DEPARTMENT OF DEPARTMENT OF PAEDIATRIC DENTISTRYPAEDIATRIC DENTISTRY

SEMINAR OF CLEFT SEMINAR OF CLEFT MANAGEMENTMANAGEMENT

CONTENTSCONTENTS Prenatal Diagnosis. Prenatal Diagnosis. Protocol For Dental Care. Protocol For Dental Care. A Multi- Disciplinary Team.A Multi- Disciplinary Team. Management Management Dentofacial OrthopedicsDentofacial Orthopedics Management of cleft Lip & Nasal Deformity.Management of cleft Lip & Nasal Deformity. Cleft Palate Repair. Cleft Palate Repair. Orthodontic Treatment. Orthodontic Treatment. Role of E.N.T. Specialist, Speech Pathologist.Role of E.N.T. Specialist, Speech Pathologist. Correction of Maxillary Hypoplasia Correction of Maxillary Hypoplasia Correction of Enamel Hypoplasia. Correction of Enamel Hypoplasia. Role of Prosthodontics Role of Prosthodontics Role of Psychologist Role of Psychologist

PRENATAL DIAGNOSIS AND COUNSELING

• Intrauterine diagnosis of orofacial clefts is possible by ultrasonography.

• Complete clefts are seen easily at 16 weeks gestation.

• Incomplete clefts are seen more readily at 27 weeks.

• Palatal clefts are difficult to visualize by prenatal ultra sonography.

• The family or obstetrician may request prenatal consultation with a surgeon.

Protocol For Dental Care of Cleft Lip and Palate in Children

At Birth At Birth • Predental treatment is provided which comprises feeding Predental treatment is provided which comprises feeding

plate, pre surgical orthopedics and helps surgeon in repair plate, pre surgical orthopedics and helps surgeon in repair by stimulating palatal bone growth and preventing collapse by stimulating palatal bone growth and preventing collapse of dental arches. of dental arches.

3-5 Month. 3-5 Month. • Alignment of the primary teeth and palatal expansion to be Alignment of the primary teeth and palatal expansion to be

started using a simple fixed appliance like warch & Arnold started using a simple fixed appliance like warch & Arnold expander plastic surgeon to repair the lip. expander plastic surgeon to repair the lip.

• Suction myringotomy for “Glue ear” Suction myringotomy for “Glue ear” 12 Months.12 Months.

• Pedodontic review palatal pro sthetic speech. Pedodontic review palatal pro sthetic speech. Appliance may by required to correct velo Appliance may by required to correct velo pharygeal incompetence.pharygeal incompetence.

• Plastic surgeon to repair the cleft palate. Plastic surgeon to repair the cleft palate.

2-6 Years. 2-6 Years. • Pedodontic showed review facial growth and development Pedodontic showed review facial growth and development

with regular monitoring one year interval.with regular monitoring one year interval.• Preventive measures for caries like fissure, sealing, fluoride. Preventive measures for caries like fissure, sealing, fluoride. • Restorative Restorative

6-7 years. 6-7 years. • Removal of super numerary teeth, correction of cross bite. Removal of super numerary teeth, correction of cross bite. • Orthodontic consultation.Orthodontic consultation.

8-9 years.8-9 years.• Suitability about bone grafting. Suitability about bone grafting. • Dental bone assessment (OPG, wrist, lateral cephalogram,.Dental bone assessment (OPG, wrist, lateral cephalogram,.• Review by the plastic surgeon, speech pathologist & ENT Review by the plastic surgeon, speech pathologist & ENT

surgeon. surgeon. • If needed to relieve crowding and retroclination of the anterior If needed to relieve crowding and retroclination of the anterior

teeth. teeth.

9 years.9 years.• Combined orthodontist and pedodontist Combined orthodontist and pedodontist

coalescence. coalescence. • Bone graft alveolar cleft at half to 1/3 root Bone graft alveolar cleft at half to 1/3 root

development of permanent cuspid. development of permanent cuspid. 10-12 years.10-12 years.

• Orthodontic consultation Orthodontic consultation • Monitoring changing dentition and growth.Monitoring changing dentition and growth.

12-15 years.12-15 years.• Orthodontic treatment. Orthodontic treatment. • Speech pathologist to review changing of Speech pathologist to review changing of

the pitch of voice in boys. the pitch of voice in boys.

A Multi-Disciplinary Team for Cleft A Multi-Disciplinary Team for Cleft Lip and Palate Patients.Lip and Palate Patients.

ObstetricianObstetrician = = Refers the child to plastic surgeon Refers the child to plastic surgeon and pediatrician for expert opinion counseling the and pediatrician for expert opinion counseling the parents.parents.

Pediatrician or Neonatology'sPediatrician or Neonatology's==Provide medical Provide medical care refers the case to the plastic surgeon. care refers the case to the plastic surgeon.

Plastic Surgeon:-Plastic Surgeon:-Carries out initial lip repair Carries out initial lip repair and palate surgery – performs pharyngoplasty or and palate surgery – performs pharyngoplasty or reversionary lip & nose surgery.reversionary lip & nose surgery.

Oromaxillofacial SurgeonOromaxillofacial Surgeon== Usually comes in the Usually comes in the picture of bone grafting – if any final orthopedic picture of bone grafting – if any final orthopedic surgery is performed at later stage. surgery is performed at later stage.

NeurosurgeonNeurosurgeon== any craniofacial syndrome is any craniofacial syndrome is associated.associated.

Pedodontist=Pedodontist= A key member who sees the baby and the parent at A key member who sees the baby and the parent at

the time of repair of the lip. the time of repair of the lip. Provides pre surgical orthopedic treatment for the Provides pre surgical orthopedic treatment for the

baby.baby. Pedodontist monitor the growth and development.Pedodontist monitor the growth and development. To maintain perfect oral health. To maintain perfect oral health. To guide the occlusion and facial growth. To guide the occlusion and facial growth. Motivates the parent & the child to cooperate with Motivates the parent & the child to cooperate with

the treatment. the treatment. Orthodontist:Orthodontist: Carries out definitive orthodontic Carries out definitive orthodontic

treatment once the full permanent dentition is treatment once the full permanent dentition is

erupted. erupted.

Speech pathologist: =Speech pathologist: = • Monitors the speech development to normal. Monitors the speech development to normal. • Test for an adequate palato pharyngeal closure and guiding Test for an adequate palato pharyngeal closure and guiding

the surgeon as to whether a pharyngeal flap may be the surgeon as to whether a pharyngeal flap may be necessary. necessary.

Audiologist:-Audiologist:- To test hearing in the baby To test hearing in the baby infants & the young child providing essential infants & the young child providing essential information in hearing loss for both speech information in hearing loss for both speech patholigist and otolarynologist. patholigist and otolarynologist.

OtolarynologistOtolarynologist:: Concerns with the health of Concerns with the health of nasopharyngeal tissues including tonsils, adenoids nasopharyngeal tissues including tonsils, adenoids and middle ear structures. and middle ear structures.

Blockage of the auditory canal and gluteneous Blockage of the auditory canal and gluteneous secretion (glue ear) is very common in these disease. secretion (glue ear) is very common in these disease.

Psychologist:Psychologist: Plays on important role when the Plays on important role when the child’s family is under stress. child’s family is under stress.

MANAGEMENT:MANAGEMENT: Infancy:Infancy:General ConsiderationGeneral Consideration:-:- Patients with C.L.P. requires, Patients with C.L.P. requires,

interdisciplinary care from a team of provides including a interdisciplinary care from a team of provides including a geneticist, plastic surgeon, oral and maxillofacial geneticist, plastic surgeon, oral and maxillofacial surgeon, otolaryngologist, dentist, orthodontist, speech surgeon, otolaryngologist, dentist, orthodontist, speech therapic audiologist, psychologist, social worker & nurse. therapic audiologist, psychologist, social worker & nurse. The role of each specialist depends on the age of the The role of each specialist depends on the age of the patient. patient.

During the first days of the infant’s life:-During the first days of the infant’s life:-The infants with a cleft palate cannot generate the negative The infants with a cleft palate cannot generate the negative intraoral pressure needed to suck from a bottle. intraoral pressure needed to suck from a bottle.

The Nurse on the team or another feeding specialist must The Nurse on the team or another feeding specialist must instruct the parents in the use of special feeding device for the instruct the parents in the use of special feeding device for the infant eg:- Haberman nipple, catheter & syringe, spoon feeding.infant eg:- Haberman nipple, catheter & syringe, spoon feeding.

Infants with cleft palate have difficulty ventilating the eustachian Infants with cleft palate have difficulty ventilating the eustachian tube. This result in the accumulation of fluid in the must be tube. This result in the accumulation of fluid in the must be treated promptly with antibiotics. treated promptly with antibiotics.

DENTOFACIAL ORTHOPEDICSDENTOFACIAL ORTHOPEDICS In unilateral complete cleft lip and palate (UCCLP) or In unilateral complete cleft lip and palate (UCCLP) or

bilateral complete cleft lip and palate (BCCLP) with a bilateral complete cleft lip and palate (BCCLP) with a protruding premaxilla, labial repair is often protruding premaxilla, labial repair is often completed with tension on the closure. completed with tension on the closure.

Orthopedic appliances bring the dentoalveloar Orthopedic appliances bring the dentoalveloar segments together facilitating a tension free labial segments together facilitating a tension free labial repair that requires undermining of tissues. repair that requires undermining of tissues.

In addition, alveolar approximate forms the skeletal In addition, alveolar approximate forms the skeletal plateform for correction of the nasal deformity and plateform for correction of the nasal deformity and permits gingivoperiosteoplasty. Alveolar closure permits gingivoperiosteoplasty. Alveolar closure eliminates an around fistula. eliminates an around fistula.

The appliance is removed at the time of labial repair The appliance is removed at the time of labial repair and replaced with a passive appliance to maintain and replaced with a passive appliance to maintain the alveolar position. the alveolar position.

Management of Cleft Lip And Nasal Management of Cleft Lip And Nasal DeformityDeformity

Single stage: Single stage: repair the unilateral complete cleft lip repair the unilateral complete cleft lip and nasal deformity in a single stage.and nasal deformity in a single stage.

Two stage repairTwo stage repair: First repair unilateral cleft lip & : First repair unilateral cleft lip & than lip nasal adhesion. than lip nasal adhesion.

Reasons For Two Stage RepairReasons For Two Stage Repair Minimize tension. Minimize tension. Increase the bulk of the orbicularis oris muscle to Increase the bulk of the orbicularis oris muscle to

construct the filtral ridge. construct the filtral ridge. Increase the vertical dimension of labial elements. Increase the vertical dimension of labial elements.

Particularly on the medical side andParticularly on the medical side and Gives the surgeon two chances to correct the position Gives the surgeon two chances to correct the position

of the lower lateral cartilage. of the lower lateral cartilage.

TIMING OF NASOLABIAL REPAIRTIMING OF NASOLABIAL REPAIR Labial repair is traditionally carried out when the child is Labial repair is traditionally carried out when the child is

approximately 10 weeks of age, weight 10 pounds, and has a approximately 10 weeks of age, weight 10 pounds, and has a serum hemoglobin value of 10mg 1 ml & total leukocyte count serum hemoglobin value of 10mg 1 ml & total leukocyte count less than 10,000/C.C. it is important to wait until the period of less than 10,000/C.C. it is important to wait until the period of postnatal anemia is corrected. The child should be gaining postnatal anemia is corrected. The child should be gaining weight and growing before under going nasolabila repair. weight and growing before under going nasolabila repair.

TECHNIQUES OF NAGOLABIAL REPAIR.TECHNIQUES OF NAGOLABIAL REPAIR.• Type of cleft lip surgery:-Type of cleft lip surgery:-• Millard’s rotation advancement flap and tennison randall Millard’s rotation advancement flap and tennison randall

triangular flap methods. triangular flap methods. • Rose Thompson straight line repair, the skoog’s procedure are less Rose Thompson straight line repair, the skoog’s procedure are less

frequently used. frequently used. • Rectangular flap method of triangular hagedorn le mesurier are Rectangular flap method of triangular hagedorn le mesurier are

rarely used. rarely used. • For bilateral cleft lip can be repaired in two stage by in a single For bilateral cleft lip can be repaired in two stage by in a single

stage by veau -III procedure, millards single stage procedure or stage by veau -III procedure, millards single stage procedure or black procedure. black procedure.

• Basic steps in cleft lip repair. Basic steps in cleft lip repair. • The lip is closed in three layers – mucosa, muscle, skin.The lip is closed in three layers – mucosa, muscle, skin.

AIM OF REPAIRAIM OF REPAIR

To achieve equal length of filtral ridges an either To achieve equal length of filtral ridges an either side.side.

Horizontal cupid’s bow. Horizontal cupid’s bow. Accurate repair of muscle, skin, mucosa without Accurate repair of muscle, skin, mucosa without

vermilion deformity. vermilion deformity. Proper alignment of white line. Proper alignment of white line. Symmetrical nostril floor, and finally an esthetically Symmetrical nostril floor, and finally an esthetically

acceptable scar. acceptable scar.

1.1.Straight Line Lip Repair.Straight Line Lip Repair.

IndicationIndication:- of incomplete and narrow clefts. :- of incomplete and narrow clefts.

AdvantageAdvantage :- Easy repair :- Easy repair

DisadvantageDisadvantage:- Limited Indications. :- Limited Indications.

Tennison Randall RepairTennison Randall Repair A triangular flap is created on the lateral side A triangular flap is created on the lateral side

of the cleft to fit into the triangular.of the cleft to fit into the triangular. This procedure can be planned exactly after This procedure can be planned exactly after

initial measurements the results can not be initial measurements the results can not be modified once the lip is cut. modified once the lip is cut.

The scar is more prominent than in other The scar is more prominent than in other procedures. procedures. • AdvantageAdvantage:- :- Measured techniques Measured techniques

More easily taught. More easily taught. Can be used for wide dept.Can be used for wide dept.

• DisadvantageDisadvantage: Scar: Scar interrupts the philtrum interrupts the philtrum line difficult to modify line difficult to modify

duringduring procedure. procedure.

VEAU REPAIRVEAU REPAIR There is only a displacement, deformation and under There is only a displacement, deformation and under

development of the muscles and the skeletal tissue.development of the muscles and the skeletal tissue. The surgical procedure should thus aim at returning The surgical procedure should thus aim at returning

there structures to their correct positions. there structures to their correct positions. The naso labial muscles are reconstructed The naso labial muscles are reconstructed

accurately and within a few weeks, without any form accurately and within a few weeks, without any form of flap closure.of flap closure.

This method gives satisfactory results in bilateral This method gives satisfactory results in bilateral cleft lip. cleft lip.

MILLARD’S Techniques (Rotation advancement MILLARD’S Techniques (Rotation advancement technique) principles of closing bilateral cleft lip. technique) principles of closing bilateral cleft lip. • Maintain symmetry Maintain symmetry • design the prolabium of proper size & shape.design the prolabium of proper size & shape.• Ensure primary muscular continuity. Ensure primary muscular continuity.

• Construct the median tubercle from lateral labial Construct the median tubercle from lateral labial elements. elements.

• Peeform primary construction of the columella & Peeform primary construction of the columella & nasal tip.nasal tip.

Procedure :-Procedure :-rotation flap and columella flap are rotation flap and columella flap are planned on the medial side of the cleft. after full planned on the medial side of the cleft. after full thickness of the lip is cut along the marking rotation thickness of the lip is cut along the marking rotation gap is produced on the medial side which is filled by gap is produced on the medial side which is filled by an advancement flap planned on the lateral side of an advancement flap planned on the lateral side of cleft. cleft.

AdvantageAdvantage:- :- Minimal tissue is discarded Minimal tissue is discarded

Allows modification during repairAllows modification during repair

DisadvantageDisadvantage: : Difficult for use in wide cleft. Difficult for use in wide cleft.

May narrow the nostrial. May narrow the nostrial.

Basic goals of palate repairBasic goals of palate repair Separation of oral and nasal cavities. Separation of oral and nasal cavities. Construction of watertight and airtight velopharyngealConstruction of watertight and airtight velopharyngeal valve. valve. Preservation of facial growth. Preservation of facial growth. Development of esthetic dentition. Development of esthetic dentition. Development of functional occlusion. Development of functional occlusion.

TIMING OF SURGERYTIMING OF SURGERY Early repair leads to a better speech development but severe Early repair leads to a better speech development but severe

mid facial growth retardation and dental malocclussion. mid facial growth retardation and dental malocclussion. Palate repair after full growth of maxilla midfacial growth Palate repair after full growth of maxilla midfacial growth

retardation & dental malocclusion problem is less but speech retardation & dental malocclusion problem is less but speech problem become more severe.problem become more severe.

Palate repair should be done 1-1½ years age give the best Palate repair should be done 1-1½ years age give the best balanced result. balanced result.

Only soft palate are closed by 6-18 months. Only soft palate are closed by 6-18 months.

CLEFT PALATE REPAIRCLEFT PALATE REPAIR

TECHNIQUES OF PALATE REPAIRTECHNIQUES OF PALATE REPAIR Single stare technique.Single stare technique.

eg:- von langenbeck repaireg:- von langenbeck repairVen wardill kilner v-y push back palatoplasty at are Ven wardill kilner v-y push back palatoplasty at are 1½ years. 1½ years.

Two stare technique:-Two stare technique:-• First stage : soft palate repair before 18 month.First stage : soft palate repair before 18 month.• Second stage hard palate repair at 4-5 years. Second stage hard palate repair at 4-5 years.

eg. Schweckendiek technique. eg. Schweckendiek technique. 1)1) Primary Veloplasty By SchweekendiekPrimary Veloplasty By Schweekendiek. .

• First soft palate is closed at an early age 16-12 months) First soft palate is closed at an early age 16-12 months) • Hard palate closed after few years.Hard palate closed after few years.• Principle of this techniques is that the soft palate aids in the Principle of this techniques is that the soft palate aids in the

speech and is essential to be closed early for velopharyngeal speech and is essential to be closed early for velopharyngeal mechanism. mechanism.

DisadvantageDisadvantage::- Speech problem (Severe) - Speech problem (Severe) Additional surgical procedure. Additional surgical procedure.

2) VON LANGENBECK’S PALATO PLASTY.2) VON LANGENBECK’S PALATO PLASTY. • Use bipedicled mucoperiosteal flaps of the Use bipedicled mucoperiosteal flaps of the

hard and soft palate for repair of the defect.hard and soft palate for repair of the defect.• There interiorly and posteriorly based flaps There interiorly and posteriorly based flaps

are advanced medially closed the palatal are advanced medially closed the palatal defect. defect.

AdvantageAdvantage:- :- Easy to perform, requires Easy to perform, requires less dissection. results in less dissection. results in decreased denuded palate.decreased denuded palate.

DisadvantageDisadvantage:-:- Failure to provideFailure to provide additionaladditional

palatal length.palatal length. - Poor results in large clefts. - Poor results in large clefts.

- Currently not commonly used. - Currently not commonly used.

Veau-Wardill-Kilnar-v-y- Pushback Veau-Wardill-Kilnar-v-y- Pushback palatoplasty.palatoplasty.

Two mucoperiosteal flaps are raised from a hard Two mucoperiosteal flaps are raised from a hard palate and nasal layers are mobilized abnormal palate and nasal layers are mobilized abnormal attachment of palatal muscles are divided from the attachment of palatal muscles are divided from the posterior border of the hard palate to be sutured in posterior border of the hard palate to be sutured in midline to the opposite side the palatal muscle. midline to the opposite side the palatal muscle.

Suturing done anterior of the nasal layer and Suturing done anterior of the nasal layer and progressed toward Uvula. progressed toward Uvula.

ORTHODONTICS AND MAXILLARY ORTHODONTICS AND MAXILLARY ORTHOPAEDICS.ORTHOPAEDICS.

Different stages of dentition methods.Different stages of dentition methods. A)A) predental treatment. predental treatment. B)B) Deciduous dentition ( 3 to 6 years) Deciduous dentition ( 3 to 6 years) C)C) Early mixed dentition ( 7 to 9 years) Early mixed dentition ( 7 to 9 years) D)D) Late mixed and early permanent dentition. Late mixed and early permanent dentition. E)E) Permanent dentition. Permanent dentition.

A) PRE DENTAL TREATMENTA) PRE DENTAL TREATMENT

II Feeding palate proper feeding advise pre-surgical Feeding palate proper feeding advise pre-surgical feeding plate. feeding plate.

II.To help the surgeon in the repair of the cleft by II.To help the surgeon in the repair of the cleft by pushing. pushing.

III. To stimulate palatal bone growth and to restore III. To stimulate palatal bone growth and to restore orofacial functional matrix. orofacial functional matrix.

IV. To expand or prevent the collapse of maxillary IV. To expand or prevent the collapse of maxillary segment. segment.

B) PRIMARY DENTITION TREATMENTB) PRIMARY DENTITION TREATMENT- Simple form of fixed maxillary lingual appliance (i.e Simple form of fixed maxillary lingual appliance (i.e

warch or an Arnold expander) are preferred over the warch or an Arnold expander) are preferred over the removable palatal expansion for improving speech. removable palatal expansion for improving speech.

C) MIXED DENTITION TREATMENTC) MIXED DENTITION TREATMENTI.I. Minor crossbites may be neglected but severe Minor crossbites may be neglected but severe

crossbites one corrected by expansion by usual crossbites one corrected by expansion by usual method. method.

II.II. Retroclination of permanent incision and anterior Retroclination of permanent incision and anterior cross bite to correct this usually partial banded cross bite to correct this usually partial banded approach is needed . approach is needed .

III.III. Crowded dentition: This may require serial Crowded dentition: This may require serial extraction primary cupids are removed to treat extraction primary cupids are removed to treat incisior crowding & the primary molars. incisior crowding & the primary molars.

IV.IV. After alveolor bone grafting. After alveolor bone grafting.

To movement carriage enough space is created To movement carriage enough space is created in the arch to allow the cuspids to erupt. in the arch to allow the cuspids to erupt.

PERMANENT DENTITION TREATMENTPERMANENT DENTITION TREATMENT The problem at this stage are posterior cross bite The problem at this stage are posterior cross bite

and malposed permanent incisors. and malposed permanent incisors. If orthognathic surgery is done to correct the If orthognathic surgery is done to correct the

underlying skeletal imbalance pre operative and underlying skeletal imbalance pre operative and post operative orthodontic treatment is needed to post operative orthodontic treatment is needed to achieve proper alignment, position and indication of achieve proper alignment, position and indication of the teeth on their respective arches. the teeth on their respective arches.

ROLE OF ENT SPECIALIST, SPEECH ROLE OF ENT SPECIALIST, SPEECH PATHOLOGISTS AND SPEECH THERAPYPATHOLOGISTS AND SPEECH THERAPY

ENT specialist, Audiologist and speech specialist ENT specialist, Audiologist and speech specialist work together to note the middle ear problems and work together to note the middle ear problems and progress in speech. progress in speech.

Detect abnormalities in articulation and resonance Detect abnormalities in articulation and resonance which is develops due to velopharyngeal in which is develops due to velopharyngeal in competence after palatoplasty. competence after palatoplasty.

The abnormalities detected by video fluoroscopy or The abnormalities detected by video fluoroscopy or nasopharyngoscopy. nasopharyngoscopy.

PROCEDURE FOR CORRECTION OF PROCEDURE FOR CORRECTION OF VELOPHARYNGEAL INSUFFICIENCYVELOPHARYNGEAL INSUFFICIENCY

Pharyngeal flap 2) Sphincter pharyngoplasty.Pharyngeal flap 2) Sphincter pharyngoplasty.

-- Pharyngeal flap designed on the basis of location and extent of Pharyngeal flap designed on the basis of location and extent of lateral pharyngeal wall motion. The raw under surface of the lateral pharyngeal wall motion. The raw under surface of the flap is lined with tissue from the nasal side of the soft tissue flap is lined with tissue from the nasal side of the soft tissue palate to prevent contracture and narrowing of the flap the palate to prevent contracture and narrowing of the flap the donor site on the posterior pharyngeal is closed. donor site on the posterior pharyngeal is closed.

• ALVEOLAR BONE GRAFTING TIME 8-11 years.ALVEOLAR BONE GRAFTING TIME 8-11 years.- Cancellous bone is used for alveolar grafting. Cancellous bone is used for alveolar grafting. - It promotes more rapid vascularization due to presence of It promotes more rapid vascularization due to presence of

living osteoblasts. living osteoblasts. - DONAR SITE OF BONEDONAR SITE OF BONE- Ilium, calvaria, tibia mandible or ribs. Ilium, calvaria, tibia mandible or ribs. - The bone should be placed within the cleft from the piriform The bone should be placed within the cleft from the piriform

aperture to the level of the alveolar crest. aperture to the level of the alveolar crest. - Gingival mucoperiosteal flaps are used for oral closure over an Gingival mucoperiosteal flaps are used for oral closure over an

alveolar bone graft because they are well vascularized. alveolar bone graft because they are well vascularized.

ADVANTAGEADVANTAGE Bony support to teeth. Bony support to teeth. Helps stabilize the maxillary segments. Helps stabilize the maxillary segments. Aesthetic appearance of the alveolus. Aesthetic appearance of the alveolus. Closure of oro nasal fistula. Closure of oro nasal fistula. Gives supports to the alar bone of the nose. Gives supports to the alar bone of the nose. Provides bone for a titanium implants. Provides bone for a titanium implants.

OPERATIVE CORRECTION OF MAXILLARY OPERATIVE CORRECTION OF MAXILLARY HYPOPLASIAHYPOPLASIA

Maxillary hypoplasia is three dimensional Maxillary hypoplasia is three dimensional deficiency deficiency

Class III malocclusion ( Sagittal plane) Class III malocclusion ( Sagittal plane) Narrowed arch (horizontal plane) Narrowed arch (horizontal plane) Over closure the mandible (vertical plane) Over closure the mandible (vertical plane)

TREATMENTTREATMENT Destruction osteogenesis. Destruction osteogenesis. Pre surgical orthodontics & Lefort – I osteotomy.Pre surgical orthodontics & Lefort – I osteotomy. Fabrication of an over lay denture may be necessary Fabrication of an over lay denture may be necessary

for improved occlusion and appearance.for improved occlusion and appearance.

DENTAL ENAMEL HYPOPLASIA: DENTAL ENAMEL HYPOPLASIA:

Defect occurs in central & lateral incisors. Defect occurs in central & lateral incisors.

TreatmentTreatment RestorationRestoration Placement of stainless steel crown.Placement of stainless steel crown. Fluoride application. Fluoride application. Dietary advice. Dietary advice. Preventive oral health care Preventive oral health care

ROLE OF PROSTHODONTISTROLE OF PROSTHODONTIST Replacement of absent maxillary lateral incisor. Replacement of absent maxillary lateral incisor. Replacement by fixed partial denture and Replacement by fixed partial denture and

implantation method. implantation method.

ROLE OF PSYCHOLOGISTROLE OF PSYCHOLOGIST The psychiatrist and psychologist evaluate the The psychiatrist and psychologist evaluate the

patient for strength and weakness in cognitive patient for strength and weakness in cognitive interpersonal, emotional, behavioural and social interpersonal, emotional, behavioural and social development: emphasis is placed on the patient’s development: emphasis is placed on the patient’s ability to cope with the emotional and psycheal ability to cope with the emotional and psycheal stress created by the cleft defect. Consultation with stress created by the cleft defect. Consultation with the parents and schools regarding educational or the parents and schools regarding educational or behavioural management if carried out when behavioural management if carried out when indicated. indicated.

CONCLUSIONCONCLUSION

The management of cleft lip & palate is The management of cleft lip & palate is necessary at correct time. If delayed in the necessary at correct time. If delayed in the treatment there may be possibility to treatment there may be possibility to developed abnormalities.developed abnormalities.

So to prevent some problems like speech So to prevent some problems like speech problem facial asymmetry, feeding problem facial asymmetry, feeding problem & infection to nasal cavity & problem & infection to nasal cavity & unasthetic appearance. The treatment is unasthetic appearance. The treatment is necessary.necessary.

REFERENCESREFERENCES

Pediatric Oral & Maxillofacial Surgery by Pediatric Oral & Maxillofacial Surgery by Leonard B. Kaban , Maria T. Troulis.Leonard B. Kaban , Maria T. Troulis.

Facial cleft and cranio synostosis By Facial cleft and cranio synostosis By Timothy A. Turvey, Kathorine W L VIG , Timothy A. Turvey, Kathorine W L VIG , Raymond J. Fansecu.Raymond J. Fansecu.

Clinical Pedodontics By Sidney B. Finn.Clinical Pedodontics By Sidney B. Finn. Oral & Maxillofacial Surgery by Chitra Oral & Maxillofacial Surgery by Chitra

ChakravarthyChakravarthy Clinical Pedodontics By Shobha Tandon.Clinical Pedodontics By Shobha Tandon.