1. Department of orthodontics & dentofacial orthopedics k. s. r
Department of orthodontics & dentofacial orthopedics k.s.r.institute of dental science & research
CLEFT LIP AND PALATE
Guided by
Dr.S.Tamizharasi.M.D.S
Professor
Presented by
Dr.N.Meiyappan
3rd yr PG student

2. SYNOPSIS Introduction Epidemiology Etiology Classification
Diagnosis(Investigations) Of Cleft Lip And Palate
Orthodontic management
- Treatment In Primary Dentition
- Treatment In Mixed Dentition
- Treatment In Permanent Dentition
- Surgical management
- Distraction Osteogenesis
Conclusion
References

3. INTRODUCTION

4. EPIDEMIOLOGY
One in 700 live births globally.
Afghans (4.9%)
Negroids (0.4%)
In south india , cleft lip and palate is 1.15 and isolated cleft palate 0.08 /1000
The incidence of oral clefts is seen more in males than in females.
Text book of Orthodontics- O.P.Kharbanda

5. Cleft lip alone- males › female
Cleft palate- females › males
Unilateral is more common than bilateral
Left is 2 times more common than right
Text book of Orthodontics- O.P.Kharbanda

6. ETIOLOGY
Heredity
Environmental
Malnutrition
Infections during pregnancy

7. ETIOLOGY
HEREDITY
Transmitted through a male as sex linked recessive gene.
Monogenic/ single gene disorder
Polygenic/ multifactorial inheritance
Chromosomal abnormalities:
- Down’s Syndrome
- Edwards Syndrome (Trisomy 18)

8. 2. ENVIRONMENTAL FACTORS:
Usually occurs due to various influences
Excessive Alcohol
Cigarette smoking
Anti epileptic drugs diphenyl hydantion and trimethadione

9. 3. MALNUTRITION:
Folic Acid
Deficiency of folic acid affects the neural tube- neural crest cell migration and differentiation.
4. INFECTION DURING PREGNANCY

10. CLASSIFICATION
Davis And Ritchie’s Classification -1922
Veau’s Classification
Fogh-anderson Classification
Schuchardt And Pfiefer’s Classification
Kernahan And Stark Classification
Kernahan’s Striped Y Classification

11. Millard’s Modification Of Kernahan’s Classification
Lahshal Classification
American Cleft Palate Association -1962
Internationally approved classification- 1967

12. VEAU’S CLASSIFICATION (1931)

13. KERNAHAN AND STARK CLASSIFICATION 1958
GROUP A : Clefts of the primary palate
GROUP B : Clefts of the secondary palate
GROUP C : Clefts of the primary and secondary palate
SCHUCHARDT AND PFIEFER’S CLASSIFICATION
LIP
ALVEOLUS
HARD PALATE
SOFT PALATE

14. KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971)

15. MILLARD’S MODIFICATION OF KERNAHAN’S CLASSIFICATION (1977)

16. LAHSHAL CLASSIFICATION
L Lip
A Alveolus
H Hard palate
S – Soft palate
H – Hard palate
A Alveolus
L Lip

17. AMERICAN CLEFT PALATE ASSOCIATION
CLEFTS OF THE PRE –PALATE :
Cleft of the lip
Cleft o f the alveolus
Cleft of the primary palate
CLEFTS OF THE PALATE :
Cleft of the hard palate
Cleft of the soft palate

18. INTERNATIONALLY APPROVED CLASSIFICATION- 1967

19. DIAGNOSIS

20. PRENATAL DIAGNOSIS
Ultrasonography is a non invasive diagnostic tool which is now routinely used as a part of prenatal diagnosis.
TIMING OF DETECTION :
Christ and Meninger :
Optimal imaging of the fetal face is not reliable with transabdominal
ultrasonograpy until gestational week 15.
Robinsen et al :
Greatly improved when performed after 20 weeks of gestation.

21. ADVANTAGES :
Psychological preparation of the parents and caregivers
Education of parents on management of cleft
Preparation for neonatal care and feeding
Opportunity to investigate for other abnormalities
DISADVANTAGES :
Emotional disturbance and high maternal anxiety
Chances to terminate pregnancy.

22. MANAGEMENT TEAM

23. NEONATAL AND INFANT MANAGEMENT
THREE MAIN PRINCIPLES:
Establishment Of Feeding
Pre-surgical Maxillary Orthopedics
Naso-alveolar Moulding

24. ESTABLISHMENT OF FEEDING
CLEFT PALATE :
1. Inability to create negative pressure for suckling
2. Nasal regurgitation
3. Chances of choking and cyanosis
4. Engulfing of trapped air which needs frequent burping

25. FEEDING POSITION FOR A CLEFT CHILD
A semi upright position ( 30˚ to 45˚ ) – reduces nasal regurgitation
Feeding should not be hurried

26. FEEDING OBTURATOR
The feeding obturator is a prosthetic aid that is designed to obturate the cleft and restore the separation between the oral and nasal cavities.

27. INFANT / PRE SURGICAL ORTHOPEDICS
Pre surgical orthodontic or neonatal maxillary orthopedics is initiated during the 1st or 2nd week following birth.
Introduced by McNeil and popularized by Burstone in 1950s .
Good functioning palate, normalise tongue positions and help in speech development.

28. Two movements must be carried out
Expansion of the collapsed segments and
Pressure against pre maxilla to its correct position.

29. THE MILLARD LATHAM PROCEDURE
Orthopedic force in newborn – 8 to 14 days
Followed by alveoloperiosteoplasty
Palatal cleft space – closed with Von Langenback procedure at 18 to 24 months
Split plastic appliance – pinned to both lateral palatal segments for maximum retention
S.S pin – 0.7 mm diameter.
Seminars in Orthodontics – September 1996; Vol 2, No 3.

30. NASO ALVEOLAR MOULDING
Nasoalveolar molding is a new nonsurgical method of reshaping the gums, lip and nostrils before cleft lip and palate surgery, reducing the severity of the cleft.
Initiated within 4-8 weeks of birth and finished before primary closure of lip.
Used for 4-6 months

32. ADVANTAGES
Proper alignment of the lip, alveolus and nose helps the surgeon to achieve a better and more predictable surgical result
The cleft deformity is significantly reduced in size.
Studies have demonstrated that 60 % of patients who underwent NAM and gingivoperioplasty did not require secondary bone grafting.
COMPLICATIONS
Irritation to the oral mucosa, gingival tissue or nasal mucosa.
Irritation to the cheeks

33. LIP CLOSURE
A good lip seal is essential for phonation , articulation and for optimal balance of muscular forcesin the orofacial region.
TIMING OF LIP CLOSURE :
At the age of 3 months (or) 10 weeks.

34. Techniques
Tennison’s triangular flap
Millard rotation flap
‘THE RULE OF 10’
Weight lbs
Age weeks
Hb gm %

35. PALATE CLOSURE
Objective:
Join the cleft palatal edges,
Lengthen the soft palate,
The timing of closure is controversial. Can be done early at months or at 9-12year
Surgery and scarring shouldnot adversely affect the dentition and growth of the maxilla

36. Closure of soft palate –age of 12 month Help in development of Speech
RECENT THOUGHT
Closure of soft palate –age of 12 month
Help in development of Speech
No growth retardation with early soft palate closure
Closure of hard palate –age of 5-6year
Hard palate repair timing and facial growth in cleft lip and palate : A systematic review - Yu-Fang Liao, Michael Mars . Cleft palate – Craniofacial Journal, September 2006, Vol 43, No 5.

37. VELOPHARYNGEAL INSUFFICIENCY
Velopharyngeal insufficiency is a disorder resulting in the improper closing of the velopharyngeal sphincter (soft palate muscle in the mouth) during speech, allowing air to escape through the nose instead of the mouth.
During speech, the velopharyngeal sphincter must close off the nose to properly pronounce strong consonants such as "p," "b," "g," "t" and "d."

38. The two main speech symptoms of velopharyngeal insufficiency are:
Hypernasality and Nasal air emission.

39. TREATMENT OF VPI
Speech Therapy
Some speech problems linked with VPI, such as mispronouncing words, can be treated by speech therapy.
Sometimes an obturator is recommended to treat VPI.
Modified obturator called speech bulb appliances are useful where palatal lift or soft palate closure is needed .
Pharyngoplasty and palate lengthening are performed to maintain velo-pharyngeal seal

40. Orthodontic Intervention During Mixed Dentition(7-12 yrs )

41. GOALS IN MIXED DENTITION
Maxillary Expansion
Alveolar Bone Graft
Primary
Secondary

42. ALVEOLAR BONE GRAFT
Aimed at providing a bony bridge to the cleft in the alveolus area.
Primary - first few days – 2.5 yrs of age .
Early secondary yrs
Intermediate or secondary – yrs
Late – after 13 yrs .
Primary and early secondary are not in practice bec of additional surgery required.

43. Secondary alveolar bone grafting
Boyne and Sands in 1972.
Aimed to bridge the cleft segment with grafted cancellous bone.
MERITS
Elimination of bony clefts and encouraging normal eruption of lateral incisor and canine through cancellous bone.

44. Orthodontic closure of cleft space becomes possible .
Helps in closure of oronasal fistulas.
Provides bony support to alar base and improvement in aesthetics.
Stabilization of maxillary segments – helpful during surgery

45. TIMING OF SURGERY
Based on root formation of lateral incisor and canine.
Favor of 8-10 year of age (when canines about to erupt-one quarter to two thirds of root complete)- Bergland et al
Erupting tooth is a potent stimulus for bone formation.
After tooth eruption is complete, it can be very difficult to induce the formation of new bone.

46. PRE –BONE GRAFT ORTHODONTICS
Contributes to better access of site for the surgeon.
Maxillary arch expansion using Quad helix appliance

48. POST BONE GRAFT FOLLOWUP
Bergland and coworkers – index to evaluate success of the grafted bone based on the height of interdental septum on IOPA .
TYPE I – normal
TYPE II – 75% of normal bone height
TYPE III- less than 75%
TYPE IV – no bony ridge

50. Orthodontic management in permanent dentition stage

51. Two to three years after bone graftng , comprehensive orthodontic treatment can be started.
If the lateral incisor is present and viable in cleft region . Every attempt shouldbe made to preserve it.
Completed by 15 yrs of age.
Rigid palatal retainers – wire framework soldered on molar bands are considered to maintain arch alignment and expansion.

52. ORTHOGNATHIC SURGERY COMBINED WITH ORTHODONTICS
Due to severe skeletal discrepancy, there is
Deterioration of esthetics and occlusion,
Psychological implications leading to low self esteem,
Defective speech,
Oronasal fistulas.
Such cases require a combined orthodontic and orthognathic approach.

53. SURGICAL PROCEDURES IN A CLEFT PATIENT
Maxillary advancement
To correct the size and position of maxilla.
Multiple segment LeFort I osteotomies –
To correct the transverse problem.
For a bilateral CLCP three-piece maxillary surgery (allows rotation of segments )
For unilateral CLCP a two piece is sufficient.(Vlachos 1996)

55. Indian J Plast Surg 2009 vol 42 No 1
Severe cases - May require bi jaw surgery.
Proffit recommends overcorrecting the anterior cross bite in excess of positive over jet- compensate for post surgical relapse.
In cases with an over jet of more than 8mm mandibular surgery (BSSO) also must be considered.
Skeletal facial balance and harmony in the cleft patient- principles and techniques in orthognathic surgery
Indian J Plast Surg 2009 vol 42 No 1

56. DISTRACTION OSTEOGENESIS
Dr. Gavril of Russia-Bone lengthening of leg.
Introduced in ORTHODONTICS BY ILIZAROV IN 1950
It is a procedure by which formation of new bone is induced by external tension created by distracting devices at the site of osteotomy.
The distractor is gradually adjust over a period of days or week to stretch the osteotomy site so that new tissue fills it.

57. External frame distraction of the midface in cleft palate patients
Ross and Subtenly
Distraction osteogenesis
Allows soft tissue adaptation, including scar tissue.
Doesn’t cause a problem with velo- pharyngeal insufficiency .
Distraction Of maxilla first proposed by Molina & Oritz-Monasterio(1998)
Maxillary distraction devices
External distractors Internal distractors
External frame distraction of the midface in cleft palate patients
Eur J Orthod 2009 vol 41

58. Direction of force is well controlled Dis advantage:
EXTERNAL DISTRACTORS
Advantage:
Direction of force is well controlled
Dis advantage:
Cranial surgery is required
Esthetics are compromised

59. Difficult to control the direction of force
INTERNAL DISTRACTORS
Advantage:
Esthetics
Psychological relief
Disadvantage:
Difficult to control the direction of force

60. Prosthodontic Treatment:
It may be required in cases where replacement of missing teeth is essential. Removable or fixed prosthesis may be given. It allows for improved speech and better esthetics.

62. CONCLUSION
Treatment of a child with cleft lip and cleft palate begins from the day of born. psychological counselling of the parent and full team effort in which an orthodontist plays a vital role and works with various specialists to provide quality care to the patient and to start hloistic treatment planning.

63. REFERENCES
Orthodontic Current Principles and techniques – Graber and Vanarsdall - 5th Edition
William R. Proffit. Contemporary Orthodontics. 5TH Edition
Textbook of Orthodontics – O.P.Kharbhanda
Cleft lip and cleft palate – diagnosis and management 2nd edition – Samuel Berkowitz

64. Cleft lip and cleft palate – Seminars in Orthodontics – September 1996; Vol 2, No 3.
Pre surgical Naso alveolar molding treatment in cleft lip and palate patients – Barry H. Grayson, Indian J Plast Surg Supplement vol 42.
Indian J Plast Surg Supplement , vol 42.

65. External frame distraction of midface in cleft patients - Indian J Plast Surg
supplement Vol 42.
Velopharyngeal impairment in orthodontic population-
Seminars in Orthodontics – September 1996; Vol 2, No 3.
Alveolar grafting - Indian J Plast Surg 2009 vol 42 no 1
Hard palate repair timing and facial growth in cleft lip and palate : A systematic review - Yu-Fang Liao, Michael Mars . Cleft palate – Craniofacial Journal, September 2006, Vol 43, No 5.

66. Thank you