Cleft lip and palate management /certified fixed orthodontic courses by Indian dental academy

CLEFT LIP & PALATE MANAGEMENT

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Incidence
CLP- is a common congenital anomaly
Incidence- 1 in 600 births
C. Lip- m>f
C. Palate F>M
( since fusion of palatine shelves in F
takes one week longer than M)


Aetilogy
Multifactorial
1. Defective vascular supply in the area
involved
2. Mechanical disturbance- the size of the
tongue may prevent union of the parts
Circulating substanceDrugs( anti- epileptic), diazepam, alcohol


3. Viral infection in utero
4. Abnormal fetal position in Utero
5. X radiation in Utero
6. Familial inheritance in CLP
Cleft lip alone shows 20% family history
and palate 40%


6. Associated anomalies
Downs syndrome, Pierre Robin
Syndrome, Trecher Collins syndrome,
Goldenhar syndrome, hemifacial
microsomia.


Classification
Kernehan and Stark 1958
1. Clefts of the primary palate only
Unilateral, Complete/ incomplete
Median , Complete/ incomplete
Bilateral , Complete/ incomplete


2. Cleft of the secondary palate only
complete/incomplete/ submucous
3. Cleft of primary and secondary palate
Unilateral, Complete/ incomplete
Median , Complete/ incomplete
Bilateral , Complete/ incomplete


KRENS Classification
LASHAL
----AL
------al
-----S—
---HSH—
LASH---Incomplete- lowercase; * submucous
Complete upper case

Submucous cleft- overlying mucosa is
intact, 1 in 1200 births, 90 %
asymtomatic, speech, hearing and
feeding problems may present later.
Recognized by the presence of bifid
uvla, a central greyish translucent zone
in the soft palate midline, palpable
notch in the HP.

Clinical problems
1. Feeding- Oro nasal communication,
difficulty in suckling
2. Speech/ hearing-Normal speech
requires velopharyngeal competence
and normal hearing. Palate function is
impaired in the presence of a cleft,
preventing an oro nasal seal.

3. Conductive deafness- abnormal
attachments of tensor veli palatini into
post part of HP instead of mid palatine
raphae, inability to close and open
eustachian tube to equalize middle ear
pressure- poor middle ear drainage and
conductive deafness


4. Dental anomalies
Missing lateral and canine, SNT,
hypo plastic teeth, delayed/ abnormal
eruption, teeth of abnormal morphology
5. Malocclusion


6. Facial appearance and growthClass III jaw relation, adverse effects of
the palatal scarring on facial growth, in
particular down and forward growth of
maxilla.
7. Self image- esteem


Aims of treatment
1. Improved aesthetics- lip, nose
dentition, jaw relation
2. Good function- speech, hearing
occlusion, respiration
3. Permanence of result- preventive
dentistry, life long dental care, stability
of occlusion
4. Improved self image

CLEFT TEAM
OMS SURGEON
Plastic surgeon
ENT Surgeon
GDP/ GP
Orthodontist
Speech therapist
Psychologist

Geneticist
Cleft support Nurse
Dental Hygienist
Dental Technician
Multi disciplinary- team approach


Management
In Utero- Fetal ultra sound- 20 week IU
TOP or intervention in utero for the cleft
Neonatal- Feeding plates, Mead Johnson
bottle, Nuyke teat,Habberman teat.
Emergency counseling done by the cleft
support nurse,

Pre surgical orthopedics- strapping,
appliance
Improves alignment of arch segments,
aids feeding, better long term result,
reduces prominence of premaxilla


0 to 3 days

Counseling,
plate fitting,
pre surgical
orthopedics

3 months

Repair of lip

6 months to 18
months

6 months- soft
palate repair
15 to 18 months
-HP


4to 6 years

Secondary lip
surgery if
required
,pharyngoplasty

8 to 10 years

ABG to allow
ectopic incisor,
canine to erupt,
Lip revision

16 and above

OGS, lip repair,
Rhinoplasty,


Secondary surgery
Pharyngoplasty- 7 years to adult life
OGS
ABG
Rhinoplasty
Secondary lip surgery
Closure of fistula


Lip repair
3 months to 6 months
Millard rotational / advancement flap
1960
De Laires functional repair
(Cheilorhinoplasty)


Objectives of lip repair
1. To close defect,
2. Inconspicuous scar
3. Restore cupid bow
4. Close the nasal floor
5. Recreate the missing philtral line
6. Buccal sulcus to be deepened
7. To form normal rounded ala

Palate repair
2

stages- SP- 6 months
 HP 12 to 18 months
 Some say both HP and SP at 18 months
 Defer repair to older age decreases the
growth disturbance but poor speech,
greater psychological impact
 Von Langenbeck 1977 – midline repair
 Furlow- Z plasty 1986

Objectives of palate
repair
1. To produce a palate of adequate
length
2. To produce a palate sufficiently
mobile to allow closure of
velopharyngeal space
3. To produce a palate whose dorsal
surface conforms to the shape of the
pharyngeal wall

Speech therapy
Pre school
2 years of age – therapy starts to
identify VPI and lip function
5 years- videofluoroscopy,
nasendoscopy to objectively assess
and record palate function


Hearing problems
Pre school audiology
Recurrent middle ear infection due to
eustachian tube dysfunctionGROMMETS placed into middle ear to
drain out pus


Dental/ Orthodontic
Anterior Xbite correction
Buccal expansion prior to ABG
Fluoride and preventive dentistry
Continued dental care


Clinical standards
Advisory group -CSAG
74 surgeons in 45 centres
2/3 UK surgeons do less than 10 cases
a year
Poor results compared to EU centres
Recommended 8 to 15 centres


THANK YOU!
Leader in continuing dental education


Cleft lip and palate management /certified fixed orthodontic courses by Indian dental academy

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