CLEFT LIP AND

PALATE
Presenter : Dr CHARISMA THIMMAIAH

Guided by : DR MADHUSUDHAN
 CONTENTS
• Introduction
• Definition
• Embryology and development of palate
• Pathogenesis of clefting
• Aetiology of cleft lip and palate
• Classification of cleft and palate
• Management of cleft lip and palate
•Multidisciplinary sequencing of treatment
•Role of pedodontist
•Pre surgical orthopedics
Nasoalveolar molding appliance
Pre maxillary retraction
•Prosthodontic approach
•Orthodontic approach
•Surgical approach
•Conclusion
•References
 INTRODUCTION

• Clefts of the lip and palate are the most common congenital deformities
involving the orofacial region.

• It is a major public health problem due to the possible associated life-long

morbidity, complex etiology, and the extensive multidisciplinary
commitment required for intervention.
 DEFINITIONS
The two main types of oral clefts are cleft lip and cleft palate

• CLEFT LIP: A congenital anomaly of the face caused by the failure of

fusion between embryonic maxillary & medial nasal processes.”

• CLEFT PALATE:A congenital anomaly of the oral cavity caused by the

failure of fusion between the embryonic palatal shelves.

Thomas J. Zwemer, 2002

 EMBRYOLOGY

• Development of facial structures starts at the end of 4th week

5 facial prominences around stomatodeum

• Unpaired frontonasal process

• Paired maxillary prominences

• Paired mandibular prominences

In following 2 weeks –

• The 2 medial nasal processes fuse in midline – upper lip

• Mandibular processes fuse in midline – lower lip

The maxillary and lateral nasal process separated by nasolacrimal groove/duct

• Frontonasal process – bridge of the nose

• Medial nasal process – tip of nose and philtrum of upper lip

• Lateral nasal process – ala of the nose

 DEVELOPMENT OF PALATE

• Palatogenesis begins towards the end of 5th week and is completed by

about 12th week.

• The palate develops from two primordia.

– Primary palate

– Secondary palate

• The critical period of development is from the end of 6 th week till the
beginning of the 9th week.
 DEVELOPMENT OF PALATE

Primary palate

• At the end of 5th week of IU life medial

growth of maxillary and nasal process forms the
intermaxillary components/ single globular
process.

• The primary palate then gives rise to the

premaxilla, the anterior median portion of the
maxilla that encloses the 4 upper incisors
Secondary palate

• formed from 2 outgrowths from maxillary prominences – palatine shelves

• Fuse in midline at 7th week

• Incisive foramen – midline landmark between primary and secondary

Palate
• During 6th week  2 lateral palatal shelves develop behind the primary
palate from the maxillary process,

• a secondary nasal septum grows down from the roof of the stomodeum
behind the primary nasal septum, dividing the nasal part of the oronasal
cavity into two.

• During 7th week of development the oral part of the oronasal cavity
becomes completely filled by the developing tongue

• Growth of the palatal shelves continues and they come to lie vertically.
• During 8th week, stomodeum enlarges, tongue drops down and vertically
inclined palatal shelves become horizontal.

• Palatal shelves contact each other in the midline to form the definitive or
secondary palate

• Medial edge epithelia of the 2 shelves fuse to form the midline epithelial
seam.

• Fusion of palatal process is completed by the 12th week of development.

 FORMATION OF CLEFTS
• Failure of fusion of maxillary and medial nasal processes – anterior to incisive
foramen

• Failure of fusion of palatine shelves – posterior to incisive foramen

• Cleft lip – failure of proliferation of mesodermal cells in midline

 ETIOLOGY

Most clefts of the lip and palate generally are related to multifactorial inheritance .

Environmental factors Genetic factors

The aetiology of CLCP is attributed to heredity and environmental factors.

 GENETIC FACTORS
• Genetic disorders are classified into the following groups:
1. Chromosomal disorders
2. Monogenic/Single gene disorders
3. Polygenic/Multifactorial disorders
4. Mitochondrial disorders

• Out of the several genes discovered , genes responsible for causing

X-linked cleft lip/palate ,
-T-box transcription factor-22 gene,
-poliovirus receptor-like-1 gene,
-interferon regulatory factor-6 (IRF6) gene
 ENVIRONMENTAL FACTORS

1. Nutritional deficiency:-

2. Medical condition of mother

3. Defective vascular supply to fetus

5. Viral infection
6. Exposure to radiation
7. Alcohol consumption and smoking
8. Drugs:-
 SYNDROMES ASSOCIATED WITH
CLEFT LIP & PALATE
Autosomal dominant

• Van der woude syndrome (lip pits with cleft lip/ palate)
• EEC syndrome (ectrodactyl, ectodermal dysplasia and clefting)
• Larsen syndrome (originally thought to be reessive)

Autosomal recessive
• Chondrodysplasia punctata (conradi syndrome)
• Meckel syndrome
• Orofacial digital syndrome, type II
• Fryns syndrome
X linked
• Orofaciodigital syndrome, type I
• Isolated X linked cleft palate with ankylooglossia

Chromosomal
• Trisomy 13
• Trisomy 18

Non mendelian
• Pierre robin sequence
• Clefting with congenital heart disease.
 CLASSIFICATION OF CLEFT LIP AND
PALATE

DAVIS AND RITCHIE CLASSIFICATION (1922)

Pre alveolar Post alveolar Alveolar

cleft cleft cleft

Unilateral, Hard palate Unilateral,

left or right only left or right

Soft palate Median

Median
only

Soft and Bilateral

Bilateral
hard palate

Submucous
cleft
 VEAU CLASSIFICATION (1931)

CLEFT LIP

• Class I : U/L notching of vermillion border, not extending into the lip.

• Class II : cleft extending into the lip, but not including the floor of the nose.

• Class III: extending into the floor of the nose

• Class IV: any b/l cleft of the lip, whether incomplete or complete.

Class I Class II Class III Class IV

 VEAU CLASSIFICATION (1931)

• CLEFT PALATE
• Group 1:- Defects of the soft palate only.

• Group 2: Defects involving the hard and

soft palate to the incisive foramen. But
not alveolus

• Group 3: complete unilateral cleft of the

soft, hard palate and alveolar ridge on one
side.

• Group 4: Complete bilateral clefts of the

soft hard palate and and alveolar ridge on
both sides.
 FOGH- ANDERSON CLASSIFICATION
(1942)

• Hare lip- includes alveolus and as for back as incisive foramen

• Hare lip and cleft palate

• Isolated cleft of the palate as forward as the incisive foramen

 American association of cleft palate
rehabilitation classification (1962)

I. Cleft of prepalate:

• Cleft lip unilateral/ bilateral/median /prolabium/ congenital scar

• Cleft of alveolar process unilateral/ bilateral/median /any

combination of foregoing types

• Cleft of prepalate prepalate protrusion /prepalate rotation

/prepalate arrest
II. Cleft of palate:

Cleft of soft palate- extent/palatal shortness/ submocous cleft

Cleft hard palate – extent/vomer attachment/submucous cleft

Cleft of soft and hard palate

III. Cleft of prepalate and palate

Any combination of clefts described
 KERNAHAN AND STARK
CLASSIFICATION
 Cleft of primary palate
• unilateral- complete/ incomplete
• median- complete/ incomplete
• bilateral- complete/ incomplete

 Cleft of secondary palate only

• Complete
• Incomplete
• Submucous

 Cleft of primary and secondary palate

• Unilateral- complete/ incomplete
• Median- complete/ incomplete
• Bilateral- complete/ incomplete
 KERNAHANS STRIPED Y CLASSIFICATION

• 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
 MILLARDS MODIFICATION OF STRIPED Y

• A modification of Kernahan’s striped “Y” classification.

• The inverted triangles represent the nasal arch the upright triangles
represent the nasal floor.
PROBLEMS ASSOCIATED WITH
CLEFT LIP & PALATE
 DENTAL

 Tooth agenesis, hypodontia (most common)

 Supernumerary teeth (2nd most common)

 Enamel hypoplasia (CI)

 Crossbites

 Ectopic eruption, transposition

 Taurodontism, dilacerations
 SKELETAL

 Maxillary deficiency

 Mandibular prognathism

 Class III malocclusion

 Concave profile
 HEARING AND SPEECH PATHOLOGY

• Middle ear disease with attendent hearing loss in children.

• Otitis media

• Speech problems

• Language activity is omitted

• NASAL PROBLEMS: Alar cartilage is flared, Columella pulled to non
cleft side.

• FEEDING PROBLEMS: Nasal Regurgitation ,Weak sucking, Weak

swallowing reflux.

• ASSOCIATED ANOMALIES: Congenital heart defects, Mental

retardation
MANAGEMENT OF CLEFT LIP& PALATE
 MULTIDISCIPLINARY SEQUENCING OF
TREATMENT

STAGE 1 : MAXILLARY ORTHOPEDIC STAGE (Birth to 18 months)

• Management of feeding problems
• Fabrication of feeding obturator
• Premaxillary orthopaedics ( birth to 4 or 5 months) primary
maxillary
• Lip surgery ( 3 to 9 months) orthopedic stage dentition
stage
• Surgical plate repair (10 -18 months)
Treatment
plan
STAGE II : PRIMARY DENTITION STAGE mixed permanent
(18 months to 5 years) dentition dentition
stage stage
• Adjustment of obturators
• Restoration of decayed teeth
• Maintenance of oral hygiene
• Evaluating the erupting dentition

Mc donald and Avery’s Dentistry for the child and adolescent: 9th edition
 STAGE III: LATE PRIMARY/MIXED DENTITION STAGE(6 to 11 years)
• Ectopic eruption permanent central and lateral incisor
• Cross bite correction
• Maxillary expansion

STAGE IV : PERMANENT DENTITION STAGE (12 to 18 years)

• Fixed orthodontics
• Skeletal irregularities
• Cosmetic repair

Mc donald and Avery’s Dentistry for the child and adolescent: 9th edition
 ROLE OF PEDIATRIC DENTISTS
• To create a proper plan of care for oral health and overall nutrition .

• to maintain healthy dentition and gums, monitor craniofacial growth and

development, and correct jaw relationships and dental occlusion to achieve
proper function and appearance .

• Feeding appliances and presurgical infant orthopedic appliance are

most frequently provided by the pediatric dentist.
 Management Of The Neonate

• Neonates with a cleft palate have difficulty in eating, which may lead to
failure to thrive.

• Neonatal respiratory obstruction is seen which is attributed to a very small

and posteriorly displaced mandible.

• This leads to insufficient nutrition to the neonate.

• Therefore, there is a need for the early intervention by conservative means

to decrease complications by increasing body weight and decreasing risk of
complications in surgery.
 Psychological Approach/ Parent Counseling
At Birth

 The most important people associated at this stage are the parents.

 The parents need to be given support and information regarding treatment

aspects.

 a long-standing relationship between the cleft team and the affected family
must be established.
 FEEDING MANAGEMENT

• Feeding problems often associated with cleft anomalies, make it difficult for
the infant to maintain adequate nutrition.

Feeding By Nasogastric Tube

 Feeding Intervention in Cleft Lip and Palate
Patients

Ross Orthodontic Nipple

Pigeon feeder
Haberman feeder

Mead Johnson Cleft

Cups, Spoons
Palate Nurser
Katge F, Dalvi S, Shetty A, Shetty S. Feeding Intervention in Cleft Lip and Palate Patients: A
•cleft babies should be kept in upright
position (30-45 degrees) for feeding to
make gravity aid in milk feeding.
 A Modified Feeding Bottle for a Cleft Palate Infant-
Case Report (2016)

Fig 1: Feeding bottle with Fig 3:The screw thread

Fig 2: Neck part of the spoon
screw threaded cap, spoon cap with nipple and
handle is fitted completely
and nipple spoon assembled to the
bottle.

Hiremath V, Ashwini B, Rayannavar SL, Kumari N (2016) J Dent Health Oral Disord Ther 2016,
 INFANT ORTHOPEDICS

• Burstone at Liverpool pioneered this technique in the 1950s.

• Two movements are carried out:

1. Expansion of the collapsed segments

2. Pressure against premaxilla to reposition it posteriorly to its correct

position.
 HISTORY OF INFANT ORTHOPEDICS

• Hoffman (1678) – extraoral devices to retract protruding premaxilla

• Hullihen (1844) presurgical preparation of cleft s using an adhesive tape

binding

• Brophy (1927) -passing of a silver wire through both the ends of the cleft
alveolus, and then progressively tightened the wire to approximate the ends of
the alveolus before lip repair.

• McNeil (1950s) – presurgical orthopaedics

• Georgiade and Latham (1975)- introduced a pin-retained appliance to

simultaneously retract the premaxilla and expand the posterior segments over a
period of days

• Hotz (1987) – premaxilla is normally placed, by age 10, face grows downward
and forward into balance with premaxilla

Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate
patients. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of
 HISTORY

• Matsuo (1988)- Research for cartilage moulding. Matsuo used a stent,

silicone tubes to shape the nostrils

• Grayson (1993) – first technique to correct the alveolus, lip and nose in
cleft infants

• Grayson (1999) adapted the addition of nasal stent to extend from the
anterior flange of an intraoral molding plate. This new technique was
named Nasoalveolar molding”

• Presurgical nasoalveolar molding (PNAM) is a non-surgical method of

reshaping the gums, lips and nostrils previous to CLP surgery, thus
lessening the severity of the cleft.

Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate
patients. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of
 1999:Grayson in his article listed four benefits of PNAM:

1. PNAM enables surgeon to perform a gingivoperiosteoplasty;

2. Presurgical alignment and correction of deformity in nasal cartilage

3. In bilateral cleft deformity, nonsurgical columella elongation

4. PNAM used in conjugation with a modified surgical approach, allows for a

single initial surgical procedure to address lip-nose alveolar complex and
its deformity.

Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate
patients. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of
 NASOALVEOLAR MOULDING

• PNAM works on the principle of “Negative sculpturing” and “Passive

molding” of the alveolus and adjacent soft tissues.

• In passive molding, custom made molding plate of acrylic is used gently to

direct the growth of the alveolus to get the desired result later on.

• While in negative sculpturing serial modifications are made to the internal

surfaces of the molding appliance with addition or deletion of material in
certain areas to get desired shape of the alveolus and nose

Grayson BH, Shetye PR. Presurgical nasoalveolar moulding treatment in cleft lip and palate
patients. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of
 Objectives:
NASOALVEOLAR MOULDING
• Reduce severity of initial cleft deformity

• Columella – Nonsurgical lengthening (in bilateral clefts) and uprighting (in

unilateral clefts)

• • Approximation of lip segments to decrease tension in the tissues after lip

repair and thus reduce scarring.

• Reduction in the width of the alveolar cleft segments until passive contact of
the gingival tissues is achieved.
Protocol used in pre surgical NAM therapy
 PROCEDURE
IMPRESSION MATERIALS

• Irreversible hydrocolloid : poor tear strength creates possibility of having

small pieces break free occlude nasal passage or respiratory tract.

• Reversible hydrocolloid :The advantage  used in infants with oral clefts

as it can be removed before it sets in case of any emergency.

• Elastomeric impression materials are better suited in making of cleft

impression and have a good elastic behaviour, high tear strength and
produce accurate surface detail.

Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry
H. Grayson, D.D.S.1,2 and Deirdre Maull, D.M.D.2005
 IMPRESSION TECHNIQUE

• A heavy-body impression material is used to take the initial impression

• Grayson and Maull(1999) held infant in upside down position to keep

the tongue forward which permitted fluids to draw off the oral cavity
when impression tray is placed

• Yang (2003) took the impression using a pre-trimmed customized

pediatric tray with the baby being held in the erect position, by one of
the parents
• Prashanth (2013), Mishra (2010) obtained impression when the infant was
awake in a prone position on the dental chair, the child is held on the lap of
their parents

• Dubey (2011) made impression of the cleft region upper arch using ice cream
stick and impression compound.

•A number of positions have been adopted for cleft palate impression making in
infants including face down, upright Prone and even upside down
FABRICATION OF NAM APPLIANCE

• The NAM plate described by Grayson and Maull is prepared up of hard,

clear self-cure acrylic, trimmed with a denture soft material.

• The retention arm’s vertical position should be at the intersection of the upper
and lower lip

• while retention button with the aid of elastics and extra-oral tapes secures the
molding plate in the oral cavity.

• The retention arm – 40 degrees to get appropriate activation

 INSERTION OF APPLIANCE
• The NAM appliance is secured extraorally to the cheeks and bilaterally by
surgical tapes with orthodontic elastic bands at one end.

• The elastic on the surgical tape is looped on the retention arm of the
molding plate and the tape is secured to the cheeks.

• Elastics used are 0.25 inch and it should be stretched about two times the
diameter for activation force of about 2 Oz

Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate Barry
 ADJUSTMENT OF THE APPLIANCE

• Adjustments are made by selectively removing the hard acrylic and adding
the soft denture base material to the molding plate.

• The alveolar segments should be directed to its final and optimal position.

• No more than 1 mm of modification of the moulding plate should be made

at one visit.

Adjustment of appliance by selective relining and grinding

 •The alveolar segments should be directed to its final and optimal position.

•Care must be taken to prevent the soft denture material from building up on
the height of the alveolar crest as this will prevent complete seating of the
moulding plate.

Retnakumari N, Divya S, Meenakumari S, Ajith PS.Nasoalveolar molding treatment in presurgical

infant orthopedics in cleft lip and cleft palate patients. Arch Med Health Sci 2014;2:36-47.
 INCORPORATION OF NASAL STENT

• The nasal stent is added to the intraoral molding plate when the cleft
alveolar gap is reduced to 5mm or less

• Stent – 0.036-in gauge round stainless steel wire and takes the shape of a
swan neck

• The intranasal portion is formed from hard acrylic, covered with a thin layer
of soft spongy acrylic denture liner
 FIGUEROA’S TECHNIQUE,

• alveolar and nasal molding are performed simultaneously using an

acrylic plate with rigid acrylic nasal extension.

• Rubber bands are connected to the acrylic plate for gentle retraction of the
premaxilla backward.

• A soft resin ball attaching to the acrylic plate across the prolabium is
sometimes used to maintain the nasolabial angle

Retnakumari N, Divya S, Meenakumari S, Ajith PS.Nasoalveolar molding treatment in presurgical

infant orthopedics in cleft lip and cleft palate patients. Arch Med Health Sci 2014;2:36-47.
 LIOU’S METHOD
• The nasal components are made up of 0.028 inch stainless steel wire
projecting forward and upward bilaterally from the anterior part of the
dental plate

• The top portion contains a soft resin molding bulb that fits underneath the
nasal cartilages for nasal molding.

• In this method also, nasal and alveolar molding was done simultaneously.

Retnakumari N, Divya S, Meenakumari S, Ajith PS.Nasoalveolar molding treatment in presurgical

infant orthopedics in cleft lip and cleft palate patients. Arch Med Health Sci 2014;2:36-47.
 Non-surgical columella lengthening in
bilateral cleft lip and palate

• In bilateral cases, there is a need for two retention arms as well as two nasal
stents which are similar in shape to the unilateral stent.

• After adding the nasal stents in the bilateral cleft, the attention is focused
on non-surgical lengthening of the columella.

• a horizontal band of the denture material is added to join the left &
right lower lobes of the nasal Stent, spanning the base of the columella
 • This band sits at the nasolabial junction and defines this angle as the nasal tip
continues to be lifted and projected forward.

• The tape is adhered to the prolabium underneath the horizontal lip tape and
stretches downward to engage the retention arm with elastics.

• This vertical pull provides a counter stretch to the upward force applied to the
nasal tip of the nasal stent.

• Taping downwards on the prolabium helps to lengthen the columella and

vertically lengthens the often small prolabium.

Retnakumari N, Divya S, Meenakumari S, Ajith PS.Nasoalveolar molding treatment in presurgical

infant orthopedics in cleft lip and cleft palate patients. Arch Med Health Sci 2014;2:36-47.
 Benefits
• Short-term: the tissues are well aligned prior to primary lip and nose
repair

• Long-term:
• change in nasal shape is stable

• Reduced number of surgical revisions

• Reduction of treatment cost

• Shetty V et al (2017) - improves arch symmetry and stability, and thus may
prevent arch collapse in the long term
 Complications and disadvantages:

• Irritation of the oral mucosal or gingival tissue

• Ulceration of intraoral tissues

• The intranasal lining of the nasal tip can become inflamed

• Skin irritation due to tape usage

• Parent compliance required

• Moulding plate may get dislodged and obstruct the airway

 Modified muscle-activated maxillary
orthopedic appliance
• Suri and Tompson used a plate held in with outriggers  fabricated for
an infant with a wide complete unilateral cleft lip and palate.

• This modified technique, which amalgamates nasal molding with a

muscle-activated alveolar molding infant orthopedic plate.

• It helps to improve alveolar position, nasal septum alignment, nasal

symmetry, and nasal tip projection prior to the primary lip and nasal
surgical repair.
 Dynamic presurgical nasal remodeling
Bennun and Figueroa
• consists of two elements

• A perfectly adapted conventional acrylic intraoral plate, which is left

loose in the mouth of the neonate

• And a dynamic nasal bumper attached to the vestibular flange of the

intraoral plate.

• A dynamic component, a stainless steel open coil spring (2.2 mm

diameter), is inserted over the stent.
 Active alveolar molding appliance

• alveolar molding plate with an expansion screw (Jackscrew) fully opened,

incorporated into the appliance.

• The premaxilla was retracted and the cleft gap was reduced with the use of
this active alveolar molding appliance within 3 months.

• This enabled better esthetic results after surgery by reducing tissue tension
and scar formation.
 PREMAXILLARY RETRACTION

•In cases of bilateral cleft lip and palate, premaxillary segment may be
positioned severely anterior to the maxillary arch.

•If lip surgery is undertaken with the premaxilla in such an abnormal

position, the chances of lip dehiscence by increased pressure at the suture
lines.
 PREMAXILLARY RETRACTION
APPLIANCE

• An elastic strap is placed over the protruding premaxilla and anchored to

infants head using bonnet appliance.

• Soft elastic tape (Microfoam Tape) can also be used for retraction.

• Bonnet and strap appliance is worn 24 hrs a day and is removed only for
feeding. Desired repositioning is accomplished within 6-8 weeks.
 In case of laterally deviated premaxilla in an infant with a bilateral cleft lip
and palate, a straight extraoral force would not place premaxilla in facial
midline.

 In such cases an external acrylic bulb prosthesis is constructed and

appliance is fitted over protruding and laterally displaced premaxilla and
anchored to infants head with a bonnet appliance.

[Grayson et al 2001]
 PROSTHODONTIC APPROACH
• The maxillary obturator is an intra oral prosthetic device that fills the
palatal cleft and thus provides a false roofing against which the child can
suckle.

• It thus reduces the incidence of feeding difficulties such as insufficient

suction, excessive air intake and choking.

• It also provides maxillary cross arch stability preventing the arch from
collapsing.
REQUISITES OF A CLEFT PALATE PROSTHESIS

Simple, easy
Regulate
Restore basic Worn by the to construct
efficiently the
function of patient with special
function of
respiration without attention to
speech,
phonation and discomfort retention,
breathing and
deglutition and damage occlusion and
swallowing
cosmetics
 DESIGNS OF FEEDING OBTURATORS

Different Designs of Feeding Aids for Cleft Palatal Defects. J Health Edu Res Dev 4: 180. J
Health Edu Res Dev 4 Chugh A, Dahiya D, Thukral H, Verma S, Ahlawat A, et al. 2016
 Technique Of Fabrication Of Obturators

Fig 1:Cleft of soft- and Fig 2 : Primary impression Fig 3: Primary

hard-palate with heavy body putty impression tray

Chacko, et al.: Simplified feeding appliance for a cleft palate infant Oct-Dec 2014 | Vol 32|
 Technique Of Fabrication Of Obturators

Fig 4: Secondary Fig 5: Stone model of the Fig 6: Ethylene vinyl

impression with heavy body cleft impression acetate obturator
putty

Chacko, et al.: Simplified feeding appliance for a cleft palate infant Oct-Dec 2014 | Vol 32| Issue
 An Alternative Impression Technique for an
Infant with Cleft Palate-Case report 2015
•A 3-day-old male infant with cleft palate

•Intra-oral examination revealed a cleft involving the uvula and soft palate exclusively

Modified tea-spoon
impression tray
Preliminary impression of Feeding plate
the infant

Canan Akay1, Duygu Karakis, Suat Yalug, Int Dent Res 2015;5(2):38-41)
 Possible complications
 Difficulty in removal of impression due to engagement of undercuts.

 Subsequent respiratory obstruction due to lodgement of fragments of

impression in respiratory passage.

 Cyanotic episodes of which few may result in asphyxiation.

MANGEMENT

Maneuvers to relieve foreign body obstruction in infants include:

 Back Blows

 Chest Thrusts

 Finger Sweeps

V.P Sabrinath et al. Caring for cleft lip and palate infants: impression procedures and appliances
 Different designs of feeding obturators

1. Passive plate

Fig 1 fig 2
Fig 1 and fig 2 - obturator of autopolymerising resin attaching two orthodontic wire
and elastics or head bands

Fig 3-Vacuum formed feeding plate

 Fig 5: Nance obturator. Fig 6: Acrylic plate retained with clasp.

used when it is not feasible to close fistula in palate surgically, and removable
appliance is also not possible.

Different Designs of Feeding Aids for Cleft Palatal Defects. J Health Edu Res Dev 4: 180. J
Health Edu Res Dev 4 Chugh A, Dahiya D, Thukral H, Verma S, Ahlawat A, et al. 2016
 a) Active appliances

Latham’s appliance Jackscrew appliance Quad helix

Different Designs of Feeding Aids for Cleft Palatal Defects. J Health Edu Res Dev 4: 180. J
Health Edu Res Dev 4 Chugh A, Dahiya D, Thukral H, Verma S, Ahlawat A, et al. 2016
 Velopharyngeal function & Speech
Considerations
• Adequate velopharyngeal closure prevents the passage of air from the
oropharynx into the nasopharynx during function.

• Functional valving cannot be attained if a soft palate is short, limited in

mobility, or cleft.

• As a consequence, air and sound energy are transmitted into and through
the nasal cavity during speech.
• A prosthesis with a pharyngeal extension  constructed for such patients so
that adequate valving for speech purposes can be developed

•Fabrication of a palatal stent with adequate retention.

• When the child has accommodated to the pharyngeal extension

• Obturators are fabricated in the usual fashion

 • A completed speech bulb Obturators  restore velopharyngeal function very
effectively and are well tolerated by the patient.

• They need to be remade periodically to account for growth and eruption of the
permanent dentition.

E.M Bispo et al (2011). Speech therapy for compensatory articulations and velopharyngeal
function: A case report. Journal of applied oral science : revista FOB. 19. 679-84. 1
 ROLE OF ORTHODONTIST
• Orthodontists play a significant role in the treatment of a child with cleft lip
and palate there are four distinct processes.

• The first process begins from 0 to 7 years, after the initial treatment
plan is devised with the craniofacial team.

• The orthodontist will confer with the pediatric dentist and oral maxillofacial
surgeon that care for a child with cleft lip and palate .

•This is to determine proper timing for the implementation of orthodontic

treatment.

Cleft lip and palate. Diagnosis & management. Samuel Berkowitz, 2 nd edition.
 PRIMARY DENTITION TREATMENT

•This occurs in the latter period of 5to 7 years

•Simple form of fixed maxillary lingual appliance W-Arch or Arnold

Expander can be given.

•Palatal expanders can be provided for better speech.

Palatal expanders
W-Arch expander Arnold Expander
MIXED DENTITION TREATMENT
•Minor crossbite correction by expansion of the maxilla with full time
retention.

•Correction of retroinclination of permanent incisors and anterior crossbite by

banded approach.

•Serial extraction of primary cuspid and primary molars to correct incisor

crowding and hasten the eruption of first bicuspids.

•Alveolar bone grafting is done just before eruption of canine, thus space is
created for them to erupt.

Cleft lip and palate. Diagnosis & management. Samuel Berkowitz, 2 nd edition.
PERMANENT DENTITION TREATMENT

•Correction of posterior crossbite and malposed permanent incisors.

•Orthognathic surgery is done to correct the underlying skeletal imbalance in

case of class 3 occlusion after skeletal maturity.

Cleft lip and palate. Diagnosis & management. Samuel Berkowitz, 2 nd edition.
 SURGICAL APPROACH
LIP REPAIR
• The reconstruction of the lip should restore the faulty formation and the
defective development.

• The lip can be divided into 3 zones:

• Studies say that the newborn age is the best because one may be able to
garner some of the benefits of “scarless” fetal healing.

• lip repair  3-4months of age.

• follow “Millards rule of 10”

Age - 10 weeks
Weight - 10 pound
Haemoglobin - 10 gm /dl
 Rose Thompson introduced the first lip repairs  simple straight-line
closures, which left the shape considerably distorted.

 Blair, Brown, and McDowell introduced the design of a flap just above
the vermilion and a system of measurements to achieve reasonable
symmetry.

Cleft lip and palate. Diagnosis & management. Samuel Berkowitz, 2 nd edition.
 MILLARD’S ROTATION ADVANCEMENT
OPERATION
• The incision is located at the philtrum column just below the columella,
often with a “cutback” incision on the non cleft side.

• The whole central flap is then rotated down to a normal position and the
defect just below the nostril floor is closed with a triangular flap from the
lateral cleft margin.

This was first described by Dr. Ralph Millard Jr. and was presented at the First
International Congress on Plastic Surgery in Stockholm in 1955.
 TENNISON RANDALL REPAIR

• A triangular flap is created in the lateral side of the cleft to fit into the
triangular defect produced on the medial side of the cleft.
In this method vermillion flap from either lateral side is brought down over the
prolabium to augment the vermilion in the centre of upper lip.
 PALATE REPAIR

Main objectives of palate repair are:

Normal speech development

Provide anatomical palate closure

Minimize maxillary growth inhibition and dentoalveolar

deformities.
• The palate surgery should be performed between 6 to 12 months as the
palatal shelves narrow with age specially when lip continuity is restored.

Timing of closure depends upon:

• Delayed closure (Zurich approach) – Less inhibition of maxillary growth
and minimize surgery to widen maxilla.

• Early closure – Better speech and swallowing patterns develop early which
cant be corrected later.
 PRINCIPLES OF PALATOPLASTY

• Closure of the defect

• Correction of the abnormal position of the muscles of the soft palate,

especially Levator Palati.

• Reconstruction of the muscle sling.

• Retropositioning of the soft palate

• Minimal or no raw area should be left on the nasal side or the oral surface.

• Tension-free suturing.

• Two-layer closure in the hard palate region and a three-layer closure of the
soft palate.

Indian J Plast Surg. 2009 Oct; 42(Suppl): S102–S109

 DIFFERENT SURGICAL TECHNIQUES

• Von Langenbeck Technique

• Veau-wardill-kilner Palatoplasty

• Bardach Two-flap Palatoplasty

• Furlow Double Opposing Z-Plasty

• Raw area free palatoplasty

A history of the repair of cleft lip and palate in Britain before World War II.Wallace AF
Ann Plast Surg. 1987 Sep; 19(3):266-75.
 COMPLICATIONS OF CLEFT PALATE
SURGERY
IMMEDIATE COMPLICATIONS
• Haemorrhage
• Respiratory obstruction
• Hanging Palate
• Dehiscence of the repair
• Oronasal fistula formation

LATE COMPLICATIONS
• Bifid uvula
• Velopharyngeal Incompetence
• Abnormal speech
• Maxillary hypoplasia
• Dental malpositioning and malalignment
• Otitis media
 CONCLUSION

• One of the commonest congenital treatable anomaly

• Multi disciplinary approach

• As pedodontist , we should have considerable knowledge about the

embryology, aetiology ,available treatment modalities, procedures and
appliances which lead to a better coordination and understanding in cleft
lip and palate care.

97
 REFERENCES
• Samuel Berkowitz. Celft Lip and Palate. 2006. 2nd edition Page number 451-8.
• Mc donald and Avery’s Dentistry for the child and adolescent: 9th edition
• Neelima Malik
• Graber Vanarsdall and Vig. Orthodontics: Current Principles and Techniques.
Elsevier 2012
• Inderbir Singh. Human embryology. Macmillan India. Seventh edition 2001.
• Sommerland BC. Management of cleft lip and palate. Current Paediatrics 1994
• Reddy S et al. Incidence of cleft Lip and palate in the
state of Andhra Pradesh, South India. Indian J Plast Surg. 2010
Jul-Dec; 43(2): 184–9.
• Allori AC et al. Cleft lip and palate classification: Thenand
Now.Cleft Palate–Craniofacial Journal 2016;53(1)
• John B. Thornton, Sue Nim Paul S. Howard. The incidence, classification,
etiology and embryology of oral clefts. Semin Orthod 1996;2:162-168
• Peter Mosby et al. Cleft Lip and Palate. Lancet 2009; 374: 1773–85
 REFERENCES
• Jamal GA et al. Prevalence of Dental Anomalies in a Population of Cleft Lip and Palate
Patients. Cleft Palate–Craniofacial Journal, 2010;47(4):413-20
• Ana Paula Ramos Bernardes da Silva, Beatriz Costa, Cleide Felício de Carvalho Carrara,
Dental Anomalies of Number in The Permanent Dentition of Patients With Bilateral Cleft
Lip: Radiographic Study, The Cleft Palate-Craniofacial Journal. 2008;45(5):473-476.
• Berkowitz S. A Comparison of Treatment Results in Complete Bilateral Cleft Lip and
Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure. Semin
Orthod 1996;2:169-184
• Peterson S. The Relationship Between Timing of Cleft Palate Surgery and Speech
Outcome: What Have We Learned, and Where Do We Stand in the 1990s? Semin Orthod
1996;2:185-191
• Vlachos C. Orthodontic Treatment for the Cleft Palate Patient. Semin Orthod 1996;2:197-
204
• Posnick J. Orthognathic Surgery for the Cleft Lip and Palate Patient.Semin
Orthod 1996;2:205-14
• Gardener LK, Parr GR. Prosthetic Rehabilitation of the Cleft Palate Patient. Semin Orthod
1996;2:215-19
• Dalston R.Velopharyngeal Impairment in the orthodontic patients.Semin Orthod
1996;2:220-7.
Thank you