BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS 1

CLEFT LIP & PALATE

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• A cleft lip is a type of birth defect that affects
the upper lip.
• Cleft lip and cleft palate is the most common
congenital craniofacial malformation in man
since prehistoric times.
• Second most common overall (behind club
foot)

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• It reflects a failure of the normal mechanism
during early embryological development of
face.
• CLP & CP can be broadly subdivided into
– Non syndromic, occur in isolation
– Syndromic, occur in combination with other
anomalies
• Cleft lip with or without cleft palate (CL/P) or
isolated cleft palate (CP).
• CL/P and CP differ with respect to
– Embryology, etiology, genetically, associated
abnormalities, and recurrence risk.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Prevalence
• CL/P is more common than CP and varies by
ethnicity.
• CL/P
– High in American Indians and Asians (1/500
newborns)
– Low in African races (1/2500 newborns)
– Intermediate level in Caucasians (1/1000
newborns)
– Over all incidence in human is 1 in 700

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Males are more affected by orofacial clefts
than female by 2:1
• CL&P is more common in males at ratio of 2:1
• Unilateral clefts account for 80 %
• Isolated CP occurs in only 1/2500 newborns
and does not display variation by ethnicity.
• Isolated CP is more in females 4: 1
• Site of cleft : Left: Right: Bilateral** 6:3:1
• Prevalence is increasing.
BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS
 Recurrent Risk
Affected relative Risk in child, percent
Cleft lip with or without cleft palate
Parent 2%
Sibling 4 – 7%
Parent and Sibling 11 – 14%
Two Siblings 10%
Cleft palate only
Parent 7%
Sibling 2 – 5%
Parent and sibling 14 – 17%

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Classification Systems
• Significance ?
• A number of classification systems
• No entirely satisfactory classification
• Vide variety of presentation of the CL&P
• Most convenient method is to describe the
defect of each individual

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Davis & Ritchie’s classification:(1922)

• Based on location of cleft relative to alveolar process

• Group I:
• Prealveolar process cleft (clefts affecting the lip)
• Group II:
• Postalveolar process cleft (clefts affecting the palate)
1. Soft palate
2. Hard palate
3. both

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Group III:
• Alveolar process cleft (any cleft involving the
alveolar process)
• All these 3 groups may be
1. Unilateral ( right / left: complete /
incomplete )
2. Bilateral (complete/incomplete )
3. Median (complete/incomplete)

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Victor Veau’s classification (1931)
• Veau proposed most widely used system of
classification.
• Morphological
• Classified in 4 broad groups

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 A: Cleft lip

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

• Class II : cleft extending

into the lip, but not
including the floor of the
nose.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Class III: extending into
the floor of the nose.

• Class IV: any bilateral

cleft of the lip, weather
incomplete or
complete.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 B: Cleft palate
• Class I : soft palate

• Class II : soft/hard
palate extending no
further than incisive
foramen.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Class III: complete
unilateral cleft, extending
from uvula to incisive
foramen, then deviating
to one side
• Class IV: two clefts
extending forward from
the incisive foramen into
the alveolus.
BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS
Kernahan and Stark’s stripped Y
classification (1971)

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Kernahan and Stark’s
stripped-Y: Modification by
Ehlsaky (1973) and Millard
(1976)

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

Classification of international confedration
for plastic & reconstructive surgery : 1968
• Group I: clefts of anterior primary palate
– Lip: right, left, both
– Alveolus: right, left, both
• Group II: clefts of anterior & posterior palate
– Lip: right, left, both
– Alveolus: right, left, both
– Hard palate: right, left, both
• Group III: clefts of posterior secondary palate
– Hard palate: right , left
– Soft palate: median
 ETIOLOGY
• The exact cause of clefting is unknown
• Multifactorial
• Cleft may be part of syndrome or occur in
isolation
• Syndromic CLP & CP are associated with a
number of causative genes and associated
with other birth disorders or syndromes.
• Non Syndromic Clefts are not associated with
other health related problems.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Clefting syndromes are less & only 5%
• Over 450 syndromes e.g.
– CLP ectodermal dysplasia
– Clefting hypodontia
– Treacher Collins syndrome
– Pierre Robin syndrome
– Van der Woude’s syndrome
 Non syndromic forms
• Poorly understood
• Unidentified factors
• Multifactorial nature
• Variety of disturbances in mechanism during facial
development
• Heridity & environmental interactions is most
probable cause
• Genetics (inherited characteristic) from one or
both parents.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Environmental factors

• Drugs: corticosteroids (anti-inflammatory),

phenytoin (anticonvulsant), valium, cytotoxic
drugs, Insulin, antibiotics
• Viral Infections: rubella, influenza during
pregnancy.
• Alcohol consumption, smoking, hypoxia during
pregnancy
• Dietary and vitamins deficiencies (like folic
acid and hyper vitaminosis A)
BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS
• Maternal Age
• Diabetes
• Toxemia
• Reduced blood supply
• Racial – mongoloids
• Radiations
• Stress

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Clefting of lip
Clefting of lip occurs because of failure of fusion
between the medial & lateral nasal processes and
the maxillary prominences, at about 6th week of
development. Fusion defects can occur anywhere
between these prominences.
 Development of Palate: We have two parts of
two different embryonic origins:
1) Primary palate: The triangular part of hard palate anterior
to incisor foramen originates from the frontonasal
prominences by fusion of 2 medial nasal prominances
develop between 4th and 8th week of gestation. Primary
palate form the pre maxilla which carries the incisor teeth.
2) Secondary palate: Remaining part of the hard
palate and all soft palate posterior to incisor foramen
which comes from palatine shelves of the maxillary
prominences develop between 8th and 12th week of
gestation.
Closure of the palate in mouse embryos (which are very
similar to humans at this stage of development)

Before elevation of palatal Depression of tongue &

shelves elevation of palatal shelves
• Before elevation of palatal shelves
• Shelves during elevation
 secondary palate after
Initial fusion of shelves fusion
 Embryological Background
• Various theories have been given for its
development.
1. Alteration in intrinsic palatal shelf force
2. Failure of tongue to drop down
3. Lack of fusion of the palatal shelves.
4. Rupture of cyst formed at the site of fusion
5. Abnormalities in programmed cell death may
contribute to lack of palatal fusion.
6. Isolated disruption of palate shelves can occur
after closure of the lip
7. Palatal closure is not completed until 9 weeks
post-conception.
 DENTAL PROBLEMS
• Clefts involve primary, perm teeth &
jaw
• Clefts usually extend b/w canine &
lateral incisor
• Absent, supernumerary or
malformed
• Crowding
• Displacement
• Ant /post X bite
• PD complications
BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS
 OCCLUSAL PROBLEMS
• Discrepancies in size, shape, position of jaws
• Deficient maxilla & relative prognathic mand.
• Class III malocclusions
• Retardation of max. growth in all 3 planes
• Narrow, high arch palate
• Constricted & retruded max.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Feeding problems
• Prevent suction
• Feeding is major problem
• Food & liquid regurgitate through nose
• Specially designed nipples
• Inhale a lot of air

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• A TEAM APPROACH IS REQUIRED
–Paediatrician
–Surgeon
–Omfs
–Orthodontist
–ENT Surgeon
–Psychiatrist
–Speech therapist
–Nurse Coordinator

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• NASAL DEFORMITY: deformities of nasal
architecture

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• Ear problems: mid ear infections, otitis media,
• Hearing impairment is common in CP pts
• Speech difficulties:
– Hyper nasal speech
– Hearing impairment aggrevate speech
– Retard of consonant sounds

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 PSHYCHOLOGICAL PROBLEMS
• Impaired facial aesthetics
• Hearing
• Speech
– Family support
– Professional help
– Social worker

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Management
• Complex long term treatment depending upon
the severity of cleft
• Life long implications
• Aim is to achieve principle objectives
– Good facial appearance
– Good orofacial function during speech, eating and
swallowing
– Esthetic, functional & stable occlusion
– Good hearing
– Psychological uplifting
BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS
 Stage I
• I: Fabrication of a
passive obturator

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 II: Presurgical orthopedics
• Reduces the size of cleft; Aids
in Surgery
• Partial obturation aids in
feeding
• Traction by external elastic
with headcap
• Intra-oral elastic devices
• PNAM (pre surgical naso
alveolar moulding)
BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS
• Pre-surgical Orthopedic (PSO) appliances -
custom-made acrylic base plate that provides
improved anchorage in the moulding of lip,
nasal and alveolar structures during
presurgical phase.
• Duration – 2-3 months
• The use of infant orthopaedic plate before CL
repair may favour
• Correct arch form establishment in infants
with unilateral complete cleft lip and palate
 Stage I treatment ( cont.):

• iii. Surgical management of cleft lip: 3 months

• Millard "rule of tens”:10 weeks old, 10 grams
Hb, 10 pounds weight, WBC count of 10,000/
mm3
• iv. Surgical management of cleft palate: 9-18
months

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Stage two treatment:

• Comprises treatment carried out during

primary dentition period.
• Preventive dentistry
• Orthodontic treatment is rarely indicated

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

 Stage three treatment

• Carried out during mixed dentition phase.

• Prevention of dental disease.
• In this phase, secondary alveolar bone grafting
is common.

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

• A period of orthodontic
treatment is required prior to
graft placement to
– Expand collapsed max arch
– Create surgical access
– Maximizing the amount of
bone placed
– Quad helix is used
 Alveolar bone grafting
• Placing cacelleous bone in to
max alveolar defect
• At age of 8-10 yrs of age prior
to eruption of permanent
canine when root formation
is about two third complete.
 Stage 4 treatment
• Treatment during permanent dentition.
• Orthodontic treatment alone or combination
with orthognathic surgery
• Osteogenic distraction
• Crowding, narrow retrusive max arch, cross bite,
anomalies associated treated with fixed app
• General principles will be followed
• Long term retention is required
ROLE OF ORTHODONTIST
 THANKS

BHITAI DENTAL & MEDICAL

B D & M C COLLEGE, MIRPUKHAS
BCQs TEST # CLEFT
LIP & PALATE

BHITAI DENTAL & MEDICAL COLLEGE, MIRPUKHAS

# 1# Cleft lip and cleft palate is the
a. Most common congenital craniofacial
malformation in human body
b. Most common congenital malformation
c. Second most common congenital craniofacial
malformation in human body
d. Least common congenital craniofacial
malformation in human body
e. Least Common congenital malformation
• # 2# All these syndromes / conditions are
characterized by cleft lip & palate except
a. CLP ectodermal dysplasia
b. Adenoid face
c. Clefting hypodontia
d. Treacher Collins syndrome
e. Pierre Robin syndrome
• # 3# Cleft lip & palate is usually associated
with
A. Impaired facial appearance
B. Impaired speech & hearing
C. Impaired occlusion, mastication and
deglutition
D. All of above
E. None of above
• # 4# Cleft lip arises due to failure of fusion
between
a. Median nasal processes
b. Median nasal processes and maxillary
process
c. Palatine shelves
d. Mandibular processes
e. Nasal plate & primary palate
• # 5# Veau’s classification of Cleft lip & palate
is
a. Embryological
b. Morphological
c. Etiological
d. Symbolic classification using a stripped
“Y”
e. Developmental
• # 6# This structure is least affected by clefts
a. Upper lip
b. Lower lip
c. Soft palate
d. Hard palate
e. Alveolar ridge
• # 7# Clefting anterior to the incisive foramen
is defined as
a. Cleft of primary palate
b. Cleft of secondary palate
c. Complete cleft
d. Isolated cleft palate
e. Cleft lip
• # 8# A complete cleft palate involves
a. Vermillion border of lower lip, soft and
hard palate
b. Soft and hard palate
c. Soft palate, hard palate & uvula
d. Incisive foramen, soft and hard palate
• # 9# Mildest form of cleft palate is
a. Cleft of soft palate
b. Cleft of hard palate
c. Cleft of incisive foramen
d. Bifid uvula
• # 10# Which of the following is not an
associated problem of Cleft lip with cleft
palate
a. Mid line diastema
b. Ear problems
c. Speech difficulties
d. Impaired facial aesthetics
e. Crowding of teeth
• # 11# Most Clefts of alveolus & palate cases
exhibit
a. Class I malocclusion
b. Class II div 1 malocclusion
c. Class II div 2 malocclusion
d. Class III malocclusion
e. Nothing significant
• # 12# Who suggested the rule of 10
a. Veue
b. Millard
c. Davis
d. Ritchie
e. Kernhan
• # 13# The management of Cleft lip & palate
can be divided in
a. 2 stages
b. 3 stages
c. 4 stages
d. 5 stages
e. 6 stages
• # 14# Surgical repair of cleft lip is usually
carried out between
a. 1 to 3 months
b. 2 to 5 months
c. 3 to 6 months
d. 2 to 5 years
e. 12 to 15 years
• # 15# At which stage, secondary alveolar
bone graft usually carried out
a. Birth
b. 3 months
c. 9- 10 months
d. 9- 10 years
e. 18 years
 Key
• 1. a • 9. d
• 2. b • 10.a
• 3. d • 11.d
• 4. b • 12.b
• 5. b • 13.c
• 6. b • 14.c
• 7. a • 15. d
• 8. c