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

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

INTRODUCTION

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

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

ETIOLOGY Heredity Environmental Malnutrition Infections during pregnancy

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)

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

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

CLASSIFICATION Davis And Ritchie’s Classification -1922 Veau’s Classification - 1931 Fogh-anderson Classification - 1942 Schuchardt And Pfiefer’s Classification Kernahan And Stark Classification - 1958 Kernahan’s Striped Y Classification

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

VEAU’S CLASSIFICATION (1931)

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

KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971)

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

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

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

INTERNATIONALLY APPROVED CLASSIFICATION- 1967

DIAGNOSIS

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.

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.

MANAGEMENT TEAM

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

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

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

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.

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.

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

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.

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

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

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.

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

PALATE CLOSURE Objective: Join the cleft palatal edges, Lengthen the soft palate, The timing of closure is controversial. Can be done early at 12-18 months or at 9-12year Surgery and scarring shouldnot adversely affect the dentition and growth of the maxilla

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.

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."

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

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

Orthodontic Intervention During Mixed Dentition(7-12 yrs )

GOALS IN MIXED DENTITION Maxillary Expansion Alveolar Bone Graft Primary Secondary

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 - 2- 5 yrs Intermediate or secondary – 6- 13 yrs Late – after 13 yrs . Primary and early secondary are not in practice bec of additional surgery required.

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.

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

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.

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

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

Orthodontic management in permanent dentition stage

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.

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.

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)

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

DISTRACTION OSTEOGENESIS 1903 .- 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.

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

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

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

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.

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.

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

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 1 2009 vol 42. Indian J Plast Surg Supplement 1 2009, vol 42.

External frame distraction of midface in cleft patients - Indian J Plast Surg supplement 1 2009 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.

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