protocol in management of Cleftlip and palate

Protocol in management of
cleft lip and palate
www.indiandentalacademy.com

Causes of cleft lip and palate
• Genetic or hereditary
Polygenic
Monogenic or syndromic
• Nutritional deficiency
• Vascular defects
• Mechanical disturbances
• Drugs and alcohol
• Infection
• Lack of inherent developmental forces

Syndromes associated with oro-facial cleft
• First arch syndrome
• Pierre robin syndrome
• Treacher collins syndrome
• Goldenhar’s syndrome
• Hemifacial microsomia
• Oro facial digital dysostosis
• Oculo dental digital syndrome
• Chromosomal anomalies
• Premature cranio synostosis
• Minor abnormalities of the oral cavity.

Classification of cleft lip and palate
• Classifications proposed by various
authors are
• Davis and Ritchie
• Veau
• Kernahan and Stark
• Hawkins and associates

• Classification of cleft
lip and palate
Lip
Lip and alveolus
Lip,alveolus,palate
Hard palate and soft palate
Soft palate
These are further
classified into unilateral or bilateral
cleft, complete or incomplete cleft.www.indiandentalacademy.com

• Cleft of the primary palate only
• Unilateral cleft
• Lip only involved
• Supplemental central or lateral incisor which erupt normally.
• Supplemental tooth have deep lingual invagination
• Radiograph are needed to decide on extraction.
• Cleft of the lip and alveolus
• Surgery is performed to close the lip and the alveolar cleft at 5
months of age to make the child more acceptable to the parent.
• Bilateral cleft of the primary palate
• Comprises 2%of all clefts
• One side is more affected than the other
• If both the sides have total clefts primary palate will protrude on
the face at birth.
CLINICAL
FEATURES
AND
TREATMENT
PLANNING

• Cleft of the secondary palate
• More common in girls than in boys(60:40)
• Consists of cleft of the soft palate and soft
plus hard palate extending forward to the
anterior palatine foramen.
• It is a median cleft
• Septum may be attached to either side of the
maxilla or detached.
• May vary in severity from bifid uvula to total
cleft
• Following palatal surgery the maxillary
retrusion may be accentuated producing class
III malocclusion.
CLINICAL
FEATURES
AND
TREATMENT
PLANNING

• Cleft of the primary and secondary palate
• Total unilateral
• Most commonest clefts comprising 40% of all clefts.
• They are complete unilateral clefts extending from the lip to the uvula
but involving only one side of the primary palate.
• Twice as common in boys compared to girls
• Twice as common on the left side than on the right side.
The base of the nose (ala base)is dragged laterally so that the nostril
has a flattened appearance.
• This appearance remains throughout life.
Features
• -the upper arch has a normal width with normal occlusion in the
posterior teeth.
• -sometimes it is unduly wide with the buccal segments in scissor bite.
• -there may be a collapse of the detached segment in the canine
region.
• Following surgery there is some collapse of the small segment while
the incisor and non cleft side may be in cross bite.
CLINICAL
FEATURES
AND
TREATMENT
PLANNING

Treatment protocol

• Treatment of cleft lip and palate involves a
multidisciplinary approach involving members
from various specialties.
• Primary members –present during every patient
visit
• Secondary members-come when specific need
arises
• Tertiary members-involved in diagnosis and
treatment planning. Do not visit a single session.

• Primary members
• Oral surgeon
• Orthodontist
• Speech therapy
• Pediatrician
Plastic surgeon
• Secondary members
• Genecist
• Ent specialist
• psycologist

• Treatment protocol is the timetable used
for scheduling certain treatment aspects.
• It must be a scientifically motivated,
judged and proven plan.
• All members must adhere strictly to the
treatment protocol.

Why do we need a treatment
protocol
• To treat infant, child or adolscent at the
optimal time.
• To treat infant, child or adolscent with
optimal surgical technique.
• To avoid uneccessary surgical or
orthodontic treatment.

Functional orthopedic
treatment and presurgical
phase

Treatment from birth to 2 weeks-
functional and pre-surgical phase
• Appliance used-suction and drinking plate
• It functions as an obturator.
• ALWAYS used in hard and soft palate cleft.
• SOMETIMES used in soft palate cleft when the mandible
is severely retrognathic.

Suction and drinking abnormalities occur in infants
with
-total soft palate cleft
-both hard and soft palate cleft
Infants who do no suffer from drinking
abnormalities are those with complete unilateral or
bilateral cleft of lip alveolus and palate.

Functional orthopedic movement
• Primary orthopedic movement means movement of the
alveolar or dento-alveolar segments closer to each other
before the first surgical intervention.
Why should primary orthopedic movement be done?
• To get individual segments perfectly aligned as possible.
• This results in optimal occlusal function after surgery.

Functional orthopedic movement
• Appliance used
• Functional orthognathic suction and drinking plate
• Function of the appliance
• -Initiates movement of the lateral alveolar segment
• -creates a temporary closure between the oral and nasal cavity.
• When is placed?
• Within the first 2 weeks of birth preferably first few hours after birth.
• At the age of 5-6 months the infant ejects the plate spontaneously
ejects the plate.
• Patient tolerance to the appliance
• Tolerates the appliance well
• Shows displeasure when the appliance is removed from the mouth.

Bilateral facial cleft deformity
Repositioning of premaxilla
• Active repositioning of premaxilla is needed in bilateral
cleft lip, alveolus and palate. Infants with bilateral facial
cleft have protruding premaxilla and prolabium.
Why does protrusion of premaxilla and prolabium occur?
• -Intrauterine projectile growth of nasal septum takes
place relocating the alveolar segment and the lip in an
anterior direction.
• Buccinator mechanism is defective.
• There is deficient growth of the columella.

• Appliance used
• A special strap with an elastic band positioned
on the upper lip is used to reposition the
prolabium and premaxilla in the normal position.

• Timing of treatment
• Treatment commences with a functional orthognathic suction and
drinking plate which includes prolabium premaxillary component.
• Infant is asked to wear it for 3 weeks to get adapted to the plate.
• After 3 weeks the premaxillary component of the the functional-
orthognathic suction plate is removed .
• Space is created in the anterior part of the palate for accomodation
of the premaxilla and lateral segment .Strap is inserted at the same
visit.
• Appliance is worn 4-6 weeks ,24 hours a day.
• Difficulties encountered
• 1.infant will object to the placement of constant pressure .
• 2.constant observation of infant is needed.
• 3.If partial stimulation occurs there will be hyperplasia of the nasal
septum.

Unilateral facial cleft deformity
• Premaxilla is rarely
extended anteriorly.
• Treatment of anterior
repositioning in unilateral
cleft
• A cheek sticker is
attached to the cheek.
Adhesive tape is placed
under tension from
sticker to sticker.

Unilateral facial cleft deformity
• Purpose of functional orthognathic suction
and drinking plate in unilateral cleft.
• 1.Achieve functional orthognathic
movement.
• 2. Achieve normal suction and drinking
pattern.
• 3.Discourage any abnormal habits.
• 4.to support parent psychologically.

Primary surgical repair of the
palate.

• Primary repair involves repair of
• Soft palate
• Hard palate
• Anterior nasal floor

• Soft plate cleft is repaired at the age of 5 months.
If soft and hard palate cleft only without lip and alveolus
• The surgery is done at the age of 7 months.
Complete unilateral cleft-5mm of hard palate is closed
surgically along with soft palate.
Complete bilateral cleft-one half of hard palate along with
soft palate on both sides is corrected.
Soft palate

• Surgical procedure for
soft palate cleft is an
intravelar veloplasty
• -it is a anatomical and
functional approach for
primary closure of soft
palate.
• -it involves careful
dissection of uvula,
palatopharygeous, levator
veli plati, tensor veli
palati.

Hard palate
• Surgical repair of hard palate cleft is done at the
age of 7 months followed by anterior nasal floor
reconstruction and cleft lip at the same visit.
• In bilateral cleft one half of the cleft palate is
repaired along with the soft palate at the age of
5 months and the other half is closed at the age
of 7 months.
• In very broad cleft >10mm without alveolar cleft
hard palate is closed between 12-18 months so
that considerable narrowing of the cleft occurs.

Anterior nasal floor
• Purpose of anterior
floor reconstruction.
1.Tight closure of the
dento-alveolar arches
inhibits formation of
oro-antral fistula.
2.Prevents collapse of
the dentoalveolar
arch alignment.

Primary surgical repair of the the lip
and nose

Primary surgical repair of the the lip and
nose involves
• Repair of unilateral cleft lip
• Repair of bilateral cleft lip
• Nasal deformity and its primary correction
including lengthening of the columella.

Repair of unilateral cleft lip
• Cleft lip and alveolus
is done at 7 months.
Cleft lip alone
is done at 5 months.
Repair of cleft lip is done last after repair of palate
and alveolus .
-to obtain tight seal.
-to prevent formation of oroantral fistula.

• Factors to be taken into during repair of
cleft lip
-aesthetic appearance of the lip
-function of the lip with muscle alignment
-long term midfacial growth disturbance.
-effect of closure of cleft lip on nasal
structures.

• Techniques of lip surgery
• Millard’s advanced rotational flap
• Lip plasty technique.
• Tennison method.
• Lip adhesion technique.
• Mirault blair technique

Primary surgical repair of the
bilateral cleft lip
• Done at the age of 7 months.
• A complete bilateral cleft lip has atrophic
columella.
• After surgical closure of the bilateral cleft
nasal floor is flatter than normal in the
antero-posterior dimension.
This flatness corrected at 12 months of age.

Correction of nasal deformity and
columella lengthening
• Severity of nasal cleft deformity depends on
-width of the cleft lip
-completeness of cleft lip.
Abnormal appearance of nose is due to rotated
nasal cartilage.
In unilateral cleft
- columella has an oblique slant .
- Nasal septum is not straight.
- Surgical procedure done at 7 months of age.

Columella lengthening
• Done in complete bilateral cleft lip.
• Done at 12 months of age.
• Alar-sill-columella procedure gives best
result.

Feeding in a child with cleft lip and
palate

Precautions to be taken
-Respiratory obstruction
-Middle ear disease.
-Maintaining satisfactory feeding regimen
Infant should be held at 30-45 degrees.
Mother should be asked to burp the child after each
feed because large quantites of air is swallowed.
Feeding bottles with special nipples are used.
Example is a mead’s nipple which is larger than a
normal nipple and has a larger orifice is used.

Speech –language therapy and
velopharyngeal incompetence.

Speech and language therapy and velopharyngeal
incompetence involves the following aspects
-speech language therapy
-velopharygeal insufficiency
-surgical repair of velopharygeal inadequacy.

Speech language therapy
Phonetic sounds are produced at the age of
4-6months.
Therefore cleft of soft palate
repaired at this age.
12months- three short words.
2years- half of all the words used at home.
4 years- majority of the words.
6-8 years- all words of the language.

• Evaluation of speech involves
Nasal emission
Nasal resonance
Phonation
Articulation
Speech language therapist treats the child
intensively for 6 months.

Velopharygeal incompetence
• Velopharygeal incompetence is sealing of
oral cavity from nasal cavity by means of
contact between soft palate and pharygeal
wall.
• Hypernasality-typical sign of
velopharygeal incompetence.

• Speech problem encountered in patient
with cleft is hypernasality.
• Method of examination
-fluoroscopy
-endoscopy

Fluoroscopy
Involves evaluation of the dynamics of the
velopharygeal valve during production of speech.
Can be recorded on normal radiograph or video
Lateral facial view shows movement of soft palate
and posterior pharynx.
PA view shows movement of the superior
constrictor.
Radio-opaque dye is coated over the nasal and oral
cavities for better visibility.

Relaxed state
Active statewww.indiandentalacademy.com

• Nasal endoscopy
• Useful in the examination
of the uvula.
• Gives indication of fine
closure
- between posterior
pharygeal wall and soft
palate.
-Soft palate and lateral wall
of pharyx.

Prosthodontic treatment for
velopharygeal inadequacy
• At the age of 3.5 to 5.5 the child is
referred to prosthodontist for placement of
speech bulb.
• If velopharygeal seal is established the
speech bulb is removed and
velopharygeal closure reassessed.
normal speech-no surgery
incompetency-surgery indicated.

Surgical repair of velopharygeal
incompetency.
• Placement of pharygeal flap between
posterior pharygeal wall and soft palate.
• Intensive speech language therapy is
needed post-surgically to correct
compensatory speech habits.
• Optimum age-3.5 years.

Oro nasal fistula

Oro nasal fistula
• Is a small opening between the oral cavity and
nasal cavity occuring after primary closure.
• Size of fistula determines type of closure and
timing of closure.
• Hairline oroantral fistula has no effect on
speech.
• For temporary closure of large fistula an
obturator is used.
• Permanent closure is by means of surgery

• Complication of oronasal fistula
-hypernasality
-food pushed into the nasal cavity

Location of oronasal fistula
Anterior nasal floor
and hard palate
In the hard palate
Junction of hard and soft
palate-common
Soft palate

• Surgical repair of
oronasal fistula is
done if
speech defect exists
at 4.5 years .
• If normal speech
in present closure
is done at
11±2years.

Orthodontic treatment

Orthodontic treatment
Done at four stages
• Infant-functional orthopedic treatment
• Mixed dentition-cross bite correction
• Permanent dentition-comprehensive
orthodontic treatment
• After growth-orthodontic treatment for
orthognathic deformity

Early orthodontic treatment
• This involves functional orthopedic treatment
• The aim is to align the lateral dentoalveolar
arches and the premaxilla.

Orthodontic treatment in the mixed
dentition.
Problems present
• Minor cross bites.
• Mandibular prognathism.
• Hypoplastic or duplicated decidous lateral
incisor.

Correction of anterior cross bite
-Normal overjet is obtained
-Reduction in pseudo class III tendency.
In bilateral cleft correction of anterior cross bite
-prevents abrasion of labial surface of teeth.
Orthopedic movement of premaxilla indicated.
Z spring or anterior expansion screw is used.

Orthodontic treatment in the
permanent dentition.
The problems in the early permanent
dentition are
• Delayed eruption of permanent teeth.
• Crowding
• Missing teeth
• Abnormal tooth formation
• Impacted and supernunerary teeth
• Posterior cross bite

• Aims of orthodontic treatment
• To relieve crowding
• Expansion of the buccal segment
• Alignment of teeth
• Correction of vertical discrepancies
• Closure of space
• Proper selection of appliance

Transverse discrepancies
• Posterior cross bite corrected with quad helix or
expansion screw.
• Retention-6months ,fulltime wear
Vertical discrepancies
• Correction of deep bite
• Extruding submerged premolar and molar
• Complete lack of vertical development –orthognathic
case
Anteroposterior discrepancies
• Mild malocclusion-reverse pull headgear
• Severe maxillary deficiency-presurgical orthodontics

Presurgical orthodontics
• Aims of fixed appliance therapy are
• Alignment of teeth
• Surgical planning of transverse and
vertical discrepancy.
• Surgical closure of cleft space whenever
possible.

Periosteoplasty and osteoplasty

• Periosteoplasty-surgical
procedure where the
periosteum is placed
over the alveolar cleft for
promotion of bone
induction in the area.
• Done at 7 years of age
when 2/3 of growth is
over.
• Results in bony fusion of
dentoalveolar segments.

• Osteoplasty-surgical procedure where bone is
transplanted into the cleft alveolus.
• Donor site -iliac crest, mandible,rib and calvaria
• Primary osteoplasty-during infancy
• Secondary osteoplasty-5-7years
• Late secondary osteoplasty-11±2years
• Tertiary osteoplasty-late adolescence
• Severe midfacial disturbance occurs during
primary and early secondary osteoplasty

Orthognathic surgery

Types of orthognathic deformities
• Lateral collapse of the dentoalveolar segment
• Retrognathism of the maxilla
• Apertognathism of the maxilla
• Vertical maxillary excess in patients with early
velopharygeal closure
• Compensatory mandibular prognathism.
• A combination of maxillary deficiency
and mandibular excess.

• Evaluation of a patient for orthognathic surgery involves
a clinical examination, cephalometric assessment and
study models.
• Various surgical procedures involved are
• Coticotomy
• Segmental osteotomy
• Le fort I osteotomy
• Le fort II osteotomy
• Mandibular orthognathic surgery
• Sagittal split partial ramus osteotomy
• Sagittal split full ramus osteotomy
• Anterior segmental osteotomy

Prosthodontic treatment
• Obturator
• Obturator is a artificial appliance which closes an
opening in the palate
• It differs from suction plate in that it is placed after
surgery to close existing oroantral fistula.
• May be placed at 4.5 yearsof age when speech
difficulties persist.
• Speech bulb
• It is given so that velopharygeal incompetence is
overcome and speech develop normally
• Given when surgical intervention for velopharygeal
insufficiency is not yet advisable..

• Palatal lift
• It is designed to elevate the soft palate when
temporary treatment of palatopharygeal
incompetency is required.
• The palatal lift is used until a child is able to
speak without hypernasality.
• Pharygeal speech aids
• They are manufactured for adolescent and
adults where there is insufficient tissue of the
soft palate or destruction of tissue.
•

• Removable prosthesis
• A partial denture is given in a patient with cleft of the lip,
alveolus and palate.
• It is given in the mixed dentition when the child has a
articulatory problem.
• Given after completion of main orthodontics to replace
missing teeth.
• Implants
• This depends on the amount of bone in the cleft area.
• Broad alveolar bone-submergible implant used.
• Narrow alveolar bone-non submergible implants.
• In cases of crestal bone loss alveolar reconstruction by
guided tissue regeneration is performed.

Fixed prosthodontics
• Four different types of prosthesis
• No tooth loss-porcelain veneer on an
abnormal lateral
• Maryland bridge-tooth missing in cleft
alveolus
• Crown on implant
• A fixed bridge to replace missing teeth in
the cleft area.

Revision surgery

• Revision surgery involves
• Lip scar revision
• Lip volume adjustment
• Revision of nasal deformity
revision surgery is done at the age
of 16 years when major cleft treatment
has been completed.

• Lip scar revision
• The following aspects are assessed
• The aesthetic appearance of the scar
• The type of cleft lip repair done
• The length of the lip on the repaired side.
• The orbicularis muscle reconstruction and
function
• The scar at the vermilion border.
• The concavity of the lip nasal floor junction.

• Lip volume adjustment
• Patient with bilateral cleft may have tight
upper lip which is thin and atrophic.
• Lip volume adjustment is done after
orthodontic and orthognathic surgery is
completed.
• Indicated in unbalanced lips.

• Revision of nasal deformity
• Unilateral nasal deformity
• Deformities of the nose which occur on the cleft side are
• Nasal tip deviation
• A posteriorly displaced alar cartilage
• Bending of the lateral part of the alar cartilage
• Obtuse angle between the medial and lateral angle of alar cartilage.
• Bilateral nasal deformity
• Short columella
• Wide columella
• Deviation of the alar cartilages
• Widened nasal sill with wide nostrils.

A happy moment in our life-if we
had the chance to bring about that
transformation
We do have a major role to play.www.indiandentalacademy.com

Thank you

protocol in management of Cleftlip and palate

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (16)

Ähnlich wie protocol in management of Cleftlip and palate

Ähnlich wie protocol in management of Cleftlip and palate (20)

Mehr von Indian dental academy

Mehr von Indian dental academy (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

protocol in management of Cleftlip and palate