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COMPREHENSIVE MANAGEMENT OF CLEFT LIP AND PALATE PATIENT BY A PEDODONTIST
 
 
EXPERTS INVOLVED BASIC CONFUSION
 
 
Heredity-  defect seems to run in families Environmental factors- teratogens like rubella virus, thalidomide
Syndromes associated with cleft lip and palate   ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Diagnosis
Parental Counseling At Birth
The photos of the treated patients  can be used for parents counseling
Feeding Advise
[object Object],[object Object]
Feeding by nasogastric tube
Feeding of cleft lip and palate patients Pigeon feeder  Haberman feeder Squeeze bottle
Feeding Spoon Feeding teats
Cleft Babies Should Be Kept In Upright Position For Feeding To Make Gravity Aid In Milk Feeding Fruit drinks, baby fruit juices and squashes have an erosive potential .
[object Object],[object Object],[object Object],[object Object],[object Object],OBTURATOR OBTURATORS
[object Object],[object Object],[object Object],Technique of fabrication of Obturators:
[object Object]
[object Object],[object Object],[object Object],Definitive impression.
[object Object],softened green stick compound is placed in the infants mouth and molded and allowed to set which will serve as the special tray. A handle is also molded at 45 0 Putty consistency addition silicone impression material ,[object Object]
Method  3 ,[object Object]
[object Object],[object Object],[object Object],Custom acrylic tray smoothened and polished
[object Object],Final Impression of BCLP infant in fast setting putty material.
The Pre Maxillary orthopedics  Naso Alveolar Molding
It is a modern presurgical  orthopedic device that allows for a positive  growth of alveolar ridges into a improved arch form   NAM is non surgical method of reshaping alveolus,  lip and nostrils before cleft lip and palate surgery, lessening the severity of cleft.  It is the passive method of bringing the gum and lip together by redirecting the forces of natural growth
[object Object],[object Object],In 1689, Hoffmann demonstrated the use of facial binding to  narrow the cleft and prevent postsurgical dehiscence. 
[object Object],[object Object],[object Object],A small opening measuring 6-8 mm in diameter is made on the palatal surface of the moulding plate to provide an airway in the event that the plate drops down posteriorly.
[object Object],[object Object],[object Object],[object Object],Materials  used ,[object Object]
[object Object],[object Object],[object Object]
Appliance insertion and taping ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Appliance Adjustments ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],If the appliance is lost or not worn the cleft gap that been closed early during the moulding therapy may widen  again as the infant places his or her tongue into the cleft.
Nostril horizontally oriented. ,[object Object],[object Object],Clinical features
 
The nasal stent  is delayed until the cleft of the alveolus is reduced to about  5-6 mm in width.  Incorporation of the nasal stent 
[object Object],[object Object],[object Object]
Advantages of performing NAM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
[object Object],[object Object],Non-surgical columella lengthening in bilateral cleft lip and palate
[object Object],In cases of bilateral cleft lip and palate,  premaxillary  segment may be positioned severely anterior to the maxillary arch if lip surgery is undertaken with the premaxilla in such an abnormal position, the chances of lip dehiscence by increased pressure at the suture lines are increased.
[object Object]
[object Object],This appliance is fitted over the protruding and laterally displaced premaxilla and anchored to the infant's head with a bonnet appliance.
[object Object]
LATHAM S APPLIANCE FOR PRESURGICAL REPOSITIONING OF THE PROTRUDED PREMAXILLA IN BILATERAL CLEFT LIP AND PALATE  The appliance is designed so that it could be secured to the palatal segments with stainless steel pins(pinning principle as described by Georgiade in 1970
[object Object],[object Object],Journal of Cranio-Maxillo-Facial Surgery 1992:20,99-110
[object Object],[object Object],[object Object],Emmy M Konst et al Cleft Palate-Craniofacial Journal,Jan 2004,41(1);71-77 CONTROVERSIES  OF INFANT ORTHOPAEDICS
 
SURGICAL REPAIR OF CLEFT LIP & PALATE
Palatoplasty
[object Object],[object Object],[object Object]
Timing of cleft palate repair
[object Object],[object Object],[object Object]
DENUDED BONE   The filling in of the denuded area  produces scar tissue, which exerts an initial  contracting force on adjacent tissues resulting in midfacial growth retardation and skeletal malocclusion hemorrhage, and hematoma formation, or contraction during healing, tends to pull the flaps away from the vault. The lowered, irregular vault impinges on the space available for the tongue and interferes with tongue posture and function. Effect of palate reconstruction on maxillary complex
[object Object],Non   cleft cleft 14 yrs 4 yrs
HEARING ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object]
A lateral cephalogram showing A: a low-draped soft palate and a wide opening in the velopharyngeal port, and  B: elevation of the soft palate by the palatal lift prosthesis.
Clinical Examination   ,[object Object],[object Object]
Tooth brushing ,[object Object]
[object Object],[object Object]
[object Object],BDJ 2000
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],MIXED DENTITION (6th  year to 11nth year.)
Orthodontic treatment  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Katsuhiro Minami et al  J Cleft palate craniofacial anomalies
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Quad helix appliance Rapid palatal expansion appliance
Expansion Screws Bonded Type Banded Type An acrylic splint with full occlusal coverage  bonded to expand (0.2mm/day) for one month has shown approximately 4.2mm expansion.
[object Object],[object Object],[object Object],[object Object],[object Object]
The children should be  instructed to wear the facemask a minimum of 12-14 hrs/day. Though the skeletal changes are limited, they produce marked improvements in the soft tissue profile Orthopedic  expansion and protraction of maxilla in cleft palate patients-a  new treatment rationale. Protraction using a Petit’s face mask orthopedically Moving the maxillary segments after expansion of the maxilla with an expander appliance, 450 grams per side  attached to the canines for 1.2 years.
3 months  of maxillary expansion increased arch width between first deciduous molars by 8 mm and was followed by protraction using the facial mask for 6 months. Post treatment retention period was for 1 year. Changes in 3months of expansion 8 months of protraction Changes in 1 yr retention
[object Object],[object Object],[object Object],[object Object],[object Object],Bull Tokyo dent Coll Nov 2002 Vol 43; 223 - 229
[object Object],Alveolar bone grafting
[object Object],[object Object],[object Object],[object Object]
Endosseous implant placement ,[object Object]
 
Length of implant ,[object Object],[object Object]
[object Object],Oral surg Oral Med Oral Pathol Oral Radiol Endod 2008
Distraction Osteogenesis ,[object Object],[object Object]
ADVANTAGES OF EXTERNAL DEVICES ,[object Object],[object Object],[object Object],George K. B  Sandor Oral Maxillofacial Surg Clin N Am 2005;17: 485-501 Osteotomy  Latency Distraction Consolidation and  Remodeling.
For class III occlusion  mandibular osteotomy is done after skeletal maturity(16 -18 yrs)  Preoperative and post operative orthodontic treatment is needed to achieve proper alignment, position and inclination of tooth
Psychological factors in cleft surgery Education and communication problems  Facial appearance and teacher perception.  Behavioral inhibition and lower school achievement. Speech defectiveness and self esteem.  Communication disorders are  more the result of psychological problems than phonological which influences the entire development of  an affected child. Anxiety and depression in adults with cleft lip and palate have been reported to be twice than normal controls. Odd one out
Psychological aspects Existing multispeciality care is primarily aimed at physical rehabilitation, psychological issues  often being neglected. Parents of children with clefts are more likely to spoil their child by being over protective.
Children of the lesser god?
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comprehensive management of a cleft lip and palate patient by a pedodontist

  • 1. COMPREHENSIVE MANAGEMENT OF CLEFT LIP AND PALATE PATIENT BY A PEDODONTIST
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  • 7. Heredity- defect seems to run in families Environmental factors- teratogens like rubella virus, thalidomide
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  • 13. The photos of the treated patients can be used for parents counseling
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  • 17. Feeding of cleft lip and palate patients Pigeon feeder Haberman feeder Squeeze bottle
  • 19. Cleft Babies Should Be Kept In Upright Position For Feeding To Make Gravity Aid In Milk Feeding Fruit drinks, baby fruit juices and squashes have an erosive potential .
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  • 28. The Pre Maxillary orthopedics Naso Alveolar Molding
  • 29. It is a modern presurgical orthopedic device that allows for a positive growth of alveolar ridges into a improved arch form NAM is non surgical method of reshaping alveolus, lip and nostrils before cleft lip and palate surgery, lessening the severity of cleft. It is the passive method of bringing the gum and lip together by redirecting the forces of natural growth
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  • 40. The nasal stent is delayed until the cleft of the alveolus is reduced to about 5-6 mm in width.  Incorporation of the nasal stent 
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  • 49. LATHAM S APPLIANCE FOR PRESURGICAL REPOSITIONING OF THE PROTRUDED PREMAXILLA IN BILATERAL CLEFT LIP AND PALATE The appliance is designed so that it could be secured to the palatal segments with stainless steel pins(pinning principle as described by Georgiade in 1970
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  • 53. SURGICAL REPAIR OF CLEFT LIP & PALATE
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  • 56. Timing of cleft palate repair
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  • 58. DENUDED BONE The filling in of the denuded area produces scar tissue, which exerts an initial contracting force on adjacent tissues resulting in midfacial growth retardation and skeletal malocclusion hemorrhage, and hematoma formation, or contraction during healing, tends to pull the flaps away from the vault. The lowered, irregular vault impinges on the space available for the tongue and interferes with tongue posture and function. Effect of palate reconstruction on maxillary complex
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  • 64. A lateral cephalogram showing A: a low-draped soft palate and a wide opening in the velopharyngeal port, and B: elevation of the soft palate by the palatal lift prosthesis.
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  • 73. Expansion Screws Bonded Type Banded Type An acrylic splint with full occlusal coverage bonded to expand (0.2mm/day) for one month has shown approximately 4.2mm expansion.
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  • 75. The children should be instructed to wear the facemask a minimum of 12-14 hrs/day. Though the skeletal changes are limited, they produce marked improvements in the soft tissue profile Orthopedic expansion and protraction of maxilla in cleft palate patients-a new treatment rationale. Protraction using a Petit’s face mask orthopedically Moving the maxillary segments after expansion of the maxilla with an expander appliance, 450 grams per side attached to the canines for 1.2 years.
  • 76. 3 months of maxillary expansion increased arch width between first deciduous molars by 8 mm and was followed by protraction using the facial mask for 6 months. Post treatment retention period was for 1 year. Changes in 3months of expansion 8 months of protraction Changes in 1 yr retention
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  • 86. For class III occlusion mandibular osteotomy is done after skeletal maturity(16 -18 yrs) Preoperative and post operative orthodontic treatment is needed to achieve proper alignment, position and inclination of tooth
  • 87. Psychological factors in cleft surgery Education and communication problems Facial appearance and teacher perception. Behavioral inhibition and lower school achievement. Speech defectiveness and self esteem. Communication disorders are more the result of psychological problems than phonological which influences the entire development of an affected child. Anxiety and depression in adults with cleft lip and palate have been reported to be twice than normal controls. Odd one out
  • 88. Psychological aspects Existing multispeciality care is primarily aimed at physical rehabilitation, psychological issues often being neglected. Parents of children with clefts are more likely to spoil their child by being over protective.
  • 89. Children of the lesser god?
  • 90. This is our domain