CLEFT LIP AND PALATE

DEPARTMENT OF ORTHODONTICS SWAMI DEVI DYAL DENTAL COLLEGE BY ANUBHA TIWARI INTERN

CLASSIFICATION OF CLEFT LIP AND PALATE

KERNAHAN AND STARK (1958)
A.CLEFTS OF PRIMARY PALATE ONLY 1. Unilateral v complete v incomplete 2. Median v complete(premaxilla absent) v incomplete(premaxilla rudimentary) 3. Bilateral v complete v incomplete

B. CLEFTS OF SECONDARY PALATE ONLY vComplete vIncomplete vSubmucosal C.CLEFTS OF PRIMARY AND SECONDARY PALATE 1.Unilateral vcomplete or incomplete 2.Median v complete or incomplete 3.Bilateral complete or incomplete

KERNAHANS STRIPED Y
1.BLOCK 1 AND 4 LIP

2.
3.BLOCK 2 AND 5 ALVEOLUS

4.
5.BLOCK 3 AND 6 HARD PALATE ANTERIOR TO INCISIVE FORAMEN

6.
7.BLOCK 7 AND 8 HARD PALATE POSTERIOR TO INCISIVE FORAMEN

8.
9.BLOCK 9 - SOFT PALATE

MILLARDS MODIFICATION
MILLARD added two triangles over the tip of the y to denote the nasal floor 1.BLOCK 1 AND 5 NASAL FLOOR 2.BLOCK 2 AND 6 LIP 3.BLOCK 3 AND 7 ALVEOLUS 4.BLOCK 4 AND 8 HARD PALATE ANTERIOR TO INCISIVE FORAMEN 5.BLOCK 9 AND 10 HARD PALATE POSTERIOR TO INCISIVE FORAMEN 6.BLOCK 11 - SOFT PALATE

LAHSHALS CLASSIFICATION
OKRIENS(1987) L - lip A - alveolus H - hard palate S - soft palate H - hard palate A - alveolus L lip

bilateral unilateral

Iowa Classification

DEVELOPMENT OF LIP

LOWER LIP

The mandibular process of the two sides grows towards each other and fuse in the midline. Fused mandibular process gives rise to lower lip and jaw.

UPPER LIP MAXILLARY PROCESS grows medially and fuses first with the lateral nasal process and then with the medial nasal process Medial and lateral nasal process also fuses with

 UPPER LIP: A.The mesodermal basis of the lateral part of the lip is formed from the maxillary process. B.The mesodermal basis of the median part of the lip is formed fromed FNP

DEVELOPMENT OF PALATE
From each MAXILLARY PROCESS a plate like shelf grows medially . This is called as PALATAL PROCESS. Basically there are three components from which the palate will be formed 1. the two palatal processes 2. the primitive palate formed from the frontonasal process

 The definitive palate is formed by fusion by: a.Each palatal process fuses with the posterior margin of the primitive palate. b.The two palatal processes fuse with each other in the midline. - their fusion begins anteriorly and proceeds Backwards c. The medial edges of the palatal processes fuse with the free lower edges of the nasal septum thus

 At a later stage the mesoderm in the palate undergoes intramembranous ossification to form the hard palate. Ossification does not extend into the most posterior portion which remains as the soft palate . The part of the palate derived from the frontonasal process forms the premaxilla which caries the incisor teeth.

PRIMARY PALATE
PALATAL development begins in week 5 but weeks 6-9 are most critical Formation of intermaxillary segment from merged MNP Primary palate forms from MNP Ossifies as premaxillary portion of the maxilla

 Lateral palatine process Ingrowth from maxillary process Eventually project horizontally above the tongue Fuse with each other ,primary palate, nasal septum Nasal septum Downgrowth of MNP Fusion of lateral palatine process starts anteriorly then moves back

 Hard palate Primary palate premaxilla Secondary palate maxillary process

Soft palate Unossified portion of the lateral palatine process

CLEFT LIP
DEFINATION Cleft lip occurs because of failure of fusion between the medial and lateral nasal processes and the maxillary process which occurs during 6th week of development.

Cleft Lip
Complete closure at 35 days postconception:
Lateral nasal, median nasal, and maxillary mesodermal processes merge.

Failure of closure can produce unilateral, bilateral, or median lip clefting. Left side unilateral cleft is the most common.

UNILATERAL

 Forms persistent labial groove Grooves should disappear as maxillary prominences fuse with merged medial nasal prominence. Stretching of epithelium causes tissue breakdown and cleft formation. SIMONARD BAND bridge of tissue spanning the cleft (arrow below)

BILATERAL
Similar Central soft tissue mass that moves freely

ANTERIOR CLEFT
Clefting of the alveolar process of the maxilla as well as lip. Complete cleft extends to the incisive foramen. Complete bilateral anterior cleft isolates the anterior and the posterior parts of the palate

POSTERIOR CLEFT
CLEFTS EXTENDING THROUGH BOTH SOFT AND HARD PALATE TO INCISIVE FORAMEN Isolates anterior and posterior parts of the palate Result from failure of the lateral palatine process to grow medially and fuse to each other

Etiology
Genes Control cell patterning, cell proliferation, extracellular communication, and differentiation Clefting usually represents a genetically complex event 2 to 20 genes are thought to interact to result in facial clefting

Etiology
TGF-beta-3 gene
Expressed just prior to palatal fusion. Results in isolated cleft palate.

IRF 6. Identified in -Autosomal dominant vander woude syndrome

Etiology
Dlx gene
Direct the destination of the distal skeletogenic mesenchyme elements to the palate. Mutations of these genes result in isolated palatal defects.

Sonic hedgehog gene

Protein that mediates ectodermal functions, might regulate the outgrowth and fusion of the facial domains.

TGF-alpha variant
Receptor ligand, usually a rare variant of TGF-alpha Family histories of cleft defects

Etiology
Cigarette smoking
Noted with mothers of children with facial clefting, both CL/P and CP. Teratogenesis has been attributed to hypoxia as well as a component of tobacco (cadmium).

Alcohol
Associated with an increased risk of fetal facial clefting. Alterations in cell membrane fluidity or reduced activity of specific enzymes such as superoxide dismutase.

Folate deficiency
Contributes to a range of birth defects. Evidence is emerging for a similar

Environmental agents
Several agents that are associated with an increased frequency of midfacial malformation. Medications phenytoin, sodium valproate, methotrexate. With corticosteroids there is no evidence of an increase in malformations.
Possible association could not be excluded

Prenatal Diagnosis
Diagnosed until the soft tissues of the fetal face can be clearly visualized sonographically (13 to 14 weeks). The majority of infants with cleft lip also have palatal involvement:
85% of bilateral cleft lips 70% associated with cleft palate. Cleft palate with an intact lip comprises 27% of isolated CL/P

Prenatal Diagnosis
The sensitivity is highest when is associated with other structural anomalies. Isolated CL/P in a low risk population, the sensitivity may only reach 50 percent. Cleft palate with an intact lip is the most difficult orofacial malformation to diagnose prenatally. Detected in only 13 of 198 cases in one large series. Three-dimensional ultrasound, can provide

Prenatal Diagnosis

PROBLEMS ASSOCIATED
FEEDING PSYCHOLOGICAL : Disfigurement caused by the condition causes psychological stress for the patient and the family

DENTAL: Clefts are associated underdeveloped maxilla 1.Multiple missing teeth 2.Mobile premaxilla 3.Impacted teeth

4. Supernumaries 5. Multiple decayed teeth 6. Periodontal complication

ESTHETIC : The patients with unrepaired clefts are badly disfigured due to the nature of the deformity

SPEECH AND HEARING: 1.Definitive speech problems 2.Are associated with infections of the middle ear

TREATMENT

Principles of Management
Assessment

Indications: restoring normal morphologic form and function Important for normal dentition, mastication, speech, hearing, and breathing Contraindications: malnutrition , anemia or other conditions that render infant unable to tolerate general anesthesia - airway obstruction , otitis media
Work-up

(1) Thorough PE to uncover any associated anomalies Additional work-up determined by physical findings that suggest involvement of other organ systems (2) Weight, oral intake, growth/development are of primary concern and must be followed closely (3) Routine lab studies generally not required ; Hgb level before Clinical Aspects of Cleft Lip/Palate surgery

Surgical Management
Cleft Lip and Palate
Multidisciplinary approach

Beyond lip repair are other issues: Hearing (otolaryngologists) Speech (speech pathologists) Dental (oromaxillofacial surgeons ,orthodontists ) Psychosocial
Integration with team-based approach

Each case is assessed independently by those involved and a global treatment plan is instituted based on present need in his/her development
Clinical Aspects of Cleft Lip/Palate

Surgical Management
S ta g i g a n d Ti i g o f S u rg e ry n m n
Different institutions = different practice

Cleft Lip
Rule of 10s

Cleft Palat
9-12 months of age

Hgb = 10g Weight of 10lbs Age 10wks

Clinical Aspects of Cleft Lip/Palate

Surgical Management
Unilateral Complete Cleft Lip
Goal: Symmetric shaped nostrils, nasal sill, and alar bases; well defined philtral dimple and ; natural appearing Cupids bow; functional muscle repair

Surgical Principle: Lengthen medial side of cleft so that it equals the vertical dimensions of noncleft side
Flap designs: 1) Triangular (Tennison-Randall) 2) Quadrangular 3) Rotation-advancement (Millard*, Mohler)

Millard Technique
Cut as you go technique Preserves cupids bow and philtral dimple Scar placed in more anatomically correct position along philtral column Tension of closure under the alar base; reduces flair and promotes better molding of the underlying alveolar processes
In simple medical student terms:

1) to

Medial flap rotates downward achieve necessary lengthening

2) Lateral flap advances into the defect produced by downward displacement of medial flap 3) Small pennant-shaped medial flap can be used to restore nostril
Clinical Aspects of Cleft Lip/Palate

Clinical Aspects of Cleft Lip/Palate

Post-op Management
Cleft Lip
1 ) Fe e d i g s a d m i i re d w i n n ste th ca th e te r ti syri g e fi d w i sm a l p n tte th l re d ru b b e r ca th e te r fo r th e fi 1 0 rst d a N i p lst a re 2 ) yspp o e s- o p a vo i e d to m i i i d n m ze stra i o n th e m u scl / ski su tu re s n e n 3) Velcro arm restraints to protect repair from flailing hands/fingers 4) Suture line care: cleansing with half strength peroxide followed with polymixin B-bacitracin ointment
Clinical Aspects of Cleft Lip/Palate

Orthodontic treatment:- performed at different stages of development.

Neonatal maxillary orthopaedics as an infant Orthodontic-orthopaedics in deciduous dentition. Orthodontics in the mixed dentition. Orthodontics alone or in conjunction with maxillofacial surgery (+/_distraction osteogenesis) in the permanent dentition. (Patients with cleft of lip only or soft palate only, defect Underhill not effect will Dr. Christine

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STAGE 1 (Neonatal Orthopaedics)

FROM BIRTH TO 24 MONTHS Performed on new born before surgical repair of lip. Rationale...realignment of the collapsed segments before surgery STRAPPING OF PREMAXILLA

First collapsed maxillary posterior segments must be expanded laterally and then pressure against premaxilla can be applied . This movement can be accomplished by light elastic strap

Definitely makes lip and anterior palate surgery easier at the time
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 Fabrication of a feeding plate or a obturator

OBTURATOR is a passive prosthetic appliance which aids in sucking Prevents maxillary arch from collapsing further

Pre surgical plates, moulding plates, feeding plates.

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Dr. Christine Underhill

Feeding plates to assist in early feeding

Obturator plate

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Dr. Christine Underhill

NAM NAM(nasoalveolar moulding) : Is a nonsurgical method of reshaping the gums lip and nostrils before cleft lip and palate surgery lessening the severity of the cleft .

To start NAM, parents work with an orthodontist. Within the first couple of weeks after birth, babies are fitted with a custom-made molding plate that looks like an orthodontic retainer. The device is attached with a small orthodontic rubberband that is taped to the baby's face.

Unlike some older techniques, the molding plate does not push or stretch the delicate tissues; it only helps gently direct the growth of the gums

 Adjustment of the molding plate is done by the orthodontist weekly or every other week depending on progress. Each appointment takes 40-60 minutes. Once the cleft gap in the gums is small enough (around one quarter-inch), a post is attached to the molding plate and is inserted in the nostril. This post is then slowly adjusted to lift up the nose and open the nostril. By the time of the surgery, the nose has been lifted and narrowed, the gap in the gums is smaller and the lips are closer together. A smaller gap means less tension when the surgeon closes the cleft.

NAM Nasoalveolar moulding

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Dr. Christine Underhill

STAGE 2 (FROM 24 MONTHS TO 6YRS)

ORTHODONTISTS basically observe Bring about changes in the obturator plate to incorporate the deciduous teeth CROSS BITES can be corrected at this stage

Orthodontic orthopaedic treatment in the deciduous dentition

STAGE 3 - (6 YRS TO 12 YEARS In vicinity of cleft alveolus .delayed eruption, malformation or absence of deciduous lateral incisor Unilateral or bilateral cross bites often present. soft tissue drape often disguises skeletal defect at this stage.
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ARCH EXPANSION Arch expansion can be done using a quad helix

Mixed dentitioncommon since event of alveolar bone grafts (ABG)

Requires careful assessment of problem, risks and benefits Timing of treatment closely related to timing of planed bone graft.. either before lateral incisor erupts (argued can effect maxillary growth), or before canine erupts When root of canine 1/3 to developed. Orthodontic treatment involves expansion to develop favourable arch form, alignment ..care not to move roots into cleft defect.. correct root angulation post grafting
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Repaired cleft palate in 8 year old

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Dr. Christine Underhill

Brackets to keep roots away from cleft

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Dr. Christine Underhill

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Dr. Christine Underhill

Alveolar bone grafting (ABG)

Provides continuity of alveolar ridge Provides bone for canine to erupt Osseous support for adjacent teeth Majority of canines erupt spontaneously others require surgical exposure often in combination with orthodontics. The erupting teeth often appear to then stimulate the formation of new alveolar bone
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Feedings
Infants with CL/P have few feeding problems. If the cleft involves the hard palate, the infant is usually not able to suck efficiently.
Experiment (special nipples or alternate feeding positions)

The infant should be held in a nearly sitting position during feeding

Prevents flowing to the back into the

Haberman Feeder
Activated by tongue and gum pressure. Milk cannot flow back. Replenished continuously as the baby feeds. Prevents the baby from being overwhelmed with milk. A gentle pumping action to the body of the nipple will increase flow.

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