cleftlipandpalatebymohammedalmuzian-121029144301-phpapp01.pdf

Cleft Lip & Palate

Doctorate of Clinical Dentistry in Orthodontics (Notes) Orthodontic Dept.

University of Glasgow

By: Mohammed Almuzian

2012

Mohammed Almuzian, Orthodontic Dept., University of Glasgow, 2012 1

Cleft lip and palate

Definition

Incomplete fusion of hard and /or soft tissue structures of the lip and palate.

INCIDENCE

A. Genetic risks

One affected parent, risk of the first child 2%

One affected child, risk of next child with is (4%).

Two affected parents, risk of first child 60%

B. Prevalence in the UK population

UCLP 40%

CP 30%

BCLP 10%

CL 10%

Others e.g. submucous cleft 10%

C. CLP

Incidence of unilateral CL(P) varies with race:

1. In UK 1 in every 1000 live births

2. In Caucasians it is about 1 in every 750 live births (Mitchell, 2000).


3. In oriental populations is around 1 in very 600 live births.

4. In Negros is around 1 in every 2000 live birth.

5. Left side is more affected than the right side (2:1).

D. CP:

Prevalence around 1 case in every 2000 live births.

55% Associated with syndromes such as Down, Treacher-Collin, Pierre-

Robin Syndromes.

E. Gender distribution:

CLP has greater incidence in males.

There is a male predominance of submucus clefts.

CP the incidence is higher in females overall (4:1).

There is equal gender incidence of isolated soft palate clefts

Syndromic and non-Syndromic clefting

15% of cleft children have additional malformations and there is a tendency for

children with bilateral clefts to have additional malformations

1. Van der Woude. Incidence of approx. 1:28,000 (2% of cleft cases). Autosomal

dominant. Lower lip pits +/or CL/P or CPO and hypodontia. No other anomalies.

2. Pierre Robin sequence. Triad of cleft palate, micrognathia, macroglossia

3. Treacher Collins


z

Embryology of clefts of the lip and palate

Lip development Facial development begins at

4-6 weeks

5 facial prominences.

Frontonasal process (unpaired),

Paired maxillary process and

Paired mandibular process

Nasal placodes on the surface

of the FNP begins to invaginate at

5 weeks, ridges around pits are the

medial and lateral nasal process

(also partly made up of the

maxillary process)

The two mandibular processes

are the first to unite and give rise

to the lower lip, lower portion of

the cheeks and other mandibular

structures.

Medial nasal processes develop into the philtrum, primary palate and the four

maxillary incisor teeth and their surrounding alveolar bone.

The maxillary processes form the remainder of the upper lip, the secondary palate

and the upper portion of the cheeks.

The lateral nasal process on each side unites to form the ala of the nose.


Abnormal lip Development

Defective fusion at any of the sites highlighted in the above figures may result in a facial

cleft.

1. Cleft mandible

2. Lateral facial cleft

3. Oblique facial cleft

4. Cleft Lip (Unilateral or Bilateral)

5. Median cleft

Development of the palate 1° palate is made up of the medial nasal process. It contains the first four teeth and

contributes the philtrum of the upper lip.

2° palate apparent at 6 weeks as inferiorly lying outgrowths from the maxillary

process, lying lateral to the tongue.

At 8 weeks shelf elevation begins .


Theories of palatal shelf elevation. (Ferguson 1981)

Extrinsic

1. Tongue movement,

2. increased mandibular prominence,

3. lifting of the head relative to the body,

4. straightening of the cranial base,

5. increased height of the oronasal cavity.

Intrinsic

1. Osmotic pressure,

2. Contraction (muscle/non-muscle, both have been proposed),

3. cellular reorganisation (increased density of epithelial/mesenchymal cells on the

palatal side of the shelf causing rotation),

4. Vascular erectile force.


Following elevation, further growth brings the medial edge of each shelf into close

contact. At this stage, mesenchyme from each shelf is still separated by an epithelial

seam of medial edge epithelium.

Three mechanisms have been proposed to explain medial edge epithelium breakdown,

apoptosis (programmed cell death), epithelial to mesenchymal transformation, and

migration of epithelium to the oral and nasal compartments.

Regardless of the mechanism, breakdown of the epithelial seam results in

mesenchymal continuity and palatal fusion. As well as fusion between secondary

palatal shelves, an important step during palatogenesis is fusion of the primary palate

to the secondary palate.

Abnormal palate Development

Clefts form when there is failure of process growth or fusion, this is due to:

1. Primary defects leading to cleft palate include:

Failure of shelf elevation;

Failure of shelf growth ;

Failure of shelf fusion.

2. Secondary defects leading to cleft palate include:

Growth disturbances in craniofacial structures

Mechanical obstruction of palatal .

AETIOLOGY

In normal development, fusions of the embryological processes that comprise the

upper lip appear around 6 W.I.U life while fusion to form the secondary palate occur

around 8 W.I.U life. Any disruption affecting the timing at which the fusion occurs

will increase the incidence of cleft.


Bixler (1981) divided clefts into 3 aetiological domains

A. Syndromic. Including chromosomal and environmental aetiologies.

B. Familial or hereditary. A gene coding for TGF has been implicated. These

encode a variety of different proteins include (FGF), MSX1 and MSX2

C. Sporadically or Isolated or non-Familial. The proband is the first person in

a pedigree with the defect. Most commonly:

Drugs like Steroids, Anticonvulsant drugs

Infection like CMV, Rubella

Smoking

Alcohol

Endocrine like Diabetes

Deficiency of vitamin supplements such as deficiency in folic acids

Trauma.

Radiation.

Maternal hypoxia

CLASSIFICATIONS

Descriptive method This is most commonly used nowadays.

A. Cleft lip

Unilateral or bilateral

Notched lip


Incomplete cleft lip

Complete cleft lip

B. Cleft alveolus (primary palate)

C. Cleft palate

Cleft uvula

Soft palate only

Submucous cleft

Complete

Incomplete

Symbolic method using the “stripped Y”.Kernahan 1971

LAHSHAL classification developed by Kriens 1989

L lip

A alveolus

H hard palate

S soft palate

UPPER CASE FOR COMPLETE CLEFT


lower case for incomplete cleft

Preventive treatment

Hartridge et al 1999 in a review investigating the role of pre-conceptional folic acid

supplementation concluded that 0.4 mgs of folic acid from pre-conception to the 12

week of pregnancy ( 4mgs for mothers with cleft children) although not proved

conclusively can have significant protective effects.

CSAG Report (Clinical Standards Advisory Group) by Shaw 1995

Professionals in the field of cleft work expressed concern regarding the quality of

treatment outcome for patients with cleft lip and palate in the UK.

In 1995 the Department of Health in the UK charged the Clinical Standards Advisory

Group to investigate the quality of care within the UK.

All children in the UK with a unilateral complete cleft lip and palate aged 5 or 12

years of age in 1996-1997 were examined. Their speech, hearing, appearance, dental

malocclusion, dental health, quality of bone graft and skeletal base relationships were

examined.

Cleft care was provided in 57 centres.

The study found that the average result in all these areas was poor.

Children from the UK centres were more likely to suffer mid-face retrusion and poor

dental relationships than three of the European centres.

Fewer than 60% of children in the UK had a successful bone graft in comparison with

97% from one of the other European centres. It was therefore clear that some patients

were not receiving optimal care in the UK.


The CSAG report made several recommendations, including:

I. Centres should be limited to 8-15 in the UK.

England and Wales, 10 centres

Northern Ireland operates as a single centre

Scotland operates as one single centre known as CLEFTSiS

II. Each centre should provide a full range of cleft care.

III. Nationwide database.

IV. Results should be regularly audited.

V. Training should be provided for specialists in cleft care in high volume centres

only.

VI. Each clinical team consists of specialist orthodontists, surgeons, speech and

language therapists, specialist nurses, geneticists, paediatricians, ENT specialists,

anaesthetists and psychologists. In addition they have support staff responsible for

data collection, audit documentation and photography.

METHOD OF ASSESSMENT

Methods of Assessment Record taking recommended at 5,10,15,20 years (Lee et al., 1993)

Lateral views

Posteroanterior views

Study models

Photographs


Index of 5-year old children (Attack et al., 1997): Index for dental relationships of 5 year old patients born with unilateral cleft

lip and palate.

It divided the cases into 5 categories to be able to compare treatment outcomes

earlier and before surgical procedures and orthodontic treatment.

Grading

1. Grade I

Positive overjet

average inclined or retroclined incisors

No crossbites

No openbites

Good maxillary arch shape and palatal vault anatomy.

Excellent outcomes

2. Grade 2

Positive overjet

average inclined or proclined incisors

Unilateral rossbite/crossbite tendency

Open bite tendency around cleft site.

Good outcomes

3. Grade 3

Edge-to-edge bite average inclined or proclined incisors;

OR

reverse overjet with retroclined incisors


Unilateral crossbite

Open bite tendency around cleft site

Fair outcomes

4. Grade 4

Reverse overjet

average inclined or proclined incisors

Unilateral crossbite, bilateral crossbite tendency

Open bite tendency around cleft site .

Poor outcomes

5. Grade 5

Reverse overjet

proclined incisors

Very Poor Bilateral crossbite

maxillary arch form and palatal vault anatomy

Poor outcomes

GOSLON index (Great Ormond Street , London and Oslo Net)

Yardstick (Mars et al., 1987) It is a record of 10 year old patients

To evaluate and compare the results of different approaches to the early

management of the child with a unilateral cleft lip and palate of children in the early

permanent dentition.

It represents the severity of malocclusion and the difficulty of correcting it.


This depend on

I. Anteroposterior Assessment of labial segements

The overjet is examined first. If there is a reverse overjet of 3 to 5 mm, this

indicates that the case might belong to group 3.

However, if there is already dentoalveolar compensation a higher category

should be considered.

The anteroposterior relationships of the buccal segments are not of importance

in determining the grouping of a case.

II. Vertical Assessment

It help in modification of the provisional category in borderline cases. Deep bite is

favourable and AOB is unfavourable

III. Transverse Assessment

It indicate a modification of the provisional category in borderline cases

Ranking of GOLSON index

1. Groups 1 and 2 have occlusions that require either straightforward orthodontic

treatment or none at all.

2. Group 3 require complex orthodontic treatment to correct the Class III malocclusion

but a good result can be anticipated.

3. Group 4 are at the limits of orthodontic treatment , and if facial growth is unfavorable,

orthognathic surgery will be required.

4. Cases in group 5 require orthognathic surgery .

Bergland index for secondary ABG Take periapical x-ray and assess the bone formation at interseptal area around the

canine to assess bone formation Bergland (1986).


1. Grade I: inter-alveolar bone at normal height

2. Grade II: inter-alveolar bone ¾ of normal height

3. Grade III: inter-alveolar bone less than ¾ of normal height

4. Grade IV: no bone at inter-alveolar area. Failed outcomes.

Kindelan score 5. After 4-6 months of ABG, take anterior occlusal radiograph and assess the

success using Kindelan score 1997.

The degree of bony fill in the cleft area was assessed using a 4-point scale:

1. Grade 1 > 75% bony fill;

2. Grade 2 50-75% bony fill;

3. Grade 3 < 50% bony fill;

4. Grade 4 no complete bony bridge.


Problems Associated with Cleft Lip and Palate

I. General difficulties 1. Feeding

2. speech

3. hearing (which inturn can effect speech development) and middle ear

infections

4. psychological problems

II. Dental disturbances in both repaired and unrepaired cleft cases 1. Hypodontia , 28% of UCLP and 60% BLCP

2. Supernumeraries

3. Delayed eruption of teeth on cleft side

4. Increased incidence of impacted upper first molar in non-cleft side (4x non-clefts

individuals) (Bjerklin et al., 1993)

5. Hypoplasia

6. Microdontia

The above due to:

Disturbtion of the development of the dental lamina which produce tooth

germs. In the patient with a cleft this process is disturbed and result in dental

problems.

Msx1 genes mutation.

III. Skeletal Features of unrepaired cleft lip and palate It is called Embryological defects


1. Cleft Lip only, maxillary arch development is generally normal.

2. Clefts in to the alveolus (incomplete) only with or without lip, Increased incidence

of cross bites (19%)

3. Complete bilateral, Premaxilla is anteriorly displaced beyond the tip of the nasal

septum. The lateral segments may have collapsed medially producing bilateral

crossbites.

4. Complete unilateral, Major segment is rotated outward so the incisor area appears

prominent, the lesser (lateral) segment is more variable and may be rotated outwards

producing a wide cleft or there may be inward displacement and segment overlap.

5. Isolated clefts of the palate, Excessive inter-tuberosity width may be observed.

6. mandibular growth reduced

7. Increase MMP angle, Possibly due to

disrupted nasal respiration,

oral respiration and a mouth open posture, allowing buccal segments to over-

erupt.

IV. Skeletal Features of repaired cleft lip and palate . (Shaw 1990) Embryological defects + Iatrogenic effect of surgery

Iatrogenic effect of surgery

1. Lip repair. Minimal effect on facial growth,.

2. Transverse disturbances. Scar tissue in the palate leads to a tendency for buccal cross

bites in the 1 and 2 dentitions.

3. AP disturbances. Palatal scar tissue around the tuberosity region hinders maxillary

translation..

4. Vertical disturbances.


An in LFH is often found. Possibly due to disrupted nasal respiration, oral

respiration and a mouth open posture, allowing buccal segments to over-erupt.

A in LFH in severe maxillary retrusion.

Ideal Cleft palate Team 1. Cleft nurse

2. Plastic surgeon

3. Orthodontist

4. Maxillofacial surgeon

5. ENT surgeon

6. Speech therapist

7. Audiologist

8. Pediatrician

9. Psychologist

Summary of the whole Treatment In red are the roles of the orthodontist and GDP

Prenatal Ultrasound assessment, 70% of the cases are detected on

ultrasound scan at 16-18 weeks

At birth Parent counselling

Feeding


Pre-surgical orthopaedic appliance

3-5 months 1. Primary surgical lip repair

2. Nasal repair

3. primary alveolar bone grafting (old regiem)

1 year 1. Palate repair.

2. Preventive dentistry/advice

2-6 years 1. Revision of lip repair

2. Pharyngoplasty

3. tympanoplasty or grommet,

Lee’s records

Index Assessment

4. interceptive orthodontic to:

correct X bite

Align the maxillary dentition (usually using fixed

appliances) in the growing child if the appearance causes

the child distress or the irregular teeth are traumatizing soft

tissues

5. Cleft orthodontists can be asked to provide obturators to

assist with speech prior to closure of any residual fistulae

at the time of alveolar bone grafting

8-10 years Lee’s records

GOSOLN Index Assessment

Maxillary expansion prior to bone grafting, extract


supernumerary teeth,

bone grafting

1. OHI and optimal oral health

12-15 Lee’s records

Index Assessment

1. Definitive alignment of the maxillary and mandibular teeth

using fixed appliances

2. Reverse facial mask

17-20 Lee’s records

Index Assessment

1. Orthognathic surgery

2. Decompensation and alignment for orthognathic surgery

using fixed appliances

3. For patients with velo-pharyngeal dysfunction, the poorly

functioning soft palate is raised with a palatal lift appliance

and the velo-pharyngeal space obturated to reduce

hypernasal speech, which assists the Speech and Language

Therapist in cases that are otherwise untreatable by

language therapy alone with/without surgery.

4. Electropalatography is a relatively new technique where

patients are provided with an upper removable orthodontic

appliance incorporating numerous electrodes. When

attached to a PC, the patient can visualise tongue to hard

palate contact on various sounds and the Speech and

Language Therapist can direct therapy sessions using this

technique. Indeed portable EPG hardware is now available


such that the patient can practice tongue positioning at

home.

Prenatal age Parent counselling:

Parents are usually in a shock after birth, therefore a counselling is important to

reassure them and facilitate the development of a bond between the mother and the

child.

70% of the cases are detected on ultrasound scan at 16-18 weeks when looking for it.

Cleft Lip and Palate Association (CLAPA) provide support for the parents.

At Birth Feeding:

1. Orthodontist should give counselling and advice on feeding.

2. Acrylic plates are no longer used nowadays.

3. However, soft feeding bottles with modified teats which help to direct the flow of the

milk into the mouth are helpful.

4. Some babies are fed by nasogastric tube. One of the most common reasons for a cleft

baby being fed this way is due to Pierre Robin sequence. Many of these babies have

severe airway problems and due to the smallness of the lower jaw, the tongue remains

in a very posterior position, making oral feeding impossible for weeks or even

months.

Pre-surgical orthopaedics:

1. Pioneered by McNeil.

2. It is usually carried out immediately after birth.


3. The aims of this are:

a. Passive obturating plates that Assist feeding

b. Extra oral strapping aid in Positioning of the segments to help surgical closure of the

lip specially in severe arch distortion

c. active obturating plates

In unilateral clefts reduces displacement of the greater segment and maintain the

position of the lesser segment.

In bilateral clefts to move the lateral segments outwards while the prolabium is moved

palatally and rotated downwards. Reduction of premaxillary protrusion in bilateral

clefts. Treatment comprises an intra oral appliance carrying an active component to

separate the lateral segments. Elastic strapping across the prolabium (upper lip) is

used to restrain the premaxillary growth.

d. Stabilizer: Help maintain the transverse dimensions after the primary surgery

(retention period about 3 months).

Recent evidences Shaw 2004 and Dutch-cleft study by Anderson suggest that these

devices offer no benefit to outcome either in terms of the surgery or feeding during

this period.

Three Months of age A. Lip Repair

Millard technique (gives best scar) with McComb nasal correction

Tennison technique (gives fuller lip)


B. Nose Repair: alar cartilages may be repositioned at this time to increase symmetry

and improve the appearance

C. Alveolar Repair, primary alveolar bone grafting not recommended. However it

depend on the use of vomerian flap to close the cleft

D. Dental roles:

continued advise on feeding,

oral health

E. ENT: tympanoplasty, aspiration and grommets

A cleft involving the posterior part of the palate and the soft palate will also involve

the tensor palate muscles, which act on the Eustachian tube.

This predispose to problems in the middle ear ventilation (glue ear).

Therefore, it is important that the cleft patient’s ears should be examined at the time

of lip surgery to ensure adequate middle ear drainage.

About 98% of the cleft patients will have otitis media (Grant et al., 1988) and will

need tympanoplasty, aspiration and grommets (ventilation tubes inserted through the

tympanic membrane under general anaesthetic.)

Six Months of age

A. Palatal Repair

Soft palate repair

1. Furlow or Z-plasty

2. Intra-velar veolplasty: radical dissection and reorientation

Hard Palate repair

1. V-Y closure technique

2. Von Langenbeck technique


3. Delair technique

4. Primary tongue flab technique

Some claim that it is better to delay the closure to 5-6 years to avoid scar occurrence

and subsequent growth retardation. But in this case the defect should be closed with

obtutator, so the speech is dramatically influenced.

B. Dental roles:

continued advise on feeding,

oral health

C. Sometime Lip and soft palate repair undertaken at 6 months at one time

D. Pharygoplasty:

In proportion of cases the repaired palate does not completely seal off the

nasopharynx during speech and nasal escape of air may occur, resulting

hypernasality.

Nasopharyngoplasty is undertaken at the same time as the primary palatal

repair is performed.

However, it is preferable to carry this procedure at the age of 4-5 years.

Aetiological factors pf speech problems:-

1. Velopharyngeal insufficiency,

2. Hearing problems

3. Dental and occlusal anomalies.

4. Developmental learning disability.

5. Psychosocial impact.


2-5 Years of age

1. Lee records at 5 years stage

2. Assessment using the 5-year-old index introduced by Atack 1997

3. Interceptive Orthodontic treatment.

Elimination of anterior crossbites

Identify potential problems such as supernumaries.

If 15 and 25 are missing plan early loss of maxillary E’s to allow

spontaneous closure of 16 and 26.

In deep bite case consider a bite plane to allow posterior tooth

eruption.

Plan loss of deciduous teeth around the cleft early to improve quality

of mucosa prior to grafting

4. Dentist roles

diet analysis

OHI

use of fluoride

restorative care

5. Speech and hearing assessment. Consideration for pharygoplasty and

grommets.

6. Primary bone grafting is carried out within the first 2 years of life and

is less popular than secondary bone grafting. Primary bone grafting is

considered unfavorable and usually results in crossbite, malocclusion

and malunion of the maxilla.


7-10 years of age

1. Lee’s records

2. Goslon Yardstick (Mars 1987) .

3. Secondary alveolar bone grafting:

Alveolar bone grafting Introduced by Axhausen (1952).

Technique popularised by Boyne and Sands (1972, 1976).

Pre graft records. Occlusal, Study models and photos

Orthodontic preparation for graft at approximately 8-11 years before the eruption of

the maxillary canine (Bergland 1986), ideally when the canine root is ¼ to ½ formed .

One exception is, if the lateral incisor tooth is present, then earlier grafting may be

considered.

The viability of the result depend in the presence of unerupted teeth otherwise the

bone will resorbe again.

Orthodontist might extract deciduous and supernumerary teeth to provide sufficient

attached gingiva.

Treat caries and pathology

The orthodontist is often required to expand the maxillary arch prior to alveolar bone

grafting, usually with a fixed expander such as a tri- or quad-helix. This expansion

maximizes the size of the bony defect, improves the maxillary arch form and creates

access for the surgeon to place the graft during surgery.

Then the expander should be replaced with a stabilising transpalatal arch with palatal

extensions prior to surgery to facilitate surgical access. Bilateral cleft cases require a

stabilising arch wire to secure the pre-maxilla, at least 19*25 SS.

Transpaltal arches should remain for upto 3 months after surgery for stabilisation.


Care should be taken when aligning the incisors, as often the bone covering the roots

of the teeth is very thin. Often the aim then is to accept the mesio-distal tip and

rotations present in the upper incisors. Therefore when placing the brackets it is wise

to accept the inclination of these teeth rather than try to upright them and moves the

roots of the teeth out of the bone and into the cleft space. After the bone graft the

brackets can be replaced and the roots moved into the correct position.

The main aims of this procedure to:

1. Aims to stabilize maxillary segments

2. Facilitate any prosthetic restoration

3. Allow spontaneous eruption of teeth into the cleft area

4. Enable orthodontic tooth movement through the cleft site,

5. Improve bony support for the alar base.

6. Eliminate any mucosal recesses liable to cause food retention.

7. Improve nasal symmetry where there is skeletal dysplasia of the area

lateral to the nostril.

Surgical technique of ABG.

1. Incision

2. After closure of the nasal surface,

3. Cancellous bone is harvested from donor sites, The best source of bone for

grafting for the alveolar cleft defect is the iliac crest, The rib, the cranium, tibia

and the mandible or artificial bone graft have also been used.

4. cortical bone is not preferred because of the reduce vasculaity and high risk of

necrosis.

5. Additional bone is placed under the ala and the nose on the cleft side to provide

nasal symmetry.

6. The covering flaps are then closed.


7. A protective palatal splint or orthodontic arch wire is sometimes used for further

stabilization,

8. Modified flaps may be needed to close residual palatal fistulae defects.

9. success rate when graft placed prior to eruption of canine 90%. 72% after or

during eruption of canine.

10. Success of UCLP=BCLP if adequate stabilisation of premaxilla.

11. then it is usually possible to proceed with orthodontic movement of teeth in the

grafted

Postoperative assessment

1. General assessment After 6 weeks to check infection

2. After 4-6 months Kindelean score

3. one year after ABG, Bergland index

The complications

1. Granuloma formation .

2. failure

3. postsurgical problem at donor area

4. Around 15% of the canines will require exposure.

5. External root resorption.

Influencing success

1. Dental development – best results when carried out before canine eruption

(Bergland et al, 1986; Lee et al, 1995; Kalaaji et al, 1996; Enemark et al,

1997)

2. Donor site: Iliac crest best (LaRossa et al, 1995) although not statistically

significant in CSAG study – Williams and Sandy, 2003) also tibia, rib, genial

and cranial


3. Pre-operative health of graft site

4. Post-operative complications

5. Socioeconomic status and ethnic group

6. Surgical procedure + more experience = better results

7. Extraction of teeth at surgery (not statistically significant in CSAG (Williams

and Sandy, 2003)

8. Surgeon specialty (OMFS better than Plastic surgeon) not statistically

significant (Williams and Sandy, 2003)

9. Bone volume – weigh alveolar bone (Kamakura et al, 2003)

10. Complete closure of fistulae

11. Impaction of canines

11-15 Years of age

Pharyngoplasty

Pharygoplasty may be undertaken at 11-15 years to improve velo-pharyngeal

competence, if not already undertaken at an earlier age.

VPI may become a greater problem in the adolescent as lymphoid tissue shrinks

effectively increasing the distance the scarred soft palate needs to breach to create a

seal.

Orthodontics

Conventional orthodontic treatment if the malocclusion is simple with or without

EOA


18+ Years of age

1. Lee’s Records

2. Orthognathic surgery

There is usually a need for pre-surgical orthodontics.

due to risk of worsening VPI and due to previous surgical scarring, the Large jaw

discrepancies of 10mms and above may also require a mandibular setback

a modified maxillary Le fort 1 advancement or Converse Wake Procedure (that

move the maxilla without influencing the position of the palate) is used with

careful attention paid to the mobilisation of the maxilla.

Use Distraction osteogenesis as alternative

Use Horseshoe osteotomy as alternative

Severe maxillary restriction may require Surgically assisted RME and 2 or 3 piece

Le fort 1 osteotomies

Any expansion gained should be permanently retained. (Proffit and White 1990)

3. Secondary plastic procedures

Such as nose and lip revision. These are best undertaken after growth, since growth can

detrimentally affect earlier revisions.

Terminology Velopharyngeal impairment is a generic term indicating that the patient is unable to

induce sufficient contact between the velum and the posterior and lateral pharyngeal

walls

Velopharyngeal insufficiency is a form of velopharyngeal impairment caused by a

soft palate whose functional length is insufficient.


Velopharyngeal incompetenceis a form of velopharyngeal impairment caused by

neuromuscular impairment .

Hypernasality is a resonance phenomenon that occurs when sound is inappropriately

generated in the nasal cavity.

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