
regenerate bone more quickly.
Presurgical expansion
Pre- versus Postsurgical Orthodontics
136
Postsurgical expansion
Improved bone consolidation
Smaller defect
Less volume of bone
Narrower defect
Better healing
Better
Easier expansion
Improved access
Lesser
Orthopedic movement
hygiene
Fistula reopening
Condition warranting presurgical expansion
• Small unilateral clefts with collapse of the arch may be easier to
graft with some presurgical expansion.
• Bilateral clefts with collapse of the lateral segments –
orthopedic movement of premaxilla to arch form

• Rotated incisors
• The rotation and angulation decreases the mesial-distal
dimension of the tooth and allows for the best bony
support of the tooth.
• Orthodontic forces of rotation and
tipping will have the undesirable
effect of increasing the mesial-distal
dimension, encroaching on the bony
support.
• Two important considerations are
▫ Expansion
▫ Tooth alignment
Pre- versus Postsurgical Orthodontics
137
Better hygiene
Improved result
Moving teeth into the cleft site
Compromising osseous support

Surgical procedure
138
Incision is made along the cleft and sulcular incision around
the adjacent teeth.
The nasal mucosa is separated from the palatal mucosa.
Palatal mucosal closure
Nasal mucosa is also closed
The bone graft is compacted into the cavity recreatedThe labial flaps are mobilized approximated and sutured.

Orthodontics in permanent dentition
• Improve the relationship of the lips
• Achieve harmonious balance of the dentition in the
opposing jaws
• Achieve favorable skeletal maxillo-mandibular jaw
relationship
• Achieve normal incisor overjet and overbite
• Correct dental axial inclinations
• Avoid the use of artificial teeth
• Achieve functional dental occlusion
• Achieve optimal nasal breathing
139

Correction of skeletal discrepancy
• Irrespective of the method used in primary cleft
repair and the surgical skill of the operator, a certain
number of patients will show maxillary retrusion.
• The maxillary growth deficiency usually is three-
dimensional
▫ shortening of maxillary length
▫ decrease in width and height.
• The treatment depends on growth of patient
▫ Growing
▫ Adult patients
140

Orthopedic correction
• Prior to orthopedic treatment, orthodontic forces
applied to the teeth by Class III elastics, did not
displace the maxilla, they flared the maxillary
incisors without creating an adequate incisor
overbite and axial inclination.
• Depends on type of cleft
141
Unilateral Maxillary retrusion
Maxillary protraction
Bilateral Premaxillary malposition
Premaxillary repositioning

Maxillary orthopedic protraction
• Rapid maxillary
expansion disarticulates
the circumaxillary
sutures.
• Rapid maxillary
expansion is sutural
expansion osteogenesis
of the intermaxillary
suture.
142
Combined use of
Rapid maxillary expansion Face mask
• Orthopedic protraction
of loosened maxilla.
• Facemask protraction of
maxilla is sutural
protraction osteogenesis
of the circumaxillary
sutures.

Rapid maxillary expansion
Criteria to be followed
• Expansion should be to displace the maxilla
anteriorly
• Disarticulate circumaxillary sutures rather than to
overexpand the maxilla.
143

Rapid maxillary expansion
Appliance used
• A double-hinged rapid maxillary expander for a
greater amount of maxillary anterior displacement.
144
Jack screw at center
Two hinge posteriorly

TREATMENT PHASE I
EXPANSION OF
MAXILLA

Maxillary expansion by nickel titanium palatal expander in
cleft palate patient
NiTi EXPANDER
MEASURE THE INTER MOLAR WIDTH AND ADD 4
MM FOR SELECTION OF NiTi EXPANDER
ACTIVATION
FREE ARM ADAPTED
TO TEETH
PUT IN COLD WATER
BEFORE PLACED IN
MAXILLARY ARCH

U – 34 mm MAXILLARY EXPANSION BY NICKEL TITANIUM
PALATAL EXPANDER
26-4-17
Intermolar width
was 29 mm

PALATAL EXPANDER AFTER 10 DAYS
4-5-17

PALATAL EXPANDER AFTER 2 MONTH
10-7-17

Circum maxillary disarticulation
• Alternate Rapid Maxillary Expansions and
Constrictions (Alt-RAMEC) of Maxilla
152
• Maxilla articulates with nearly nine bones
• Cranial bones
• Frontal
• Ethmoid
• Facial bones
• Nasal
• Lacrimal
• Vomer
• Palatine bone
• Inferior nasal concha
• Zygomatic bone
• Sphenoid

• Delaire type of fack mask
• Avoid downward pull on molar
– extrusion – tilting of palatal
plane –open bite
• But, if vertical growth is
required,
▫ More vertically directed elastics
should be used to increase
vertical vector of force –
through center of resistence
Maxillary protraction
154
Force
Duration
Direction
350-450g/side
Intermittent 12hrs/day
Downward and forward
from a hook located
mesial to the maxillary
cuspids.

Premaxillary repositioning
• The premaxilla is displaced downward and forward
in patients with bilateral CLP
• Headgear or extraoral appliance is not the appliance
of choice – inhibit growth.
• Thus a tooth-borne distraction devices.
155
Anchors on the
maxillary buccal
teeth and delivers
an intermittent
intrusion force to
the premaxilla
through the
maxillary incisors.

Skeletal correction
• In adult patients
▫ Even after regular follow up of preventive, interceptive
and corrective orthodontics aimed at attaining an ideal
maxillo-mandibular relationship.
▫ Most patients end up in skeletal class III because of
maxillary retrusion
▫ Thus, Le-forte I osteotomy maxillary advancement has
become a standard procedure for cleft lip and palate
patient.
156

Timing of orthognathic surgery
Decision for the timing of surgical maxillary
advancement is dictated by
▫ Biologic considerations
 Growth status
 Eruption status of permanent dentition
▫ Psychosocial considerations
157

• Biologic considerations
▫ Growth status
158
Delay surgery of the nasomaxillary
complex until growth has completed
Girls - around 14 to 15 Yrs
Boys – 16-17 Yrs
Advisable to take serial cephalogram with 6months interval to
confirm no further growth before the operation is scheduled.
▫ Eruption status of the permanent dentition.
Delaying surgery until the canine and second molars
have erupted
Minimizes the risk of endodontic requirements and
displacement of the second molars.

• Biologic considerations
159
• Advantages
• Stability after surgery is better if done after growth
completion.
• Avoids the need of multiple surgeries
• Disadvantage
• The psychosocial pressures from their peers, ridiculed
about their facial may result in low self-esteem and
impaired socialization.

• Psychosocial considerations
▫ Patients’ perception of their quality of life is an important
consideration and should not be overlooked in the timing of
surgery.
▫ Improving facial appearance by addressing the skeletal
disproportion at an younger age often results in dramatic and
complementary changes.
• Disadvantage
▫ Surgery being prior to maturation may result in additional
surgery needed once growth is complete.
160

Considerations for orthognathic surgery
• Previous bone grafting
▫ If had not done, more complex because lack of
adequate bone.
▫ Bone graft is recommended for following reasons
161
1. Wedged into the defects - maintain the
position of the maxilla during healing.
2. Encourages bone healing and reduces
the risks of fibrous union.
3. Midface is also malformed, used to
contour the middle face for esthetic
enhancement.
Facial clefts and craniosynostosis: principles and management. Katherine. Vig, Raymond J. Fonseca

• Perfusion to the segmented maxilla
▫ Paramount importance, as cleft maxilla receives lesser
blood supply than normal because of the
 Absence of tissues
 Multiple surgical procedures are needed to repair and
close defects.
▫ Accepting posterior crossbites and other occlusal
compromises may be judicious, rather than risking
necrosis of a segmental osteotomy.
162

• Mobilization of segmented maxilla –
▫ Tissues are commonly scarred and fibrotic.
▫ Thickness of bone
163
 Posteromedial aspect of the maxillary
sinus is unusually thick in cleft patients,
and it must be cut or fractured to permit
adequate mobilization.
 If not properly osteotomized, may lead to
cranial base or orbital fracture – Blindness.

• Residual oronasal fistula
▫ If present, will dictate the
incision and limit the soft tissue
available
▫ Extensive fistula may even
warrant overlay bone graft and
flaps from neighboring tissues
for grafting and vascularity.
164

• Presence of dental spaces
▫ Contemporary goal of cleft care is
to eliminate and/or reduce the
need for prosthetic management
by Closing dental spaces with
segmental osteotomies
▫ This maneuver results in more soft
tissue availability to create an
intact nasal lining.
165

• Velopharyngeal Considerations
▫ Small degrees of maxillary
displacement, may deteriorate,
velopharyngeal function.
▫ All patients experience hypernasality
immediately following surgery, most
gradually resolves 6 months after
surgery.
▫ Some may require special surgery or
prosthetic enhancement.
166

Camouflage surgeries
• Mandibular surgery
▫ Compensatory mandibular surgery to obviate
maxillary surgery should be avoided as far as
possible
▫ Indications
 Mandible truely prognathic as confirmed with
cephalometric analysis
 Maxillary surgery is impossible, profile can be
improved by compensatory mandibular
surgery.
Avoid increasing the vertical facial height
by autorotation of mandible
167

• Genioplasty
▫ Frequently chin is vertically long and retrusive
▫ May require vertical reduction and horizontal
augmentation genioplasty
168

Complications of orthognathic surgery
• Relapse
▫ Short term and long term changes are seen in both soft
tissue and skeletal parameters
▫ Relapse occur in both the horizontal and vertical direction
▫ Does not have correlation with
 Amount of advancement
 Simultaneous bijaw surgery
▫ More than half the total relapse happen in the first 6-8
months.
▫ Stability is achieved by 1 year.
169

Complications of orthognathic surgery
• Ischemic necrosis
▫ Loss of bone segments and teeth secondary to avascular
necrosis.
• Residual mobility of segments
▫ Large gap created during osteotomy which is not filled with
bone graft.
▫ Multiple segmental osteotomies
• Worsening of velopharyngeal incompetence
• Injury to nerves and blood vessels
170

Distraction osteogenesis
• Dr. Gavriel Ilizarov, a Russian orthopedic
surgeon in 1954 - distraction of long bones.
• Distraction osteogenesis was first applied to
the maxillofacial complex by Snyder et al in
1972.
• In 1995 Cohen et al. devised a miniature
distraction system for the midface, permitted
maxillary and midfacial advancement in young
children with cleft lip and palate or
craniofacial syndromes.
171

Distraction osteogenesis in the management of severe maxillary hypoplasia in cleft lip and palate patients.J Craniofac Surg. 2008
• External and internal DO are used in the treatment of
severe maxillary hypoplasia in cleft lip and palate patients
▫ Reproducible and valuable alternative to standard
orthognathic surgery procedures
▫ Allows for a global improvement in facial aesthetics
▫ Allows maxillary correction in patients during the period of
mixed dentition
▫ Allows either for an unchanged or better velopharyngeal
function.
172

• Distraction osteogenesis tends to be preferred to conventional
osteotomy for younger CLP patients with more severe deformities
with complete or incomplete Le Fort I osteotomy.
• Traditional ischemic complications related to conventional osteotomy
were replaced by infection of the oral mucosa due to the prolonged
retention of the distractors.
• No conclusive data on any differences in surgical relapse,
velopharyngeal function and speech between the two techniques.
• Both distraction osteogenesis and conventional osteotomy can
deliver a marked improvement in facial aesthetics.
173
A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis. Intnl. Journl of Oral and Maxillofac Surg 2006

• Indications of DO
▫ Large advancement of maxilla in patient with moderate to
severe retrusion.
▫ Downward and forward lengthening of maxilla to avoid bone
grafting
▫ Growing patients.
174
A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis. Intnl. Journl of Oral and Maxillofac Surg 2006

Velopharyngeal sphincter
175
• The opening between the oropharynx
and naso pharynx is gaurded by the
Velopharyngeal valve
▫ Anteriorly - velum,
▫ Posteriorly - posterior pharyngeal wall,
▫ Laterally - lateral pharyngeal walls,
Three dimensional movements of these structures allows
swallowing and speech.

176
• Disorders of velopharyngeal function is divided into
three major categories:
▫ Structural
 clefting of the palate, anomalies of the surrounding pharynx.
▫ Neurogenic/myopathic
 Cerebrovascular accidents, cerebral palsy , infections such as
encephalitis, and neurodegenerative diseases
 Primary myopathies and dystrophies
▫ Learned.

177
• Assessment of velopharyngeal insufficiency can be
divided into two broad categories:
▫ Direct
 Endoscopy
 Video nasopharyngoscopy
 Radiography
 Cinefluoroscopy (x-rays recorded on motion picture film)
 Videofluoroscopy (x-rays recorded on videotape) with
simultaneous voice recordings
▫ Indirect
 Rating Scales of Speech Intelligibility and Acceptability
 Nasometer
 TONAR (The Oral and Nasal Acoustic Ratio)

178
• The major problem in patients with VP insufficiency will be
hypernasality of speech due to air escape through the
incompetent valve.
• The correction of these defects involve either
▫ Surgery
 Velar lengthening
 Intravelar muscular reconstruction;
 Pharyngoplasties
 pharyngeal wall augmentation.
▫ Prosthesis

Speech Aid Appliances
• Prosthetic dental appliances are used for the
replacement of missing or malformed teeth in the line
of the cleft and, when indicated, in the design of
speech appliances.
• Indication
179
▫ Surgery is contraindicated, delayed, or
performed unsuccessfully, a dental speech
appliance may provide a satisfactory substitute.

Design
• Appliances are usually made of acrylic plastic and
retained by clasps around the teeth
▫ Palatal
▫ Velar
▫ Pharyngeal sections
180
Covers the palate and carries
clasps for attachment to teeth.
Bar shaped connects palatal to
pharyngeal portion
Extends into the nasopharynx and assists in
palatopharyngeal closure and reducing nasal resonance.

• Palatal lift appliance (PLA)
• designed to hold the soft palate up and
backward and to ultimately improve its
function by acting as an isometric training
appliance.
• Indication
• PLA be used for patients in whom there is
adequate tissue but poor control of
coordination and timing of VP movements.
• Modifications
▫ May also plump the upper lip to improve the facial profile.
▫ Vertical dimension can be increased with palatal section
covering the natural teeth.
181

Retention protocol
• Permanent retention is mandatory in any cleft treated
cases.
• Retention will be the dual responsibility of the
Orthodontist and Prosthodontist, because of
hypoplastic, missing teeth and residual palatal defects.
• When orthodontic treatment is completed by 12-13 yrs,
an interim prosthesis should be given, which should be
replaced by permanent retainer.
182
Fixed retention following cleft palate orthodontics. TA Curtis. Angle Orthod. 1968

• Requirements
▫ Retain the maxillary segments and teeth in their
optimal position.
▫ Replace missing and correct malformed teeth.
▫ Make up for anatomical deficiencies in the cleft area.
▫ Support the lip and aid in normal speech.
▫ Facilitate oral hygiene in cleft area.
Permanent retention
183
POST ORTHODONTIC RETENTION IN COMPLETE UNILATERAL AND BILATERAL
CLEFT SUBJECTS. RAMSTAD. Cleft Palate J. 1973

Future directions
• Fetal surgery
▫ Faster wound closure, increased tensile strength and the
reconstitution of a more normal tissue architecture.
▫ Interrupt the malformation’s cascade of detrimental
secondary effects, thus promoting a normal growth of the
mid-face and an excellent aesthetic result.
▫ Minimize the need for secondary corrections or additional
post-natal treatments, such as orthodontic, dental,
psychological etc.
184
▫ Scarless fetal wound healing and bone healing without
callus formation, which would also allow a better/normal
maxillary growth
▫ Signiﬁcant decrease of fetal and maternal morbidity.
Foetal surgery and cleft lip and palate: current status and new perspectives. Papadopulos, British Journal of Plastic Surgery . 2005

Fetal surgery
▫ Open foetal surgery has been performed only in a few
centers around the world – California.
▫ The considerable invasiveness of the standard ‘open’
technique major drawback were encountered
185
 Direct operative trauma to the myometrium, fetal
membranes and fetus,
 Effects of post-operative premature membrane
rupture, increase of uterine contractions.
 May lead to premature labor and fetal demise.

Fetal surgery
• The merger of fetoscopy and advanced video-
endoscopic technology has boosted feto-endoscopic
surgery.
• Main applications of feto-endoscopic surgery in
humans are on the level of the placenta, umbilical
cord and fetal membranes.
• Presently experiments on fetal cleft lip & palate
surgery
186
▫ Large animals with a long
gestation, such as the sheep,
the primate monkey

Treatment Timeline
Time Unilateral cleft lip and
palate
Bilateral cleft lip and palate
187
Infancy
(1 – 4 weeks)
Presurgical orthopedics Presurgical orthopedics
8 – 12 weeks Primary lip repair Primary lip repair
Primary palatal repairPrimary palatal repair
5 Years
18 – 24 months
Surgical repositioning of
premaxilla with bone graft
6 – 10 years Alveolar bone grafting Alveolar bone grafting
Comprehensive orthodonticsComprehensive orthodontics11- 14 years
17 – 19 years Orthognathic – revisional
surgeries
Orthognathic – revisional
surgeries

Conclusion
• Cleft lip and palate rehabilitation is a life long procedure
requiring complete involvement of the patient and
health care team members.
• Most treatment will require some compromise at some
point which are acceptable considering the amount of
defect and the effects it produces.
• As a professional, we should not give high expectations
to the patient which may result in loss of compliance.
188

Conclusion
• Orthodontist in cleft lip and palate rehabilitation team
should have
▫ Knowledge of growth and development
▫ Effect of surgeries
▫ Idea of possibilities
▫ Good communication skill
▫ Calm mind
▫ Kind heart
189

Conclusion
• It is rare to be born into this world
More so to be born as a human
Miracle to be born without any defects……
It is a great gift to be an orthodontist who can treat
these with defects, to help them lead a life which is
as normal as they can ever get.
190

References
• Cleft lip and palate . R. B. Ross, M. C. Johnston.
• Cleft lip and palate: Diagnosis & management. Samuel
Berkowitz
• Cleft lip and palate: from origin to treatment Diego F.
Wyszynski
• Oral and Maxillofacial Surgery: Cleft, craniofacial, cosmetic
surgery . Raymond J. Fonseca
• Craniofacial development By Geoffrey H. Sperber
• Epithelial-Mesenchymal Transformation during
Craniofacial Development J DENT RES 2005; 84; 678
• Management of children with cleft lip and Palate: a review
describing the application. Fetal and Maternal Medicine
Review 2005
191

References
• Current concepts in genetics of nonsyndromic clefts.
Indian J Plast Surg 2009
• Environmental etiologies of orofacial clefting and
craniosynostosis. Vandana shashi
• Growth and Development in Patients With Untreated
Clefts. LESLIE A. WILL. Cleft Palate Craniofac Journal, 2000
• Terminology and classification of facial clefting. Robert j.
Shprintzen.
• The striped Y-A symbolic classiﬁcation for cleft lips and
palates Kernahan Plastic & Reconst Surgery May 1971
• Goslon Yardstick- a new system Classification of dental
arch relationship. Micheal Mars. Cleft Palate J 1987
192

References
• Feeding infants with cleft lip and palate- an overview.
Cleft Palate J 1987
• Orthopedic advancement of cleft segment. Latham. cleft
palate J. 1980
• Lip adhesion revisited. Review of literature. K.Nagy.
Indian j plast. Surg. 2009
• Multidisciplinary management of cleft lip and palate
Janusz Bardach
• Facial clefts and craniosynostosis: principles and
management. Katherine. Vig, Raymond J. Fonseca
• Distraction osteogenesis in the management of
severe maxillary hypoplasia in cleft lip and palate
patients.J Craniofac Surg. 2008
193

References
• A meta-analysis of cleft maxillary osteotomy and
distraction osteogenesis. Intnl. Journl of Oral and
Maxillofac Surg 2006
• Fixed retention following cleft palate orthodontics. TA
Curtis. Angle Orthod. 1968
• POST ORTHODONTIC RETENTION IN COMPLETE
UNILATERAL AND BILATERAL CLEFT SUBJECTS.
RAMSTAD. Cleft Palate J. 1973
• Foetal surgery and cleft lip and palate: current status
and new perspectives. Papadopulos, British Journal of
Plastic Surgery . 2005
194

Cleft lip palate

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

Similaire à Cleft lip palate

Similaire à Cleft lip palate (20)

Plus de ShadowFighter1

Plus de ShadowFighter1 (7)

Dernier

Dernier (20)

Cleft lip palate