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THE ORTHODONTIST'S ROLE IN A CLEFT PALATE-CRANIOFACIAL TEAM

PRESENTED BY- Dr.Sita Niure PG resident

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CONTENTS

• Introduction• Epidemiology• Embryology• Etiology• Classification of clefts

• Management of cleft lip and palate:

- Infant orthopedics-nasoalveolar molding

- Treatment in mixed dentition

- Treatment in permanent dentition

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• Surgical orthodontics

• Distraction osteogenesis

• Velo pharyngeal Incompetence

• Conclusion

• References

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INTRODUCTION

• Orofacial clefts are among the second most common congenital

anomalies of all kinds. Such anomalies results in several handicaps

such as impaired suckling, defective speech, deafness, malocclusion,

gross facial deformity and severe psychological problems.

• Cleft of lip and the palate is one such condition, that occurs at such a

strategic place in the orofacial region and at such a crucial time that

it becomes a complex congenital deformity requiring a

multidisciplinary team approach in its management.

112 5Members in the team approach to patients with craniofacial anomalies

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EPIDEMIOLOGY• Cleft lip and palate is a global problem.(0.28 to 3.74/1000 live births globally)

• Least incidence in negroids(0.021 to 0.41 per 1,000 live births) and maximum

in afghans(4.9%)

• Orientals(esp Japanese)-1.14 to 2.13 per 1000 live births• In India 1.7 cases are seen in every 1000 individuals.• In India - CL+CP-1.25/1000 • CP 0.46/1000

• The incidence of oral clefts is seen more in males than in females.

• Cleft lip alone- more in males than female

• Cleft palate- more in females than males

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ETIOLOGY

GENETIC

TERATOGEN

ASSOCIATED WITH OTHER MEDICAL

CONDITIONS

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Genetics

• Genetic disorders are classified into the following groups:

1. Chromosomal disorders

2. Monogenic/Single gene disorders

3. Polygenic/Multifactorial disorders

4. Mitochondrial disorders

• The expression of a multifactorial disorder is based on a threshold model(Melnick 1972), whereby those with more of the disease causing genes and environmental factors are likely to exceed the theshold and express the disorder.

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SYNDROMES WITH CLEFT LIP AND PALATE

• Van der woude Syndrome

• Apert syndrome

• Treacher Collins Syndrome Autosomal Dominant

• Cleidocranial Syndrome

• Ectodermal Dysplasia

• Stickler’s Syndrome

• Oro-facial digital syndrome

• Pierre Robin syndrome

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• Roberts Syndrome

• Christian Syndrome Autosomal Recessive

• Meckel Syndrome

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ENVIRONMENTAL FACTORS: TERATOGENS

• The impact of a teratogen is determined by the genotype

of the mother and the child and the timing and the dose of

the drug.

• Usually occurs due to various influences during 1st

trimester.

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• Medications implicated to cleft formation:1. Diazepam and other benzodiazepines

2. Steroids(0.07% to 1.9%)

3. Amphetamine

4. Diabetes- a medical condition

5. Anti seizure drugs.eg: diphenyl hydantion and trimethadione.also causes growth retardation, craniofacial dysmorphism, mental deficiency including oral cleft.

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Environmental teratogens:

- Ethyl Alcohol- causes FAS (fetal alcohol

Syndrome).

- Cigarette smoking- 30% increase in cleft lip and palate and

20% increase in cleft palate in smoking during pregnancy.

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• Nicotine acts synergistically with TGF.• An important initial step in development of the

primary palate is a forward movement of the lateral nasal process which positions it so that contact with the median nasal process is possible.

• The hypoxia associated with smoking probably interferes with this movement.

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• Hypervitaminosis A: acute maternal exposure to 13-cis retinoic acid during first trimester causes cell death in the pharygeal arch leading to facial clefting. Vit A analogue used as an anti-acne drug-Also proved by animal experiments.

• Folic Acid: Deficiency of folic acid affects virtually every organ system. It affect the neural tube- neural crest cell migration and differentiation.

• Anaemia and anorexia

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INFECTION DURING PREGNANCY:

• Rubella infection during the first 3 months associated with clefting.

PARENTAL AGE:

• Shaw etal presented evidence that women above the age of 35 had a doubled risk of having a child with CLCP. above 39- tripled risk.

• Consanguineous marriages- increased risk of CLCP in child

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EMBRYOLOGY

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Elevation of palate

• Descent of tongue influenced by the growth of mandible and meckel’s cartilage

• Myoneural activity of tongue

• Mouth opening reflexes

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• Transition from vertical to horizontal is completed within hours

Mechanisms proposed for this rapid elevation of palatal shelves:

1. Biochemical transformations in the physical consistency of the connective tissue matrix of the shelves

2.Variations in vasculature and blood flow to these structures

3.Sudden increase in their tissue turgor

4.Rapid differential mitotic growth

5.An intrinsic shelf-elevating force-chiefly generated by accumulation and hydration of hyaluronic acid

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Prenatal Diagnosis of Cleft Lip/Palate

• Ultrasonography is a noninvasive diagnostic tool now widely used as a routine component of prenatal care.

• Ultrasonography serves to confirm fetal viability, determine gestational age, establish the number of fetuses and their growth, check placental location, and examine fetal anatomy to detect any malformations.

• Three-dimensional ultrasound imaging is a new technology that presents views of the fetal face with greater clarity than the conventional two-dimensional imaging

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Advantages of prenatal diagnosis

1. Psychological preparation of parents and caregivers.

2. Patient education

3. Preparation for neonatal care and feeding

4. Opportunity to investigate for other structural or chromosomal abnormalities

5. Possibility for fetal surgery

6. Customized surgical treatment plan by the plastic surgeon.

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Disadvantage

• An emotional disturbance and high maternal anxiety after prenatal diagnosis.

• Families choosing to terminate the pregnancy even in the absence of other malformations.

1. perceived burden,

2. expectation of recurrence,

3. religious and cultural beliefs,

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DAVIS AND RITCHIE CLASSIFICATION (1922):

Group I-Pre alveolar clefts Lip clefts only

with subdivisions for unilateral, median,

bilateral.

Group II-Post alveolar clefts degrees of

involvement of soft and hard palate to be

specified till the alveolar ridge, submucous

clefts included.

Group III-Alveolar clefts is complete clefts

of palate, alveolus ridge and lip with

subdivisions for unilateral, median, bilateral.

They classified congenital clefts based on the position of the cleft in relation to the alveolar process.

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A) Cleft lipClass I-unilateral and bilateral cleft of the Vermillion border not extending into the lip. Class II-unilateral and bilateral notching of Vermillion with cleft extending into the lip, but not including the floor of the nose. Class III- unilateral and bilateral cleft of vermilions border, involving lip and extending into the floor of the nose. Class IV-any bilateral cleft of the lip whether incomplete or complete.

VEAUS CLASSIFICATION - 1931

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B) Cleft palate• Class I- cleft involving only

soft palate• Class II- cleft involving hard

and soft palate extending no further than the incisive foramen

• Class III- complete unilateral or bilateral cleft extending from uvula to incisive foramen then deviating to one side

• Class IV- complete bilateral cleft similar to class III with two clefts extending forward from the incisive foramen into the alveolus

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KERNAHAN’S STRIPED “Y” CLASSIFICATION (1971)

• In this classification the incisive foramen is taken as the reference point

• “Y” logo are each divided into three sections, representing the lip, the alveolus and the hard palate as far back as the incisive foramen. The stem of the “Y” is also divided into three parts, representing varying degrees of clefting of the hard and soft palates.

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MILLARD’S CLASSIFICATION (1977):• A modification of Kernahan’s striped

“Y” classification. • The inverted triangles represent the

nasal arch the upright triangles represent the nasal floor.

LAHSHAL CLASSIFICATION:

L- lip

A- Alveolus

H- hard palate

S– soft palate

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MANAGEMENT OF CLEFT LIP AND CLEFT

PALATE

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• During different stages of the physical and social development of the cleft patient, role of one specialist may be more significant than the other.

• During early days, immediately after birth the feeding specialist, neonatologist, orthodontist and the cleft surgeon take the lead role.

• After the first year, issues with hearing, middle ear infections and speech therapy are more relevant and important issues to be tackled with.

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• Similarly, later during the late mixed dentition stage orthodontist would need greater indulgence.

• At adulthood, plastic surgeons, would play a key role in the correction of secondary deformities of lip and nose.

• A prosthodontist may be required to rehabilitate missing teeth and form aesthetic treatment of the dentition.

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Feeding issues• Bottle feeding • Cup & spoon feeding• Tube feeding• Posture: Infant must be held at 30 – 45 degrees or in upright position in order to aid in swallowing and prevent aspiration

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Feeding obturator• The feeding obturator is a prosthetic aid that is designed to obturate the cleft and

restore the separation between the oral and nasal cavities.

• It creates a rigid platform

• The obturator also prevents the tongue from entering the defect and

interfering with spontaneous growth of the palatal shelves.

• reduces nasal regurgitation,

• reduces the incidence of choking,

• also helps in the development of the jaws and

contributes to speech

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ORTHODONTISTS ROLE

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• Timing and sequencing of orthodontic care may be divided into four distinct developmental periods.

• These periods are defined by age and dental development and should be considered as time frames in which to accomplish specific objectives.

1. Neonate and Infant (Birth to 2 Years of Age)

2. Primary dentition( 2 to 6 years)

3. Mixed dentition stage

4. Permanent dentition

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Preoperative orthopaedic treatment

• In 1954, Mc Neil advocated the placement of a

prosthesis immediately after birth to help align max

segments in patients, with complete cleft of lip,

alveolus and palate.

• This approach is known as “infant maxillary

orthopaedics”

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• Goal- to move abnormally positioned maxillary

arches and the pre maxilla into a normal

relationship prior to surgery .

intra oral

• Appliances

extra oral

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LIP TAPING

PRESURGICAL ORTHOPEDIC TREATMENT(PSOT)

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Advantages of lip taping:• the cosmetic appearance is improved with a minor

initial surgical procedure• parents are not required to remove or adjust appliances, • postoperative care by the parents is minimal.

Disadvantage:• potential of wound dehiscence and the need for an

additional surgery

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Nasoalveolar molding GRAYSON

• Esthetically pleasing result in the treatment of cleft lip and palate difficult to achieve due to the actual anatomical deformity of the nose.

• Abnormal nasal cartilage morphology, deviated nasal septum and columella, asymmetry of the alar, and a short or even absent columella, depending on the type of cleft.

• Therefore Dr. Grayson and Dr. Cutting emphasize the importance of presurgical correction of the nasal cartilage and soft tissue deformity, which can be achieved by a combination of nasal and alveolar orthopedic molding.

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UNILATERAL DEFORMITY

• wide nostril base• separated lip segments on the

cleft side.• affected lower lateral nasal

cartilage is displaced laterally and inferiorly -depressed dome

• appearance of an increased alar rim

• an oblique columella,• overhanging nostril apex• If there is a cleft of the palate,

the nasal septum will deviate to the noncleft side with an associated shift of the nasal base.

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BILATERAL DEFORMITY• Procumbent and/or rotated

premaxilla.• Increased alar base width• lip segments are widely separated• severely deficient or absent columella- flattened nasal tip appears tethered directly to the prolabium• lower lateral alar cartilages are flared and concave where they should be convex.

Esthetic reconstruction of the deficient or absent columella-biggest challenge

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Pre -Orthodontic treatment After 3 months of Grayson molding plate application

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Concept-molding the cartilage

• The original research for molding cartilage was performed by Matsuo.

• Cartilage in the newborn is soft and lacks elasticity.• High maternal level of estrogen at the time of birth

correlates with an increase in hyaluronic acid, which inhibits the linking of the cartilage intercellular matrix.

• necessary to relax the cartilages, the ligaments and connective tissue- enabling the fetus to pass through birth canal-estrogen level decline after birth.

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• The primary objective of the treatment is stimulation and redirection of alveolar growth aiming for the non surgical approximation of the cleft deformity.

• To achieve this it is planned to treat the patients with molding appliance in conjunction with a traction force across the cleft lip followed by a nasal stent later.

• The nasal stent and alveolar molding plate help in achieving nasal and alveolar symmetry, nasal tip projection, and contact of the cleft alveolus just before primary lip, nasal and alveolar surgical repair.

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Procedure

• Timing: immediately after birth

Impressions-heavy body impression material

Infants position-upside down-presence of suregon important.

cast poured with dental stone-molding plate fabricated

(hard clear acrylic and lined with a thin coat of soft denture material)

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• Molding plate is fabricated in such a way that there are no extensions of the plate into the alveolar or palatal cleft space.

• Full time wear- except for cleaning• The appliance is secured extraorally to the cheeks,

bilaterally by surgical tapes, which have an orthodontic elastic band at one end.

• The elastics loop over a retention arm extending from the anterior flange of the plate.

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Nasal stent is added to the molding plate when the cleft alveolar gap is reduced to 5mm or less.

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a.As the wire armature of thenasal stent extends into the nostril, it is curved back on itself to create a small loopfor retention of the intranasal portion of the nasal stent. b. Hard acrylic(methylmethacrylate)is applied to the wire armatureand shaped into a bi-lobed form that resembles a kidney. c. The hard acrylic nasal stent is coated with a thin layer of soft dentureliner for comfort. d The upper lobe of the nasal stent enters the nose and gently lifts the dome until a moderate amount of tissue blanching is evident. The lower lobe ofthe nasal stent lifts the nostril apex anddefines the top of the columellaNASAL STENT

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Bilateral complete cleft

4months 1.6 years

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Complications Complications and Solutions in Presurgical Nasoalveolar Molding Therapy

Daniel Levy-Bercowski, D.D.S., M.S.D., Amara Abreu, D.D.S., M.S.D., Eladio DeLeon, D.M.D., M.S. et al

Cleft Palate–Craniofacial Journal, September 2009, Vol. 46 No. 5

Contact dermatitis

SOFT TISSUEHARD TISSUE

COMPLIANCE RELATED

Overactivation of the nasal stent may produce bruising orpetechiae in the dome area.

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Overstretching of the columella in a patient with bilateral cleft, as a result of the pressure exerted by the prolabium tape and the nasal stents.

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HARD TISSUE COMPLICATIONS

Figure: A)Patient with complete unilateral cleft lip and palate with asevere nasal deformity (pretreatment with NAM). B)After 18 weeks of NAM treatment, nasal morphologyimproved significantly. However, a T-shaped maxillary arch was created.

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FIGURE. A) Premature eruption of primary maxillary incisors due to the pressure exerted by the molding plate in a patient with bilateral cleft lip and palate. B)Patient continues with NAM treatment after the extraction of the primary incisor.

Figure: NAM modification to permit the eruption of primary incisor

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Compliance related problems

•Eight (39%) of the patients had at least one broken appointment.•The NAM appliance was removed with the tongue in seven patients (26%) and with the hands in three (11%)

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Cleft lip repair

Goal: goal of all repairs is a normal looking lip and nose which will not be distorted by the growth or aging.

Criteria for satisfactory repair:• Accurate skin, muscle & mucous membrane union.• Symmetrical nostril floors

• Symmetrical vermilion border

• Slight eversion of the lip

• Minimum scars

• Preservation of cupids bow & vermilion cutaneous ridge.

• Production of symmetrical nostrils as well as symmetrical

nasal floors.

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Timing :

• Rule of “over ten” – 10 weeks, 10 pounds, 10 gm of Hb.

• Preferably 3 – 6 months.• Techniques used:

1. Tennison's triangular flap procedure

2. Millard's rotation flap

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Cleft Palate repair

• Aim – speech, chewing & aesthetics.

• Timing : previously the surgeons involved in cleft

palate treatment usually performed surgical

procedures whose sole purpose was to close the

defect as early as possible without considering the

ultimate effect on surgery on palatal, facial or

speech development.

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• The timing of closure is controversial. Can be done early

at 18-24 months or at 9-12year

• At 18-24 month-• Development of normal speech• Tendency towards maxillary underdevelopment

• At 9-12year-• Normal growth of maxilla with unrepaired cleft• Reduces surgical morbidity and infection

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• Latest suggestion-• Closure of soft palate –age of 12 month• Help in development of Speech • No growth retardation with early soft palate closure • Closure of hard palate –age of 5-6year

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Primary Dentition Stage (2 to 6 Years of Age)

• Establishment of primary dentitions-enables to predict the developing malocclusion

• Facial soft tissues may mask the underlying skeletal deficiency of the midface in young children.

7 years 9 years

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• Treatment priorities are:1. To correct crossbite by using removal plates or

lingual arch.

2. To control or eliminate oral habits, functional shift or space loss after premature loss of primary teeth

3. After the first phase, a removable retainer (at least night time) is worn till the next phase is begun.

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Mixed Dentition Stage (7 to 12 Years of Age)

• A tentative decision on extraction of

supernumerary teeth and overretained teeth.

• Correction of cross bite- jack screw, RME,

quad helix, Niti expanders

• Maintain space for proper eruption of teeth.

• Expand collapsed segment to improve

surgical access to the graft site.• Traumatic occlusion is eliminated in

preparation of alveolar graft. (By aligning offending tooth)

• Correction of jaw relationship- Face mask Therapy

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Because deficiency of tissue is an inevitable consequence of facial clefting, not only are the teeth missing but also the supporting alveolar bone at the cleft site is compromised.

Bone defect before grafting

7 months 4 years after alveolar bone grafting

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Alveolar bone grafting

• Primary alveolar bone grafting: done at the time of lip closure at around 10-12 weeks. Common in 1950s. Causes hinderance in maxillary growth.

• Secondary alveolar bone grafting: Boyne and Sands in 1972

• done after lip closure at later stage. This is can be

divided into three:

• Early (2-5 years): performed in primary dentition.

Rationale is to allow eruption of the lateral incisor if

present. Can affect growth of midface.

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• Intermediate (6-15years): performed in late mixed

dentition time to allow the eruption of the

permanent canine in the graft. There is minimal

interference in growth.

• Late secondary alveolar bone grafting

(adolescence to adulthood):

• Aids in replacement of missing teeth with implants

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Rationale for bone grafting

1. To restore physiologic continuity of arch for esthetic and

hygenic replacement

2. To provide bone for stability of dental arch and the

premaxillary segment

3. Bone is provided into which unerupted teeth may erupt.

4. At the time of placement of graft, patent oronasal fistulas can

be closed

5. To allow orthodontic alignment of teeth

6. To provide support for the lip and the alar base and the nasal

tip.

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• Bergland and coworkers have given an index to evaluate success of the grafted bone based on the height of the interdental septum on IOPA X-ray films

• Type I—normal

• Type II—75% of normal bone height

• Type III—less than 75%

• Type IV—no bony ridge.

Post bone graft follow up

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THREE CONTEMPORARY CONTROVERSIES ARE:

1) Timing of grafting

2) The type of bone for alveolar grafting and donor site

3) Sequencing of orthodontic expansion.

Favor of 8-10 year of age (when canines about to erupt-one quarter to two thirds of root complete)- Bergland etal

• Erupting tooth is a potent stimulus for bone formation.• After tooth eruption is complete, it can be very difficult to

induce the formation of new bone.• Prevents eruption into cleft-periodontal defect• If placed after eruption of permanent teeth then chances

of damaging roots and resorption

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GRAFTING MATERIAL Autogeous Advantages

• Iliac crest adequate quantity easily condensed & placed, little donor site morbidity

• Tibia adequate volume quality similar to iliac crest • Rib for infants.

• Cranial bone inadequate quantity, less resorption, rapid vascularization, predictable quality

Allogenic grafts: it acts a scaffold into which new bone develops. Freeze dried bone( increased chances of immune reaction, HIV infection, longer post operative phase) REVASCULARISATION OF GRAFT IS SLOW.

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EXPANSION should be done before grafting, as after the graft

mature and sutures fuse it is difficult to expand maxilla later. Also

Expanding the arch before grafting increases the size of cleft and

thus more area for placement of bone. But increased amount of

bone is required and requires more soft tissue dissection for

closure.

Expansion can also be done 6wks after grafting. It has a potential

of stimulating immature bone which may enhance graft survival

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Protraction of maxilla-Face mask therapy

•Used in mild maxillary deficient cleft patient

•Orthopedic forces for maxillary protraction -350-500 gm per side over 10-12 hr / day for an average of 12-15 months.

• Stability is questionable Because of two reasons

1.Counter pressure of a tight lip on the maxilla,

which inhibits its growth

2.Scarring in pterygo maxillary region

after extensive tissue mobilization for palatal

closure

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•Protraction face mask- mid facial orthopedic forces applied– increase growth at the circum maxillary sutures.

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PERMANENT DENTITION :

Clinical feature of this stage : • Medial displacement of the maxillary segment-buccal cross

bite• Relative maxillary retrognathism-reversed incisal overjet.• Deficiency of vertical growth of the upper jaw – REDUCED

FACIAL HEIGHT• Rotation, malposition and hypodontia of teeth.• Supernumerary teeth• Accentuated curve of spee in maxilla• Collapsed arch forms• Poor oral hygiene and caries

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ALIGNMENT OF INCISOR TEETH– Incisors usually rotated and in crossbite. Corrected by means of fixed

orthodontic appliance.

CORRECTION OF LATERAL DIMENSION– Lack of bony union between two sides of the maxilla, correction in

lateral dimension is relatively straight forward.– By expansion appliance

Quad Helix Rapid Maxillary Expansion (RME)

Patients with CLP have class III malocclusion because of maxillary deficiency

(A-P and Vertically), coupled with mandibular overclosure. In such cases use of

class III elastics after leveling and aligning will result in upper molar extrusion

and favorable downward and backward rotation of mandible.

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Orthognathic Surgery combined with Orthodontics

•Due to severe skeletal discrepancy, there is deterioration of esthetics

and occlusion, psychological implications leading to low self esteem,

defective speech, oronasal fistulas. Such cases require a combined

orthodontic and orthognathic approach.

•Size and position of maxilla is often a problem, thus maxillary

advancement and occasional down grafting needs to be performed. To

correct the transverse problem multiple segment LeFort I osteotomies

may be required. For a bilateral CLCP three-piece maxillary surgery

(allows rotation of segments also) required while for unilateral CLCP a

two piece is sufficient.(Vlachos 1996)

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Decompensation:

•Usually requires 12 months.

•Multiple segment maxillary osteotomies requires segmental

treatment. The bracket positions are altered for teeth adjacent to the

osteotomy site.

•Dental compensations in the lower arch also should be addressed

i.e, alleviation of crowding and proclination.

•Gaps present in the arches due to the missing teeth must be either

closed- stable result and prevents reopening of oronasal fistula.

Pre-surgical orthodontics

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• Proffit recommends overcorrecting the anterior crossbite

in excess of positive overjet- compensate for post surgical

relapse.

• In cases with an overjet(reverse) of more than 8mm

mandibular surgery (BSSO) also must be considered. If

not then over advancement of maxilla – unstable and

speech defects.

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TIMING• Never indicated in active facial growth• Ideal time : age 18-19

•Post surgical orthodontics: involves detailing of occlusion,

closure of residual spaces and maintenance of transverse

dimension (overlay arches). Lasts for 4-6 months.

•Retention: After removal of appliance retainers should be

placed immediately.

Temporary vacuum filled retainers to be avoided-transverse

control inadequate. Soldered lingual arch preferred.

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DecompensationAge-16 years

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Patient at 17 years of age following maxillary advancement and mandibular setback surgery and undergoing postsurgical orthodontic treatment

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DISTRACTION OSTEOGENESIS

• With the advent of distraction osteogenesis, correction of severe maxillary hypoplasia solely by advancing the maxilla may be possible.

1903 . Dr. Gavril of Russia-Bone lengthening of leg.• It is a procedure that moves two segment of bone slowly

apart in such a way that new bone fills the gap.

• In distraction osteogenesis, a surgeon makes an osteotomy

in an bone and attaches a device known as distractor to

both sides of osteotomy.

• The distractor is gradually adjust over a period of days or

week to stretch the osteotomy so new tissue fills it.

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Maxillary surgery required in 25-60% of cases with clcp. (Ross and Subtenly)

Distraction osteogenesis allows soft tissue adaptation, including

scar tissue. Therefore doesn’t cause a problem with

velopharyngeal insufficiency thus good results. Distraction Of

maxilla first proposed by Molina & Oritz-Monasterio(1998)

EXTERNAL DISTRACTORS

Advantage:

•Direction of force is well controlled

Disadvantage:

•Cranial surgery is required

•Esthetics are compromised

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A, Frontal view of 19-year-old man with repaired bilateral complete cleft lip and palate, with rigid external distractor (RED)apparatus in place. B, Profile view with distraction osteogenesis appliance for advancement of the maxilla. C, Profile view before distraction osteogenesis. severe maxillary deficiency present. D, Profile view afterdistraction osteogenesis. improved position of maxilla relative to mandible.

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INTERNAL DISTRACTORS

Advantage:

•Esthetics

•Psychological relilef

Disadvantage:

•Difficult to control the direction of force

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VELOPHARYNGEAL INSUFFICIENCY

Velopharyngeal insufficiency is a

disorder resulting in the improper

closing of the velopharyngeal

sphincter (soft palate muscle in the

mouth)during speech, allowing air to

escape through the nose instead of the

mouth.

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• VPD is of 3 types:

a)Velopharyngeal Mislearning: due to articulation difficulties

b)Velopharyngeal Incompetence: Due to functional abnormalities.(paresis, dysarthia)

c)Velopharyngeal Insufficiency: Structural problems like cleft or bifid uvula etc

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VPI may be found in children who have:

• Cleft palate (about 20-30 percent of children who have cleft palate will still have VPI after the palate repair)

• Submucous cleft palate

• Certain syndromes, such a velocardiofacial syndrome

• Had previous adenoid removal

• Weak throat muscle

• Too much space between the palate and the throat

Some children have VPI from an unknown cause.

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• The main speech symptoms of velopharyngeal insufficiency are:

1. Hypernasality and

2. Nasal air emission.

3. Misarticulations of certain words

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Treatment of VPISpeech Therapy• Some speech problems linked with VPI, such as

mispronouncing words, can be treated by speech therapy. Treatment focuses on teaching the child the correct manner and place of articulation

Non-surgical management: • Sometimes an obturator is recommended to treat VPI. • An obturator is like a modified dental retainer with a

speech bulb or palatal lift attached to the back. Each obturator is shaped uniquely to fit the patient’s muscle movements.

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Speech bulb prosthesis

•An obturator can be a short-term or long-term option for children with VPI. •It can be used before or instead of surgery. •The child may start with an obturator and have surgery when he is older or they may continue to use an obturator as an adult.

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Surgical intervention:

1. Palatoplasty

2. Sphincter pharyngeoplasty

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Different protocols for the management of CLP

Nether lands protocol • Presurgical orthopedic treatment appliance(PSOT) –

birth to 1 1/2 years.• Lip closure – 5-6months• 2 stage palatal closure – soft palate-12-18months,hard

palate-6-9 years of age.• Bone grafting of alveolar cleft.

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Oslo protocol

• Evolved at the Oslo Cleft Centre.• does NOT follow preoperative orthopedics• Millard lip repair at age of 3 months• In cases with an associated cleft of the alveolus and

palate, a cranial base single layer vomer flap is sutured under the alveolus palate periosteum at the time of lip closure.

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Zurich concept

• Aim – to maximize palatal growth.• Passive plates used in conjunction with delayed

surgical procedures were introduced in zurich , Switzerland in 1960.zurich appliance is a combination of both soft & hard acrylic.

• It is worn continuously for 16 – 18 months & is replaced every 6 months.

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Zurich protocol

• Passive plates worn for 16 – 18 months• Plate changed every 6 months• Reduction of gingival side of the plate

every 3-8 weeks.• Lip closure - 6months of age• Soft palate – 18 months• Hard palate – 4-5 years.

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A Modified Surgical Schedule for Primary Management of Cleft Lip and Palate in Developing Countries

Karoon Agrawal, M.S., M.Ch., Kasinath Panda, M.S.Cleft Palate–Craniofacial Journal, January 2011, Vol. 48 No. 1

• Introduction: In developing countries cleft lip and palate (CLP) patients arrive late, and there is a risk of drop out for functionally important palatoplasty after lip repair. Patients may be underweight, anemic, and prone to recurrent infections.

• Objective: To repair cleft palate at an appropriate time and secondly to avoid the drop out after the first surgery.

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• Modified Protocol: A new surgical protocol has been designed for patients with CLP in whom the cleft palate is first repaired at 6 to 9 months of age or whenever the patient presents at the clinic. The cleft lip is repaired 3 to 6 months after the first surgery.

• Advantages of the modified protocol1. Cleft palate is repaired at the most accepted time

schedule for palatoplasty at 6–9 months for good speech result.

2. Compliance for second surgery for cleft lip repair improved.

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• In presence of unrepaired cleft lip, the mouth opening is better and hence the visibility of the palate, so the cleft palate repair is technically easier.

• During cleft lip repair, the anterior palate repair is done under good vision; hence, incidence of anterior palatal fistula is very low.

• While performing the cleft lip repair, there is an opportunity to examine the palate under GA for any abnormality.

• Cleft palate fistula if identified can be repaired along with the lip repair.

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CONCLUSION

• The management of a patient with cleft lip and palate deformity definitely requires a multidisciplinary approach and the orthodontist has proven to be an essential member in the cleft palate team. The orthodontist is not only responsible for the active orthodontic treatment but also and facial orthopedic treatment of the child with a cleft. The ultimate outcome for team-based care is to have a fully rehabilitated patient who is satisfied with the treatment outcomes in terms of speech, occlusion, facial and dental aesthetics, and function.

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Past Questions

1. You are a member of CLP team.

Q. What is the best time for cleft lip repair?

A. 3 to 6 months

Q. When do you recommend for secondary alveolar bone grafting?

A. Ideally, the permanent canine root should be half to two thirds formed at the time the graft is placed. Permanent canine root formation generally occurs between the ages of 8 and 11 years. Occasionally the graft may be placed at an earlier age to improve the prognosis of a lateral incisor.

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Q. What is the most commonly used orthopedic appliance in CLP cases?

A. Face mask

Q. At what age is usually pre-surgical orthodontics preferred for this kind of patients?

A. Presurgical orthodontics or neonatal maxillary orthopedics is initiated during the first or second week following birth unless complications arise from other congenital anomalies or medical problems

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REFERENCES

• CRANIOFACIAL DEVELOPMENT- Sperber

• Samuel Berkowitz-Cleft Lip and Palate: Diagnosis and management-2nd Edition

• Thomas M. Graber, Katherine W. L. Vig, Robert L. Vanarsdall Jr. Orthodontics: Current Principles and Techniques.

• WR Profitt:Contemporary orthodontics-5th edition

• OP Kharbanda; Orthodontics-Diagnosis and management of malocclusions and dentofacial deformities;First edition

• Cleft lip and palate, Seminars in Orthodontics

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• Grayson et al, Pre surgical naso alveolar molding, cleftliip- craniofacial journal 1999:35

• B. H. Grayson and C. B. Cutting, “Presurgical Nasoalveolar Orthopedic Molding in Primary Correction of the Nose, Lip, and Alveolus of Infants Born with Unilateral and Bilateral Clefts,” The Cleft Palate-Craniofacial Journal, Vol. 38, No. 3, 2001, pp. 193-198.

• Advances in management of cleft palate: Edwards and Watson

• Baik et al. surgical orthodontic treatment in patients with clcp: conventional surgery v/s maxillary distraction, world J Orthod;2:331-40

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THANK YOU