Treatment of the new-born with Cleft Lip and Palate.

(PSO)
There are several forms of orofacial cleft, yet the incidence varies considerably
among races and the type of cleft.
Approximately one out of 700 children born with orofacial cleft in Indonesia.
Cleft lip is higher among males. Cleft palate is common in female.
The majority of cleft is unilateral, but in 1020% of all newborn children with a
cleft
the deformity is bilateral which implications for growth and nal
development of the facial skeleton and dentition are greater.
Cleft lip with
Cleft palate
Cleft lip

palate

45%
30%
25%

From the data estimated that half of all Indonesian babies

with cleft palate will die from feeding problems.
Orofacial problems

what

dentist

can

do

born

each

year

After delivery -> Paediatricians detections -> orofacial anomaly -> Paediatric
dentist.
Complicated work & long term -> multi diciplines team works.

At birth the observed width of the cleft is a combinatio of :

the primary cleft malformation and
the secondary deformity
in which the cleft segments are displaced by the unbalanced pull of the
discontinues facial muscular and the wedging eect upward of the tongue in the
cleft -> producing upward and outward displacement of the cleft segmen ->
displacement of the skeletal base.
The displacement of the skeletal base which will complicated later surgical
management.
Although the soft tissues can usually be mobilized and advanced to allow closure
of these wide cleft the underlying skeletal elements are inherently unstable.

Classification
There are various classication systems available in the Veaus classication of
cleft lip and palate.

Cleft Management
Some Babies with Veaus Class 1 and 2, there is communication between nasal
and oral
cavities, but still can feed normally, depend on the cleft severity.

Proper positioning of the baby while feeding is important by cradle the baby in
the mothers arm in a semi-sitting posture with the infant body upright and tilted
slightly backward.

Some have diculties while feeding as the uid tends to ow out of the nose.
Encourage breast feeding or if not possible -> boile feeding.

Babies with Veaus Class 3 and 4, feeding is more dicult. When there
is unilateral cleft, due to muscle pull, the major segment is pulled towards the
non cleft side, in the bilateral clefts,
the premaxilla portion moves labially and
becomes everted.
So if an opposing and a shearing force are applied, the distortion can be
minimized and the major and minor segments can be pulled together. This will
make the task of the plastic surgeon easier.
The construction of a simple intraoral appliance on series of corrected models
modied progressively toward normality.
The function is to mould the deformed arch into correct anatomical alignment.
This treatment begins afer birth as soon as possible.
The Main Aim of PSO
1. Normalizing oral function in regard to feeding, swallowing
and
tongue
posture.
2. Re-approximating grossly divergent maxillary segments to facilitate primary
repair.

3. To reduce the secondary deformity of the cleft in the newborn by molding the
displaced
segment into a more normal alignment, prior to lip repair and nasal
reconstruction.
Impression Taking
An impression should be taken of the upper dental arch using a fast setting
alginate using a suitable
tray or a preliminary impression can be with a low
fusing compound wax supported on the operators nger -> poured in dental
stone +2% potassium sulphate solution under vacuum mixing -> to produce
a set cast in 2-3 minutes -> then an acrylic special tray can be fabricated.
The special tray should be extensively perforated to retain alginate.
The tray should be tried in, and if necessary be modied with periphery wax
and tray adhesive.
The cleft should be carefully inspected for any deep undercuts or area where
alginate may become lodged during impression taking. Such area may be
blocked out using ribbon gauze.
The baby should in fully active protective reexes positions during the
impression procedure. Neither sedative or GA required for impressio taking in
neonates.
The baby should be rmly wrapped in a towel and placed on procedure table or
the dental chair.
All equipment should be set out, turned on, tested, and ready to use. Essential
equipment included:
Surgical suction
Oxygen with a neonatal resuscitation bag and mask, infant laryngoscope,
college tweezers, small dental mirror and good lightning.
The alginate should be mixed with an increase powder to liquid ratio to
decrease excessive ow and to speed the setting.
When the alginate is mixed, it is loaded into the tray and smoothed under
running water. The tray is then seated while the baby is in supine.The babys
mandible should be supported
to maintain a clean airway during
impression taking.
Crying is evidence that the baby is maintaining a patent airway.
When the alginate has fully set, the baby should be rotated onto its side, and
the tray carefully removed.
The anterior portion of the tray should be dropped in an arch inferiorly and
posteriorly, then gently withdrawn.
The whole procedure should take less than one minute.
Once the tray has been seated, no matter what happens, no attempt should
be mad to remove the tray until the alginate has set.
If the tray is withdrawn before the alginate has fully set, the impression
material will fragment and become an airway hazard.
Immediately after withdrawal of the impression, the babys mouth should be
carefully and thoroughly checked for fragments of impression using
the
laryngoscope and suction.
Once the mouth is free of obvious alginate fragments and the baby is
breathing comfortably, the
impression should be checked for any tears
which indicate where fragments of materials may have been left in the mouth.
Model Preparation

Conclusion
Pre-Surgical Orthopedics should be used where indicated. A reported benet of
PSO:
In feeding, improved sucking,
Reduced nasal regurgitation,
Elimination of naso-gastric tubefeeding,
Reduced feeding time,
Facilitate easier surgical repair of the defect.