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1. CLEFT LIP AND PALATE AND
ITS MANAGEMENT IN
ORTHODONTICS

2. Introduction
• Clefts of the lip and or palate unfortunately, are by far
the most common major facial malformations in
mankind. Fortunately, as a result of technical
advancements in the fields of medicine and their
families for treatment, much can be done and achieved
for them.
• The orthodontist, by virtue of having gained in depth
knowledge of the craniofacial complex, it’s growth
and development, and expertise in tooth movement,
has to play a role of prime importance in making
critical decisions, planning treatment and rendering
care to these patients.

3. INCIDENCE
Incidence of cleft lip and Incidence of different
palate in different races: types of cleft
Geographic
Section/Race
Incidence per 1000
llve birth
Negro 0.5
Caucasians 1.0
Japanese 2.34
American 2.91
Type of
cleft
Incidence
(Percent of all
cleft cases)
Cleft lip
alone
25%
Cleft plate
alone
25%
Cleft lip
and palate
both
50%

4. • Prevalence of different types of cleft in India
• Predicted incidence of the defect with affected relatives
• CLP males > female
• CP females > males
• ULCLP is very common that to left side
• Consanguis Marriages
Palace Type of cleft with percentage
CLP CP CL
Dharwad 44.3 12.8 42.9
Delhi 68 18 14
Chennai 84.7 1.9 13.3
Affected relatives Predicted incidence (%) of cleft lip and palate
One sibling 4.4
Two sibling 9.0
One sibling one parent 3.2
Two sibling one parent 15.8

5. ASSOCIATED SYNROMES
1. Down’s Syndrome (Trisomy 21)
2. Wardenburg’s Syndrome (Abnormalities of pigmentation of hair,
iris and skin deafness).
3. Vander woude’s Syndrome (lip pits)
4. Orofacial digital syndrome: median cleft lip associated with
bilateral accessory toes is found only in indians.
5. Treacher Collins Syndrome (hypoplastic zygoma, micrognathia,
external and middle ear defects.)
6. Pierre Robin syndrome (micrognathia, glossoptosis with
respiratory obstruction).
7. Klippel Feil Syndrome (short neck with an abnormal or missing
cervical vertebra)

6. Development Of Palate
Four week of IUL 5 brachial arches develop at the site of the future
neck.
• The first arch (mandibular arch) Development of naso-
maxillary complex.
• From first arch, maxillary arch is formed and give rise to upper
lip, upper port of cheek.
• Palate developed from
1- Frontonasal process give - primitive palate – premaxilla.
2- Maxillary processes give - Palatal process - Hard palate and
soft palate

7. Development of CLP
A. Complete BCLP
B. Unilateral complete CLP
C. Midline cleft extending in to hard palate
D. Bifid Uvulae
E. Cleft of soft palate

9. CLASSIFICATION OF CLP
Morphological
Embryological
Morphological – Dow & Ritchie (1922) Veau (1931) have
given morphological classification
Group I - Cleft soft palate only
Group II - Cleft of hard & soft plate
Group III - Complete unilateral
Group IV - Complete Bilateral

10. EMBRYOLOGICAL CLASSIFICATION
I Fogit & Andersen 1942
- Hair lip (includes alveolus as far bat as incisive foramen)
- Hair lip & Cleft palate
- Isolated clefts of palate as far back as incisive foramen
II. KERNAHAN & STARKS 1985
Group I – Cleft of the primary palate only
• Unilateral
• Bilateral
• Total
• Subtotal
Group III – Cleft of the secondary palate only
• Total
• Subtotal
• Submenus

11. Group IV – Cleft both primary & secondary palate
• Unilateral - Total, Subtotal
• Medium - Total, Subtotal
• Bilateral - Total, Subtotal
III SPINA CLASSIFICATION
Group I - Pre- incisive foramen clefts
• Unilateral
• Bilateral
• Median (cleft of the lip with /without an alveolar cleft) total, partial.
Group II - Transincisive foramen clefts (cleft of the lip, alveolus & palate).
• Unilateral
• Bilateral
Group III – Post incisive foramen clefts
• Total
• Partial

12. Dais & Ritchie classification (1922)
Based on the location of the cleft relative to the alveolar proven
‘3’groups
Group I Pre alveolar clefts – involving lip are sub classified as
- Unilateral
- Bilateral
- Median
Group II Post alveolar clefts
Different hard & soft palate clefts that extend up to the alveolar ridge
Group III Alveolar clefts
Complete clefts involving the palate , alveolar ridge and the lip.
Subdivided into
 Unilateral
 Bilateral
Median

13. SCHUCHARDT & PFEIFER’S SYMBOLIC CLASSI FICATION

14. KERNAHAN’S stripped ‘Y’ classification

15. LAHSHAL CLASSIFICATION
Simple classification presented by OK ring in 1987. LAHSHA in a
paraphrase of the anatomic areas affected by the cleft.
L- Lip
A- Alveolus
H- Hard palate
S- Soft palate
H- Hard palate
A – Alveolus
L- Lip.
E.g
L----S - Cleft fright lip & soft palate
t-----S – Cleft right lip Alveolus, soft palate with combination of left cleft
lip

16. Internationally approved classification
Internal ion confederation for plastic & constructive surgery 1967 Rome.
Classification of cleft of the lip, alveolus & palate this classification is bared
on embryonic principle.
Group I – Clefts of anterior ( primary palate)
Lip: Right and / or left
b) Alveolus : Right & / or left
Group II – Cleft of anterior posterior (Primary and secondary ) palate
a. Lip: Right / or left
b. Alveolus Right / or left
c. Hard plate : Right / or left
Group III – Clefts of posterior (secondary) palate
a. Hard palate : Right / or left
b. Soft palate : Medial

17. FACIAL GROWTH IN CLP CASES
Prenatal Growth
• Over maxillary segment on non cleft side
- Pull of lip & cheek muscles
- Tongue pressure
- Relatively unstrained nasal septum growth
• Over maxillary segment on the cleft side.
- Intrinsic deficiency
- Presence from alas base due to stretching of the nostril

18. In compel unilat CLP
cases:
- Large maxillary segment
on non deft side thorns a
scare deviation of the
midline away from the cleft
- Smaller maxillary
segment retro positioned /
collapse / prohibition
- Nose toward normal side
- Ala grow in deformed
matrix
In Bilat CLP cases:
- Primarily tilts forward /
shifts one side due to
tongue procure
- Smaller maxillary
segments cither side
similar growth pattern as
in
• Due to above forces the defects produced in CLP basics are

19. FACIAL GROWTH IN UNREPAIRED CLP
- A functionally normal facial skeleton develops in unpaired cases
- Presence pf local bony defect due to intrinsic deficiency in the humiliate
area of the cleft
- Absence normal lip pressure abnormal development of dento alveolar
process can occur
- Mestre et al 1960 Ortiz monarteri et al 1961 & Birhona 1976 fond no
significant difference in overall size with normal adults in un-operated clefts
- Biohara 1973 found retro poritional maxilla & mandible than normal but no
significant differences in any parameters b/co operated & unoperated cases.
- Localized growth defects in un-operated subjects, region immediate to cleft
o alveolar arch defects occurred particularly in lateral & vertical growth at the
region of the alveolar cleft.
- STARK 1968 – A deficiency of mesodermal tissue rather than a more
failure of fusion of embryonic elements pathogenic back ground
- FUSTER & LAUELLE 1971 – the teeth in cleft subjects significantly
smaller
AMETON 1967 reduction in subject of the elements of maxilla at all ages, didn’t
progressively greater with age.

20. FACIAL GROWTH AFTER SURGICAL
REPAIR
• Effect of lip repair
- Increased tighten in the upper part of the upper
lip inhibits growth banal bone of maxilla increased
tighten in the lower pout of the upper lip ratiocination
of dento alveolar an structures
• HAYASHI et al 1976 The growth of the maxilla
repaired cleft lip and palate tends reduced in all planes
of space
Effect of palate repair- Inhibit the growth of the
maxilla scar contractor, reduction in the maxillary size
may occurs

21. PROBLEMS ASSOCIATE WITH CLEFTS
1. Dental
• Congenital missing teeth (usually )
• Neonatal teeth
• Super numorary teeth
• Ectopically erupting teeth
• Peg shaped teeth
• Delayed eruption if teeth
• Enamel hypoplasia
• Microdontia / macrodontia
• Fused teeth
• Spacing / crowding
• Posterior & anterior cross bite

22. 3. Hearing and speech
• Associated with disorders with of the middle ear affect hearing
Differ cuties in language uptake speech.
Speech defects CP patients
• When sound M.N & N.G
• Speech defects when sounds UL / BL CL patients are not
approximating
• When upper teeth maloccluded sounds th, F,V,S, ZE, SH.
• Surgical operations
• Speech therapy
4. Psychological Problems
Psychological stress due to their abnormal facial appearance they have to
put up with staring, curiosity, pity et
•

23. 2. Esthetic problems
The clefts involving the lip can result in lot of facial
disfigurement. The oro-facial structures may be
malformed and congenitally missing. Deformities of nose
can also occur thus esthetes greatly affected

24. MANAGEMENT OF CLP
• Multi-disciplinary team for cleft lip and palate patients
S.No. Experts involved Role
1. Obstetrician - Refers to plastic surgeon and pediatrician counseling the
parents
2. Pediatrician or Neonatologist - Refers to the plastic surgeon
3. Plastic surgeon - Leads the team of CLP cases discusses the case with
members of the team phayngoplasty reversionary lip
4. Oromaxillofacial surgeon - Bone grafting
5. Neurosurgeon - Craniogacial syndrome is associated
6. Pedodontist - Presurgical orthopedic treatment for the baby monitors the
growth and development to maintain oral health to guide the
occlusion and facial growth
7. Orthodontist - Provides presurgical dental orthopedic consultation definitive
orthodontic treatment once the full permanent dentition is
erupted.
8. Speech pathologist Monitors the speech development to normal
9. Audiologist - Hearing in the young child
10. Otolaryngologist - Nasopharyngeal tissues, including tonsils, adenoids and
middle ear blockage
11. Psychologist - Plays an important role under stress.

25. • CLP difficult management problem.
• Esthetics, speech, respiration and
mastication that most be dealt with in the
rehabilitation of cleft child
• The orthodontist has to give maximum
attention to the child bs of the longitudinal
nature of his cancer

26. MANAGEMENT IN GENERAL
1. Parent counseling at birth
2. Feeding advise
3. Pre-dental orthodontics
4. Surgical approach
5. Post-dental orthodontics
- Primary dentition period
- Secondary dentition period
- Permanent dentition period

27. Orthodontic management by fish man
a) Predental treatment – prior to eruption of
primary molars
Pre-surgical
post-surgical
b) Deciduous dentition (3-6yrs) – After eruption of
primary duration.
c) Early mixed dentition treatment (7-9yrs) –after
during eruption of maxillary permanent incisors
d) Late mixed permanent dentition treatment (9 12
yrs on words)

28. PRE- DENTAL
• Initiated by Mc NEIL 1954 and developed by Burstone
1958
• Advantages of this appliance
- To facilitate feeding
- To help in psychological boost to the parents
- To assist the surgeon in his initial repairs
- To stimulate palatal growth
- To restore the oro-facial ‘functional matrix’
- To help in reducing ear infections
- To expand or prevent collapsed segment
- To reduce the need for later orthodontic treatment
- To guide tooth eruption
- To improve esthetics
- To re-establish proper sutural growth patterns early.

29. IMPRESSION
• Extend into the nasal chamber undercut
• Custom trays are preferred
• Posterior limit – up to maxillary puberosity
• Fabrication of a combination soft and hard acrylic passive
maxillary orthopedic appliance
OBTURATOR
• Placement of the appliance and surgical closure of the lip.
This is usually at 10 days to 2 weeks autogenous alveolar
bone graft.
• Stabilization of the graft 2 months or so, using the orthopedic
appliance as a splint.
OBTURATOR -USES
• It facilitates lip repair
• It facilitates the feeding
• It prevents the collapse of the palatal segments

30. Obturator for CBLP

31. METHODS OF PRE SURGICAL ALIGNMENT
• Discussed in two aspects
I. Control of maxillary elements
• Achieve upper arch form which confirms to that of
lower arch
• Stabilization of the arch can be achieved by simple
upper appliance
• Expansion of the upper arch can be achieved by
screw appliance or pre-expanded appliance
• Retention of above appliances by the force of the turn
and the lower jaw, the extra orally ‘whiskers’ are
facilitate handling of appliance

32. A. In bilateral clefts the displaced premaxilla is readapted to confirm to the
arch
B. In unilateral clefts the displaced greater segment is readapted to
conform to the arch

33. II. Control of Pre-maxillary elements
Both unilateral and bilateral clefts extra-oral strapping across
the pre maxilla, attached either directly to the face
Retrusion of the pre-maxilla can only be achieved at the
extends of distortion of the nasal septum.
All these procedure should be done with in 3 months
Huddart 1974 found that use of an intra – oral appliance
restricted further widening of the maxillary arch allowed
normal growth to proceed at margins of cleft.

34. Lantham appliance – Retraction,
Incomplete BCLP

35. Lanthem Appliance with
retention Pin

36. PRIMARY BONE GRAFTING
• Objective – It is to make good the hard tissue
deficiency
• Good surgical grafting improve the oral contours
improved function
Advantages claimed
a) Prevention of collapse of anterior portion of arch
b) Allowing eruption of teeth into the graft site
c) Allow mid line adjustment that is so necessary
to minimize the asymmetry of treated cleft lip
and palate.

37. PRIMARY DENTITION PHASE
• Common problems encountered
a) Cross bite of incisor or buccal teeth
b) A functional shift of the mandible
c) An oronasal fistula
d) Premaxillary protrusion in bilateral clefts
• Expansion fixed maxillary lingual arch
appliance either W-arch or an Arnold expander
• Anterior cross bites a removable inclined plane
on lower incisors or maxillary Hewley retainer
with finger spring. Supernumerary teeth should
be extracted

38. MIXED DENTION PHASE
• Problems are more severe a short period
& effective of orthodontic treatment
a) Sagittal deficiency of the maxilla,
b) Anterior cross bite
c) Downward rotation of the maxillary plane
d) Function deviation of the Mandible
e) Missing teeth
f) Dental crowding

39. MAXILLARY PROTRACTION (FACEMASK)

40. Protraction headgear – 5 – 8 yrs, acrylic maxillary
splint with occlusal coverage, cemented on
maxillary teeth with heavy elastics.
500g forces, 10o
to occlusal plane, for 14-16hrs day
for 6 to 12 months.
Leads remodeling changes in the anterior maxilla and
a backward rotation of the mandible.
Contra indicated in mandibular prognatism and high
mandibular plane cases.

41. OTHER AUXILIARY APPLIANCES
Cross bite central incisor
• Negative overjet and maxillary incisor rotations
are corrected simultaneously by lower bite planes,
removable appliance with Z-spring are used.
Maxillary contraction (Transverse / buccal cross
bite)
• Expansion of the maxillary arch by :
– Quad Helix appliance 036 blue engiloy provides
controlled force appliance
– NiTi palatal expanders effect maxillary expansion more
dentoalveolar than skeletal effects.

42. Expansion Appliances

43. LINGUAL RETAINERS
Open end of U shape retainer facing posteriorly-
located canine and premolar area.
Uses of semi fixed and lingual sheaths type designs
have 4 advantages –
1. Adjustments / replacement easy
2. Transition from expansion to retention is
immediate
3. Avoid interference during bone grafting
4. Allows rapid replacement with easy secondary
design.

44. Retainers

45. Functional deviation of the Mandible
Occurs due to interference of incisors
Correction of incisors cross bite and
expansion of the maxillary arch invariably
permit to the mandible to achieve a normal
path of closure

46. Missing Teeth
- Most common in 2 2 next to the
cleft followed by second bicuspids I
both the arches and maxillary third
molars
- Retainers replacing missing teeth
should be worn until permanent
dentition treatment

47. Dental crowding
Because of the incisors retruction arch length is often
reduced I both the arches
A class III tendency man require an oven greater retruction
of the mandibular incisors to establish normal overjet. Serial
extraction is the mode of treatment
If should be also noted that the class III elastics are usually
worn in permanent dentition so that if first biocuspids have
been removed space closure in the mandibular arch may be
difficult to accomplish without excessive lingual tipping of
the mandibular incisors.

48. Alveolar Bone Grafting
Indicated-
To stabilize the premaxilla,
to close oronasal fistula and anterior palatal clefts
To ensure better periodontal support for the erupting
teeth and the teeth burdening the cleft,
to build up the piriform rim and alar base symmetric
with the normal side,
To lend sup[port to the depressed lip[ over the cleft]
To provide bony continuity in the alveolous for
eruption and orthodontic movement of the teeth
adjacent to the cleft in their optimal positions.

49. -Cancellous iliac crest grafts done between
9 and 11 years of age allow quite favorable
eruption of the maxillary canine through
the graft either by itself or by prthodontic
mechantotherapy, with the best possible
periodontal support to be expected.
-Secondary bone grafts or greater
acceptance than the primary bone grafting

50. Permanent dentition
- Most difficult case of treatment
- In case analysis three considerations must be stressed
a. Stability of teeth and maxillary segment
b. Facial esthetics
c. Preparation for a prosthetics
Surgical procedures which are particularly traumatic
which must be assessed on an individual basis and
treatment must be planned accordingly
Problems includes,
a. Vertical jaw relations
b. Jaw relation
c. Lateral jaw relations and dental irregularities

51. Vertical jaw relations
Freeway space is atmost important treating this
problems this excess free way space can be
corrected by
a. Vertical elastics
b. Vertical development plate – used for both open
bite closure which is usually in cuspid region and
forced eruption of all maxillary teeth
c. Mandibular acrylic bite opening plate in
conjunction with vertical elastics – Best method,
because the plate covers mandibular incisors and
provides lingual rest for maxillary incisors

52. Anterio –Posterior jaw relations
- This directly related to the freeway space, so that the
A-P must be made with the mandible in rest position
- A-P relations in females is known to stabilize at
13-14 years where as in males it is 17-18 years. So
stable results may not be achieved until this age
Surgery for severe A-P discrepancy cases
- May be advised if large excess freeway and
mandibular over closure
-Maxillary advancement – preferred in case of mid face
deficiency
-Surgery to be delayed until puberatal growth spurt. 14
years for females and 17 years for males
-Beginning of orthodontic treatment will be after
surgery

53. Lateral Jaw relationships
Expansion should be overdone in order to maintain for
several years with a palatal retainers
Dental irregularities
Teeth frequently crupt in the palate (because of surgery).
Lateral cuspids are commonly involved in which case
retention of these teeth after may be alignment may be
difficult particularly, if the root apex is palatably placed.
Serial extraction often it is indicated it is
satisfactory to remove one or more mandibular incisors
to relieve crowding, this makes treatment much simpler
and co-ordination to mandibular incisors is less critical
in cleft cases

54. Surgery
Time of surgery is quite a contraoversy
Different according to different school
of thought generally,
 Cleft lip- 3-6months
 Cleft palate – 1 1/2 – 2years
Most surgeons follows the rule of 10-
-10 weeks of age
-Weight 10pounds
-Hb 10%
-WBC should be lesser than 10,000

55. Cleft lip surgical repair
-Various methods of CL repair aimed
to lengthening the philithral ridge on
the cleft side to correct the nose
deformaties have much as possible
-The lip is closed in three layers –
mucosa, muscles,skin
- Most favorable surgical operations
are Millerd’s rotations advancement
flap, Tennison Randal repair, Veau
repair

56. Millard’s Repair of CL
Millard’s rotation flap (a) and Columella flap(c) or planned
medial side of the cleft . After full thickness of the lip cut
along the markings a rotation gap is produced on the medial
side which is filled by an advancement flap(b) planned on
the lateral side of the cleft

57. Tennison Randall repairs
• A triangular flap is created on the lateral side of the cleft to
fit in to the triangular defect produced on the medial side
of the cleft. This procedure can be planned exactly after
initially measurements. The results cannot be modified
once the lip is cut. The scar is more prominent than in
other procedures.

58. Veau repair
It is the simplest one stage straight line
closure and produces satisfactory results u a
bilateral cleft lip. In this method vermilion
flap from either lateral side of the cleft is
brought down over the prolabium to augment
the vermilion I the centre of the upper lip

59. Cleft palate surgical Repairs
1. Von Langen beck’s simple
palato plasty of CBCLP

60. 2.Von Langen beck’s palatoplasty for
CUCLP

61. 3. Veu Wardill Kilner V-Y
push back palatoplasty
Cleft palate repair by a double
opposing Z- plasty of Furlow
is relatively new procedure
aimed are reducing the
midfacial growth retradation
problem. However more
experience is required with
this procedure before reaching
any conclusion

62. Distraction Osteogenesis
- This technique is Increasing popular and has a good
potential for severe maxillofacial deformities, where in
a bone segments are lengthened by using intra oral,
extra oral devices
- Maxillary distraction for CLP cases has been shown
to be particularly useful when the maxilla to moved
forward enlarged distance, which by orthognathic
surgery alone may not be technique feasible or stable.
Since this technique involves fixing of considerable
hardware on the cranium for a few months, the choice
is restricted to select cases having a large maxillary
retraction

63. Relapse and retention
CLP cases requires long term if not permanent retention for the
following reasons:
• In adequate bone support
• Absence of some teeth
• Presence of stretched scar tissue
- For this reason, retention, the orthodontist’s final frontier
must be planned in detail
Retainers of choice
i. Soldered lingual retainers
ii. Hawley’s retainers with Pontiac to replace missing tooth
iii. Bonded spiral wire retainers for derotated incisors

64. CONCLUSION
The course of the individual CLP patients ’s
rehabilization depends not only on the quality of
the individual components of the treatment, but
also on organization and co-ordination to ensure
the right timing, sequence and balance during
the often protruded course of treatment. For this
reason, a well adapted CLP protocol, with a
collectively operating inter disciplinary rather
than multidisciplinary approach to provide
integrated cleft care seems to be absolutely
imperative.

65. The myriad manifestation of the
malocclusion typical in Cleft lip and palate
necessities a harmonious medley of a multitude of
mechanotherapy procedures that emancipates the
orthodontist from the monotonous momentum of
mundane tooth moving procedures. CLP
rehabiltative treatment is the privilege and real
reward. In that endeavourer, our responsibilities go
beyond orthodontics. We can always go further;
we can always work harder; we can always find
newer possibilities; but for that we must keep
going and doing