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Cleft lip and palate - Introduction and Orthodontic Considerations
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Transcript of Cleft lip and palate - Introduction and Orthodontic Considerations
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Congenital abnormal space or gap in the upper lip, alveolus and palate
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More common in south far Asians: 1 in 500
Less frequent in Africans: 1 in 2000
Prevalence in Europeans and Americans: 1 in 750
Prevalence in Pakistan1: 1 in 523
1. Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A. Epidemiology of cleft lip and cleft palate in Pakistan. Otolaryngol Clin North Am. 2007 Feb; 40(1):27-60.
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Male to female ratio – 3 : 2
Cleft Lip and Palate are twice as common in
boys as in girls
Isolated Clefts of Palate are more common in
girls
75% of Clefts are Unilateral, rest are Bilateral
Left side is more frequently involved
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The medial nasal swellings enlarge, grow medially and merge with each other in the midline to form the intermaxillary segment
Human embryo: 7 weeks
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Kernahan “Striped Y”
Millard Modification of Kernahan “Striped Y”
Kriens “LAHSHAL”
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Kernahan “Striped Y”
Lip
Alveolus
Primary Palate
Hard Palate
Hard Palate
Soft Palate
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Millard Modification of Kernahan “Striped Y”
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Kriens “LAHSHAL” Capital letter = complete cleft Lowercase letter = incomplete cleft “.” or “-” = normal
Example: LA- - - - l = complete right cleft lip and alveolus,
incomplete left cleft lip
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Microform Cleft: May look like
a little dent in the red part of lip a scar from the lip up to nostril
Muscle tissue underneath cleft can be affected and may require surgery
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Submucous Cleft Palate: Midline deficiency or lack of muscular tissue Often a submucous cleft palate is associated
with a bifid or cleft uvulaPosterior nasal spine is almost always missingSpeech problems are common
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Transabdominal Ultrasonography :Reliable after 4th monthClefts of lipClefts of palate:
Sagittal View Axial View Coronal View
Transvaginal UltrasonographyThree-dimensional ultrasonography
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Advantages of Prenatal Diagnosis:
1. Time for parental education2. Time for parental psychological
preparation3. Preparation for neonatal care
and feeding4. Opportunity to investigate other
associated anomalies5. Gives parents the choice of
continuing the pregnancy6. Opportunity for fetal surgery
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8-9 Year: Initial interventional
Orthodontics Preparation for
alveolar bone grafting10 Year:
Alveolar Bone Grafts12-14 Year:
Definite Orthodontics16 Year:
Nasal Revision Surgery17-20 Year:
Orthognathic Surgery
Birth: Initial Assessment Pre-surgical assessment
3 Month: Primary Lip repair
9-18 month: Palate Repair
2 Year: Speech assessment
3-5 Year: Lip Revision Surgery
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Genetic Scientist Pediatrician Pedodontist Orthodontist Oral and Maxillofacial Surgeon Prosthodontist ENT Surgeon Plastic Surgeon Psychiatrist Speech Therapist Social Worker
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Feeding
Dental problems
Nasal Deformity and Esthetic Problems
Ear Problems
Speech Difficulties
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Cleft lip Makes it more difficult for an infant to suck
Cleft Palate May cause milk to be accidently taken up into
nasal cavity Inability to create negative pressure inside oral
cavity Frequent regurgitations Upper respiratory tract infections
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In Patient with Cleft lip Special nipples to allow baby to latch properly
Mead Johnson/Enfamil Cleft Feeder
Pigeon Feeder Dr. Brown’s Natural Flow
Special Needs Feeder / Haberman Feeder
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In patients with cleft palate
Avoid feeding without palatal obturator
Feeding in an upright position
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Local Dental Problems: Congenitally Missing teeth (Hypodontia, Oligodontia) Hyperdontia Presence of natal and neonatal teeth Abnormal tooth morphology (microdontia, macrodontia ) Fused teeth Enamel Hypoplasia Gemination, Dilacerations Poor periodontal support
Orthodontics Problems: Class III tendency Anterior and Posterior Cross bite Spacing and crowding
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Facial Disfigurements
Poor nasal shape
Scar marks of surgeries
Poor lip function during
speech
Poor dental alignment and
smile
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Middle ear disease - 22% to 88% Conductive hearing loss and chronic
suppurative otitis mediaRepeated tympanostomy tube placement
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Abnormal curvature of eustachian tube lumen
Altered width and angulation of skull base
Abnormal insertions of the tensor and levator veli
palatini muscles into cartilages and skull base
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96% of children require tympanostomy tube placement1
50% of these children required repeat tympanostomy tube placement 1
Frequency of otitis media decreases as the child with CP ages
Audiology and tympanometry as well as exams / clinical history
1Muntz HR, An overview of middle ear disease in cleft palate children, Facial Plast Surg. 9 (1993) 177-180.
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Hearing loss hampers proper development of speech
Velopharyngeal Insufficiency (VPI)Poor pronunciation of Bilabial, Labiodental,
Linguoalveolar sounds
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Maxillary StrappingNasoalveolar Moulding Appliances (NAM)
Advantages:1. Reduces the size of cleft; aids in surgery2. Partial obturation aids in feeding3. Parental reassurance at a crucial time
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Indications of NAMs:1. Large lip defect requiring presurgical
approximatiom2. Severe deviations in nasal cartilages columella,
nasal tip, and lateral wall3. Post surgical nasal molding and tension
reduction across suture line
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Premaxilla is extremely protrusive
Premaxilla and prolabium can be of variable size
Columella is deficient/almost nonexistent
Palatal shelves are collapsed
Bilateral Cleft Lip
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Bilateral Cleft Lip Repositioning of protrusive
maxilla Support from intraoral
component Retention with
Denture adhesive Elastic strap
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• Time of surgery: approximately at10 weeks “Rule of Ten”
Child weighs 10 pounds Child has a hemoglobin of at least 10 grams/dl Child has a WBC count < 10 thousand Child is at least 10 weeks of age
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Cleft Lip Repair Unilateral
Millards’s rotation-advancement flap
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Cleft Lip Repair Bilateral
bilateral rotation advancement with attachment to premaxilla mucosa
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Dorf and Curtin1
10% occurrence of articulation errors when palatoplasty was completed by 1 year
86% incidence of articulation errors when repair was complete after 1 year
Haapanen and Rantala2
Significantly fewer children in the groups repaired before 18 months had hypernasal speech, articulation errors, or required secondary surgery to correct speech
1. Dorf DS, JW Curtin: Early cleft palate repair and speech outcome: A ten year experience. J Bardach HL Morris Multidisciplinary Management of Cleft Lip and Palate. 1990 WB Saunders Philadelphia 341-348.
2. Haapanen ML, Rantala SL. Correlation between the age at repair and speech outcome in patients with isolated cleft palate. Scand J Plast Reconstr Surg Hand Surg. 1992;26(1):71-8.
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1. Schweckendick’s Primary Veloplasty
2. Von Langenbeck Palatal Repair
3. V-Y Pushback
4. Furlow Palatoplasty
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1. Schweckendick’s Primary Veloplasty Incisions made in soft palate Muscle bundles released from posterior hard
palate and rotated Reconstruction of levator sling Closure of mucosal layers separately
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2. Von Langenbeck Operation
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V-Y Pushback (WARDILL OPERATION) Two uni-pedicled flaps (greater palatine artery)
raised Posterior flaps rotated in a V-Y advancement Improved speech results Indicated for incomplete clefts
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V-Y Pushback (WARDILL OPERATION)
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Furlow Palatoplasty Lengthens soft palate Reconstructs the muscle sling Used to correct velopharyngeal insufficiency Can be used for treatment of submucous clefts
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Aim: Prepare the dentition adjacent to cleft for the secondary alveolar bone graft
Avarge Duration: 6-12 months Appliances:
1. Bonded edgewise appliance2. Supported with a maxillary expander quad
helix expander
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Use of Quadhelix to expand maxillary arch
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Use of Spider appliance to expand maxillary arch
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Use of bonded edgewise appliance
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Primary Bone Grafting
1. Bone graft done at the time of primary cheiloplasty
2. Bone graft done during the first 2 years of life
3. Bone graft done prior to the eruption of the primary canine
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Secondary Bone GraftingDone before eruption of the permanent canine
In CLP dental age lags behind chronological age
Early bone graft: 2-5 years of age Intermediate bone graff: 6-15 years of age Late bone graph: 16 year and older
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Advantages:1. Provides bone for eruption and orthodontic
repositioning of teeth2. Closure of oro-nasal fistulas3. Support and elevation of alar base4. Stabilization of pre-maxilla in bilateral cases5. Establishing continuity of alveolar ridge
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Autogenous Cancellous- iliac crest Cortical- calvarium, mandible Cortico-cancellous- iliac, rib, tibia, mandible
Allogeneic1
Graft resorbs, remodels, may contribute to osteoinduction and osteoconduction
Alloplast2
Bone grows into, around alloplast No active osteoinduction but some osteoconduction Teeth do not erupt through alloplast
1. Nique T, Fonseca RJ, et al: Particulate allogeneic bone grafts into maxillary alveolar clefts in humans- A preliminary report. J Oral Maxillofac Surg 45: 386-392, 1987.2. Horswell BB, El Deeb M: Nonporous HA in the repair of alveolar cleft defect in a primate model. J Oral Maxiilofac Surg 47:946-952, 1989.
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Preoperative Post Operative
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Preoperative Cleft Defect
Postoperative Bone Graft
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• Correction of anterior crossbite
• Arch expansion• Stability of results is
questionable• Slower results as
compared to normal subjects
Face mask therapy:
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Late mandibular growth may aggravate problems
Hypernasality may increaseDefinitive dental prosthesis may be plannedTreatment planning
Mild skeletal discrepancy: Dental compensations Moderate skeletal discrepancy: Orthognathic surgery Severe skeletal discrepancy: Distraction osteogenesis
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Lefort I maxillary advancement Relapse after rigid fixation1
Mean maxillary horizontal relapse of 20.5% Mean vertical relapse of 22.2% within first year
Velopharyngeal insufficiency
1. Heliövaara A, Ranta R, Hukki J, Rintala A. Skeletal stability of Le fort I osteotomy in patients with unilateral cleft lip and palate. Scand J Plast Reconstr Surg Hand Surg 2001;35:43-49.
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Maxillary advancement with distraction Osteogenesis
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Midfacial Advancement Pretreatment Decompensation
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Maxillary advancement with intraoral distractor
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Pretreatment Postreatment
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Maxillary advancement with Extraoral distractor
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Patients with a cleft lip and palate require Patients with a cleft lip and palate require highest standard of highest standard of multidisciplinary care multidisciplinary care
Management starts pre-natally after initial Management starts pre-natally after initial diagnosis, followed by a long treatment aiming diagnosis, followed by a long treatment aiming at restoration of oral health and function while at restoration of oral health and function while achieving optimum estheticsachieving optimum esthetics
Right intervention at right time Right intervention at right time can significantly can significantly improve the quality of lifeimprove the quality of life
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Timing: 17-20 years of age
Standard techniques Tip projection Alar rotation Columellar lengthening
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Goals of Surgery
1. Reducing the size of opening between oral and nasal cavities
2. Reconnecting palatal muscles to restore function
3. Restore the anatomical length of soft palate
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Dorrance and Brown’s – U shaped push back palatoplasty
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Use of Pharyngeal flap
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Posterior pharyngeal wall augmentation with implants and injections
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