ClEFT LIP AND PALATE / DENTAL COURSES

Habilitation of cleft lip
and palate patient
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Contents
History
Embryology
Etiology and pathogenesis
Incidence
Complications
Classification
Management

History
• Hippocrates (400 BC) and Galen (150
AD) mentioned cleft lip, but not cleft
palate.
• For centuries, perforations of palate
were considered secondary to syphilis
• Cleft palate recognized as a congenital
disorder in 1556, by Fanco.

History
• The first successful closure of a soft
palate defect was reported in 1764 by
LeMonnier, a French dentist.
• The first closure of the hard palate was
performed in 1834 by Dieffenbach.
• In the 1930's, Kilner and Wardill
independently developed the "pushback"
procedure.

Embryology
"It is not birth,
marriage, or
death, but
gastrulation, which
is truly the most
important time in
your life."

Lewis Wolpert
(1986)

Etiopathogenesis
• Clefts of lip and palate may be
isolated deformities or may be part
of a syndrome
• Non syndromic clefts are
multifactorial in origin

Drugs
Phenytoin
Maternal illness
smoking
Alcohol
Polygenic
inheritance
Genetic
predisposition
Non syndromic
clefts

Some of the more common syndromes
associated with CL/P
• Chromosomal
– Trisomy 13
– Trisomy 18
– Velocardiofacial
syndrome (22q11
deletion)
• Non-Mendelian
– Pierre Robin syndrome
– CHARGE association
– Goldenhar syndrome
• Teratogenic
– Fetal alcohol syndrome
– Fetal phenytoin syndrome
– Fetal valproate syndrome
• Mendelian disorders
– Ectrodactyly-eetodermal
dysplasia-clefting syndrome (AD)
– Gorlin syndrome (AD)
– Oto-palato-digital syndrome (XL)
– Oral-facial-digital syndrome (XL)
– Smith-Lemli-Opitz syndrome
(AR)
– Stickler syndrome (AD)
– Treacher Collins syndrome (AD)
– Van der Woude syndrome (AD)
• Unknown
– de Lange syndrome
– Kabuki syndrome

Incidence
• Best data given by Fogh-anderson 1943,
Jensen et al 1988 denmark, 1.45/1000
live births in 1942 to 1.89/1000 in 1981.
• Racial difference:
American Indians 3.7/ 1000
Japanese 2.7/1000
Maoris & Chinese 2.0/1000
Caucasians 1.7/1000
Blacks 0.4/1000 ( Vanderas 1987)www.indiandentalacademy.com

• Cl(P) male : female :: 2 : 1
• Unilateral cleft, right : left :: 1 : 2
• CP alone 1/500 live births, greater in females
• Cleft deformities of all races grouped
50% CL(P)
30 – 35 % CP
15 – 20 % CL alone
Incidence

Complications
• Apart from deficient esthetics, patients
with cleft palate may have the following
complications:
Abnormal midface development,
Velopharyngeal incompetence,
Speech defects, and
Abnormal eustachian tube function.

• Disturbances in function of mastication,
swallowing, speech, respiration & facial
expression
• Abnormal patterns of facial growth
Premaxilla protrusion
Medial position of maxillary segments
Reduced maxillary development
Apparently large mandible
Open gonial angle
Low tongue posture
Anterior open bitewww.indiandentalacademy.com

Classification
• Early attempts at classification by
 Davies & Ritchie in 1922
 Veau in 1931
• Fogh-Anderson in 1942 studied incidence of
CL(P) in Denmark
a. Hare lip including alveolus as far back as incisive
foramen
b. Hare lip & CP
c. Isolated clefts of palate as far forward as incisive
foramen

Kernahan and Stark's classification
of clefts (1958)
Clefts of primary palate only
• Unilateral (right or left)
– Complete
– Incomplete
• Median
– Complete (premaxilla absent)
– Incomplete (premaxilla
rudimentary)
• Bilateral
– Complete
– Incomplete
Clefts of secondary palate
only
– Complete
– Incomplete
– Submucous
Clefts of primary and
secondary palate
• Unilateral (right or left)
– Complete
– Incomplete
• Median
– Complete
– Incomplete
• Bilateral
– Complete
– Incomplete

Cleft lip and palate team
Social
worker
Pediatric
psychiatrist
Geneticist
Prosthodontist
Speech
pathologist
Orthodontist
Otolaryngologist
Pedodontist
Plastic
surgeon
Pediatrician
Team
approach

Role of prosthodontist in
CL(P) management
• Replacement of teeth and other missing
anatomic structures
• Stabilization of cleft maxillary segments
• Retention of tooth position
• Camouflage for inadequate treatment

Management
• Diagnosis
• Parent counselling
• Presurgical orthopedics
• Primary surgery
• Pedodontic and preventive care
• Speech development, assessment, early
intervention and treatment

Management
• Assessment and surgical management of
velopharyngeal incompetance
• Orthodontics
• Secondary surgery of lip, nose, palatal fistulae
• Alveolar bone grafting
• Orthognathic surgery
• Restorative dental treatment
• Management of treatment failures

Treatment timing
• Infancy – primary lip surgery,
primary palate closure
• Primary dentition
• Mixed dentition
• Adolescent
• Adults

Diagnosis and examination
• Intrauterine
- Sonographic diagnosis
- Karyotyping
• Post partum
- Clinical
- Radiographic (intra and extraoral,
cineradiography, laminography, pantography)
- Additional aids (speech and sound recording,
measurement of nasal and oral pressures,
psychiatric examination)

Prenatal, perinatal & postnatal
parental counselling
• Requisites
Accurate information should be given by an
expert in the field
Support must be available soon after diagnosis
Parents and members of family given
opportunity to express concern and emotional
response

Prenatal, perinatal & postnatal
parental counselling
Give a clear view of how the baby is likely to
look
Discussion on pregnancy termination based
on accurate information
Promote early adjustment and acceptance of
the baby by the parents and family
Long term dependence on counselor should
be avoided and normalization of family life
should be encouraged

Early feeding management
• The most immediate problem caused by a cleft lip
or palate is likely to be difficulty with feeding.
• Many babies with a cleft lip can breastfeed.
However, some have difficulty in forming a vacuum
in order to suck properly.
• Babies with these problems may need a special
teat and bottle that allows milk to be delivered to
the back of the throat where it can be swallowed.

Early feeding management
• A more upright feeding position controls nasal
regurgitation
• In infants with failure to thrive because of cardiac
problems, laryngospasm, gastric tube feeding is
adviced.
• Under these conditions small prosthesis to obturate
cleft is indicated to encourage oral feeding,
presently considered largely unhelpful.
• Babies who find it difficult to feed may gain weight
slowly at first, but have usually catch up by the time
they are six months old.

Pre surgical orthopedics
• Principal aim is
to realign the
bony elements
of the cleft to
provide a more
normal base for
surgery
Bulb held by bonnet straps

Pre surgical orthopedics
Di Biase appliance
Modified bulb without bonnet

Primary surgery
Clefts of primary palate
• Timing of surgery
Arbitrary criteria :
1. The child must be free of any systemic or
local disease
2. Child must have a minimum weight of 7 lb
3. The child must be in a weight gaining phase

Unilateral cleft lip
Le Mesurier
Tennison
Mirault
Millard

Bilateral cleft lip
– Bilateral Tennisons
approach (2 – stage)
First stage
Second stage

Secondary operations
– Residual unilateral / bilateral deformities
– Collumellar lift: Barsky, Modified Marcks
procedure
– Modified Erich procedure to create
symmetry of nose
– Lip shave operation
– Delayed bone grafting

Clefts of secondary
palate
• Surgical period
varies from
anywhere between
18 months to 4
years

• Position of
obtained maxillary
segments is not
lasting as dental
crossbite is
incidental as long
as bone continuity
in the upper arch is
not established
10 years 16 years
• Children with bilateral cleft ,
premaxilla is prominent at this age.
• Lateral incisors may be in the cleft
and must be preserved

• Parents must be instructed in preventive
dental practices
• Fistulae of palate or labial sulcus may be
present
• For palatal fistulae simple Hawley type
prosthesis may be delivered for speech
improvement
• Repositioning of cleft segments seldom
necessary before permanent incisors erupt

• Treatment should be designed to secure
optimal vertical height of maxilla, position
of teeth and arch form
• Lateral incisors are most commonly
missing
• Supernumerary teeth may be present
adjacent to cleft, their prognosis is
determined & extracted

• Premolar teeth when
absent complicates
development of an
adequate upper arch
• Appliances used to
reposition maxillary
segments
• Speech and hearing
evaluation
• Secondary revision of
lip, nose, palate
considered
Use of quad helix for
arch expansion

• Orthodontic treatment initiated to achieve
– Normal positioning of maxillary segments
– Adequate vertical development of maxilla
– Alignment of teeth for efficient occlusion
– Esthetics
– Positioning of teeth to permit conservative
prosthodontic replacement of missing teeth
• Orthodontist and prosthodontist must be in
consultation in later part of treatment

• When canine final positioning has been
attained, permanent stabilization of the arch
by establishing bone continuity considered
• Bone grafting accomplished safely at 14 – 16
years
– Inlay grafts
– Onlay grafts
– Combination
• Prosthdontic replacement of missing teeth
can be carried out

• Removable dentures given to maintain space
and esthetics
• Fixed prosthesis, implants planned in late
adolescence
• Final cosmetic revision of lip and nose may be
planned in late adolescence
• Considerations given for orthognathic
surgery to improve esthetics by correcting
skeletal malrelationship

Orthodontic correction

Bone grafting

Le Fort I osteotomy
Sagittal split ostoetomy
Genioplasty
Orthognathic surgery

• Some patients may not have received
optimum treatment and may require
removable prosthesis to camouflage
collapsed segments and reduced vertical
development of maxilla
• Use of pharyngeal obturator to aid speech
• Edentulous cleft patient represents a
failure in habilitation

Prosthodontic
rehabilitation

Indications of prosthesis
• In unoperated patients
– Wide cleft with deficient soft palate
– Wide cleft of hard palate
– Neuromuscular deficiency of soft palate and
pharynx
– Delayed surgery
– Expansion prosthesis to improve spatial
relationships
– Combined prosthesis and orthodontic appliance

• In operated patients
– An incompetant paltopharyngeal mechanism
– Surgical failures
• Contraindications for prosthesis
– Surgical repair is feasible
– Mentally retarded patient
– Uncooperative child and parents
– Rampant caries
– Lack of prosthodontic training or skill

Premaxilla Positioning Appliance
• In the case of a complete
bilateral cleft lip, the
premaxilla and prolabium
are protrusive and rotated
upward.
• This makes surgical repair
difficult because the clefts
may be wide and there
would be excessive tension
along the suture lines of
the surgically corrected lip.

Premaxilla Positioning
Appliance
• The premaxilla
positioning appliance
(Reisberg et al., 1988;
Figueroa et al., 1996)
is a nonsurgical
technique that
retracts and rotates
the malposed segment
to a more favorable
position for lip repair.

Nasal Conformer
• Surgical repair of a cleft lip can result in a
flattened contour of the nasal alar cartilage.
• Aside from the cosmetic deformity this presents,
it can also contribute to nasal airway obstruction.
• Often the patient must have a corrective surgical
procedure at a later age.
• Grayson et al. (1999) has described the use of a
nasal orthopedic molding appliance to minimize or
avoid this problem.

Articulation Development
Prosthesis
• Repair of a cleft palate is performed by 1 year of age
in order to minimize speech articulation abnormalities
(Dorf and Curtin, 1982).
• However, in some cases surgical repair must be
deferred. This may be due to an excessively wide
cleft or a compromising medical condition that
precludes surgery at that time.
• An articulation development prosthesis (Dorf et al.,
1985) is used to prosthetically create a normal palate
for speech development until the surgical repair can
be performed. www.indiandentalacademy.com

• This resin plate covers the gum pads and palate
area but does not extend into the cleft. This
design permits appositional growth at the cleft
margins.
• The prosthesis is retained with denture adhesive
and is worn continuously except for cleaning
several times a day.
• The prosthesis will not impede the eruption of
teeth, and if any teeth are already present, it can
be designed to circumvent them.

Palatal Obturator
• Even after cleft palate surgery residual oronasal
communication may occur on the palate or in the
alveolar ridge or labial vestibule.
• It usually does not cause a problem for feeding, but
speech may be affected.
• A palatal obturator covers the opening and contributes
to normal speech production.
• It eliminates hypernasality and assists speech therapy
for correction of compensatory articulations.

Palatal Obturator
• The prosthesis consists of a resin palatal plate with
retention clasps of stainless steel orthodontic wire.
• If any teeth are congenitally missing, they can be
attached to the plate to improve articulation and
appearance.
• This prosthesis is often used as an interim measure
until the residual communication can be surgically
closed.
• If the oronasal opening cannot be surgically repaired,
the palatal obturator may serve as a definitive
treatment.

Oronasal Fistula

Palatopharyngeal Obturator/
speech bulb
• Velopharyngeal insufficiency occurs when a cleft palate
is unrepaired or when a surgically repaired soft palate
is too short to make contact with the pharyngeal walls
during function.
• There is excessive nasal airflow and inadequate oral
pressure for normal speech.
• There may also be nasal regurgitation during feeding.
• A palatopharyngeal obturator provides velopharyngeal
closure and contributes to normal function.

Palatopharyngeal Obturator/
speech bulb
• The palatal portion of this resin plate covers the hard
palate and is attached to several teeth with wire
clasps. This serves to retain and stabilize the
prosthesis.
• The velar portion extends into the pharyngeal area at
the level of the palatal plane and seals the nasal cavity
from the oropharynx during function.
• This prosthesis is most often used as an interim device
until corrective surgery can be performed.
• It may serve as the definitive therapy when no further
surgery is planned.

Speech Bulb

Palatal Lift
• Velopharyngeal incompetency occurs when the
surgically repaired soft palate is of adequate
length but of inadequate mobility to elevate to
achieve velopharyngeal closure.
• A palatal lift prosthesis covers the hard palate and
extends posteriorly to engage the soft palate and
physically elevate and extend it to the proper
position to achieve closure

• This prosthesis is most effective when the soft palate has
little muscle tone and offers little resistance to elevation.
• Adequate retention must be achieved at the palatal
portion by clasping multiple teeth.
• A pharyngoplasty or pharyngeal flap surgical procedure
may correct this problem.

Palatal Lift

Tooth Replacement /
Restorative treatment
• Congenitally missing anterior teeth are common in cleft
patients.
• The lateral incisors are missing most often, but cuspids
and central incisors may also be affected.
• If not missing, these teeth may be malformed and
malposed.
• The bone support of teeth adjacent to the cleft is
usually compromised. In bilateral clefts, the bone
quality of the premaxilla is poor, which jeopardizes the
central incisors.

• Edentulous spaces in which
teeth are congenitally
missing can be closed
orthodontically or
surgically during an
orthognathic procedure.
• Then tooth replacement is
not necessary.
• Most commonly, the cuspid
is moved to the position at
which the lateral incisor
would be and the premolar
is moved to the cuspid
position.

• When edentulous cleft site is not closed
orthodontically or surgically, some type of
prosthetic treatment is required
• Options for tooth replacement
include
– a fixed or
– removable partial denture or
– a dental implant

Removable prosthesis
• A removable partial denture is most
often used as a temporary form of
tooth replacement.
• Although it can provide good esthetics,
portions of the prosthesis must rest on
soft tissues of the palate and can cause
irritation.

• There may be movement of the prosthesis
during function.
• The fact that it is removable accentuates
its artificial character, which is a common
objection from patients.
• It is used only as a definitive means of
tooth replacement, where multiple teeth are
missing and the edentulous space is too long
to be spanned by a fixed restoration.

in compromised
dentition
Precision attachments
Removable denture

Fixed prosthesis
• A fixed partial denture
attaches to teeth on each
side of the edentulous
space to provide a more
natural tooth replacement.
• If the abutment teeth
need no other restoration,
then a resin bonded fixed
partial denture can be
used.

• Alternatively, a
conventional fixed partial
denture can be used.
• Like the resin-bonded
prosthesis, function and
esthetics are excellent.
Long-term success is
more predictable.
• In patients where bone
grafting has not been
done a fixed removable
Andrews type of
restoration may be used

Dental implants
• If adequate volume of bone exists in
the edentulous space, tooth
replacement can be achieved using
dental implants.
• A titanium alloy analog of a tooth root is
surgically placed in the bone at the site
of the missing tooth.
• This can be placed in natural bone or at
a bone-grafted site.

• This restores the
dental arch to the
most natural state,
provides excellent
function and
appearance, and does
not require the
involvement of
adjacent natural teeth.
• Major limitation :
finding adequate bone
of good quality
particularly in the line
of cleft, bone grafting
improves success

General Dental Care

The Future of Prosthetics
• There are currently many exciting areas of
research that will impact on prosthetic
habilitation.
• In utero corrective surgery, the use of bone
morphogenic protein, and tissue and genetic
engineering will eventually play a significant
role in the care of the cleft/craniofacial
patient in general and on prosthodontics and
prosthetics in particular.

References
• Management of cleft lip and palate. Watson,
Sell and Grunwell
• Maxillofacial rehabilitation. Beumer, Curtis &
Fritell
• Maxillofacial prosthetics. Chalian VA, Drane
JB, Standish SM
• Cleft lip and palate. Grabb, Rosenstein and
Bzoch

References
• Doddamani S, Patil RA, Nerli S. Multidisciplinary
approach for improving esthetics in cleft palate
and alveolus patient: A clinical report. JIPS
2005; 5: 39 – 42
• Reisberg DJ. Dental and Prosthodontic Care for
Patients With Cleft or Craniofacial Conditions.
The Cleft Palate-Craniofacial Journal: Vol. 37,
No. 6, pp. 534–537.

References
• Abadi BJ, Johnson JD.
The prosthodontic management of cleft palate
patients.
J Prosthet Dent. 1982 Sep;48(3):297-302.
• Mazaheri M. Prosthodontics in cleft palate
treatment and research. J Prosthet Dent 1964;
14: 1146

References
• Immekus JE, Armany M. a fixed removable
partial denture for cleft palate patients. J
Prosthet Dent 1975; 34: 286
• Arcuri MR. Implant supported prosthesis for
treatment of adults with cleft palate. J

References
• Aram A, Subtelny JD. Velopharyngeal function
and cleft palate prosthesis. J Prosthet Dent
1959; 9: 149
• Dalston RM. Prosthodontic management of the
cleft palte patient: A speech pathologist’s view. J

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