CLEFT LIP AND PALATE

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
•Surgical orthodontics
•Distraction osteogenesis
•Conclusion
•References
 INTRODUCTION

• Orofacial clefts are second most common congenital

anomalies. Causes :- impaired suckling,
- defective speech,
- deafness,
- malocclusion,
- gross facial deformity
- severe psychological problems.
• Cleft of lip and the palate is a complex congenital
deformity requiring a multidisciplinary team approach in
its management. 
 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.
• 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
  EMBRYOLOGY
 ETIOLOGY

ANATOMICAL GENETIC TERATOGEN

 ANATOMICAL FACTORS
•According to Tongue Obstruction Hypothesis during
mandibular development anatomical obstruction occurs.

•There is interposition of the tongue in the space created

between the ascending shelves when there is compression of
the chin against the sternum.

•These results in U shaped palatal deficiency & have tissue

deformation with a normal growth potential.

•Ectomesenchymal differences & cellular phenomenon affects

this palatal deficiency
 Genetic factors

• SKI/MTHFR 1p36, RARA 17q21, BCL3 19q13

• PVRL1 11q23, TGFB3 14q24, TGFB2 1q41, TGFA

•2p13, SX1 4p16, 4q31, 6p23 & GABRB3 15q11.

A. Monogenic or single gene disorder

B. Polygenic or multifactorial inheritance
C. Chromosomal abnormalities. (18%)
 TERATOGENS :
1. Retinoic acid
2. phenytoin
3.corticosteroids.

Other factors :

1.Deficiency or excess of Vitamin A , Follic acid deficiency

2. Physiologic, traumatic & emotional stress & infections .
3. Maternal alcohol consumption & cigarette smoking
4. Viral infection like rubella
5. Consangunious marriages

Smoking mothers doubles the frequency of development of cleft as

compared to non-smoking mothers..
SYNDROMES WITH CLEFT LIP AND PALATE :

• Van der woude Syndrome

• Apert syndrome
• Treacher Collins Syndrome
• Cleidocranial Syndrome AUTOSOMAL
• Ectodermal Dysplasia DOMINANT
• Stickler’s Syndrome
• Oro-facial digital syndrome
• Pierre Robin syndrome

• Roberts Syndrome
AUTOSOMAL
• Christian Syndrome
• Meckel Syndrome  RECESSIVE
 CLASSIFICATION OF
CLEFT LIP AND PALATE.
 Davis and Ritchie classification (1922):

Group I: Pre-alveolar clefts, unilateral, median, or bilateral.

Group II: Post-alveolar clefts involving the soft palate only

the soft and hard palates, or a submucous cleft .

Group III: Alveolar clefts, unilateral, bilateral, or median

 Veau in 1931
Type-1: Cleft of the soft palate only;
Type-2: Cleft of the hard and soft palate extending no further than the incisive foramen,
thus involving the secondary palate alone;
Type- 3: Complete unilateral cleft, extending from the uvula to the incisive foramen in the
midline, then deviating to one side and usually extending through the alveolus at the
position of the future lateral incisor tooth;
Type-4: Complete bilateral cleft, resembling type 3 with two clefts extending forward from
the incisive foramen through the alveolus. When both clefts involve the alveolus, the small
anterior element of the palate, commonly referred to as the premaxilla, remains suspended
from the nasal septum.
 Pfeiffer symbolic representation (1964)

2nd International Symposia on Cleft Lip and Palate in Hamburg

C Balakrishnan
An Indian classification of Cleft Lip and Palate defects. - 1975
Cleft type Abbreviation :
Cleft lip Gp 1
Cleft palate Gp 2
Cleft lip, alveolus and palate Gp 3
Right R
Left L
Midline M
Alveolus A
Partial P
Submucosal S
Simonart’s band sb
Microform micro
Kernahan striped Y symbolic classification :(1971)
Elsahy modified Kernahan Striped Y classification :
(1973)
Example-1: A complete cleft lip and palate on the left side
would be recorded as 00444
Example-2: A bilateral complete cleft lip with complete
cleft alveolus and palate on the left side and cleft alveolus
on the right side would be recorded as 43444;
Example-3: A cleft soft palate and submucous cleft would
be recorded as 00200;
 PROBLEMS ASSOCIATED WITH CLEFTS:

*COSMETIC PROBLEM
*PSYCHOLOGICAL AND SOCIAL PROBLEMS
*FEEDING PROBLEMS
*NASAL PROBLEMS
*DENTAL PROBLEMS
*SKELETAL PROBLEMS
*EAR PROBLEMS
*SPEECH PROBLEMS
*ASSOCIATED ANOMALIES
 CLINICAL MANIFESTATIONS

• Difficulty with feeding.

• Speech is often characterized by air emission from the nose and has a
hyper nasal quality.
• Patients with cleft lip usually have cosmetic problems and problems for
production of labial sounds.
• Sounds most frequently misarticulated include
• S - (63%)
• Z - (61%)
• D- (48%)
• Ch- (44%)
• P- (11%)
• B- (9%)
• Clefts of the soft palate, including sub mucosal clefts,
are often associated with velopharyngeal incompetence .

Hearing disorders are prevalent among individuals with

orofacial clefts. These disorders are a result of chronic
otitis media with effusion due to eustachian tube
dysfunction.
DENTAL PROBLEMS:
1. Missing - permanent lateral incisors
2. High incidence of missing teeth -especially missing bicuspids
3. Supernumerary teeth
4.Ectopically positioned teeth
5. Lack of osseous support for some teeth
6. Accentuated curve of Spee in the maxilla, the mandible, or both
7. Collapsed arch form
8. Poor oral hygiene, caries, periodontal disease
SKELETAL:
skeletal Class III
Underdeveloped maxilla.
Concave prolife
 MANAGEMENT OF
CLEFT LIP AND CLEFT PALATE
MANAGEMENT OF CLEFT LIP AND CLEFT PALATE:
 Prenatal Diagnosis of Cleft Lip/Palate

Prenatal diagnosis of oral cleft is important for those

parents at increased risk for recurrence

Ultrasonography
-non-invasive diagnostic tool
-confirm fetal viability,
-determine gestational age
-examine fetal anatomy to detect any malformations.
Transabdominal ultrasound:
Not reliable until gestational week 15
performed at or after 20weeks of gestation.

Transvaginal sonography:
earlier visualization of the face
better image resolution,
yielding high specificity and
sensitivity of prenatal cleft lip detection

 
Genetics counselling:

The geneticist provides genetic evaluation and counsels the patients

and parents about the prognosis in a given syndrome, and about the
future risk of having babies with CLP or a broader syndrome, and
helps in directing care for non-CLP aspects of the syndrome.

Psychological issues:

Psychological support and guidance, both for the family and

patient, from the very beginning, and even starting with antenatal
diagnosis, be included as part of the overall treatment plan.
  FEEDING :

PATIENT IS FEEDING FROM A

BOTTLE IN A SEMI VERTICAL
POSITION.

NEAR THE END OF FEEDING ,INFANT

ASSUMES A MORE VERTICAL
POSITION TO PREVENT THE
SWALLOWING OF AIR.
 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
ORTHODONTISTS ROLE
1. NEONATE AND INFANT (BIRTH TO 2
YEARS OF AGE)
2. PRIMARY DENTITION( 2 TO 6 YEARS)
3. MIXED DENTITION STAGE
4. PERMANENT DENTITION
 Presurgical orthopaedic treatment
 

• Prior to lip repair an orthodontist may be involved in a

phase of oral orthopedics to align the displaced cleft
segments termed presurgical orthopedic 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”
• Goal- to move abnormally positioned maxillary arches
and the pre maxilla into a normal relationship prior to
surgery .

intra oral
• Appliances
extra oral
 LIP TAPING PRESURGICAL ORTHOPEDIC
TREATMENT(PSOT)
 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.
 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
  Nasoalveolar moulding 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.
 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.
(infant orthopedics should be started after 3- 6 weeks of
birth).
• necessary to relax the cartilages, the ligaments and
connective tissue- enabling the fetous to pass through birth
canal-estrogen level decline after birth
• The primary objective of the treatment is stimulation
and redirection of alveolar growth aiming for the non
surgical approximation of the cleft deformity.

• 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.
Procedure

Impressions-heavy body impression material

Infants position - upside down - presence of surgeon

important.

cast poured with dental stone-molding plate fabricated

(hard clear acrylic and lined with a thin coat of soft denture
material)
• 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 Latham Technique:

Used to treat facial orthopedic abnormalities in unilateral and bilateral cleft lip
and palate patients.
The Latham appliance applies controlled direction that forces the
repositioning of the displaced basal segments and realigns soft tissue
margins prior to corrective surgery.
The Latham pinning technique obtains anchorage from the base of the
maxilla to affect orthopedic repositioning of the cleft maxillary segments or
premaxilla.
The Latham appliances have proven to be successful in
-aligning the maxillary segments,
-retruding a protruded premaxilla,
-aligning bilateral alveolar ridges,
-creating less tension on surgical closure and
-statistically reduction of fistulas.
 
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.
 Timing :
•WILHELMSEN AND MUSGRAVE – Rule of 10 for children.
weight of 10 pounds
Heamoglobin 10 gram/100ml of blood
Total wbc count of 10,000/mm3

MILLARD proposed GENERAL Rule of 10

Weight more than 10 pounds
Haemoglobin more than 10 grams per 100ml of blood
Age more than 10 weeks
• Techniques used:
1. Tennison's triangular flap procedure
2. Millard's rotation flap
 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.
• 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
• 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
 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
• 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.
 
Mixed Dentition Stage (7 to 12 Years of Age)
•A tentative decision on extraction of
supernumerary teeth and over retained
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
 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.
• 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
• 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: Interdental septum height is almost normal (<25% of bone
resorption).
Type II: Interdental septum height is equal to or greater than ¾ of the normal
height (bone resorption 25%–50%)
Type III: Interdental septum height is less than ¾ of the normal height (bone
resorption 50%–75%).
Type IV: Bone graft failure; no continuous bony bridge is visible across the
cleft (bone resorption ≥75%)
THREE CONTEMPORARY CONTROVERSIES ARE:

1) Timing of grafting
2) The type of bone for alveolar grafting and donor site
3) Sequencing of orthodontic expansion.

1. 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
2. GRAFTING MATERIAL:

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.
•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
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
PERMANENT DENTITION STAGE:
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)
1.BIOMECHANICAL BASIS OF RAPID MAXILLARY EXPANSION:

•“If the applied transverse forces are of sufficient magnitude to overcome

the bio-elastic strength of the sutural elements, orthopedic separation of
the maxillary segments can occur.” This is the basis of rapid maxillary
expansion.(Bell R A 1981)
• Active expansion usually takes place for 2-3 weeks followed by 3-6
months of the appliance being left in place as the suture reorganizes.

2. EXPANSION APPLIANCES:

Apart from these conventional methods, most recently Eric Lio proposed a
Fan type expander with a protocol of Alternate Rapid Maxillary
expansion and constriction (AltRAMEC), for the growth of a
hypoplastic maxilla not only for the growing patients with cleft lip and
palate, but also for those without cleft .
 PROTOCOL OF EXPANSION IN CLEFT:

• (Ekstrom C, 1977; Story E., 1973). RME exerts a force of

around 120N
•quad helix type of an appliance or W –appliance or fan
shaped appliances as suggested by Eric Liou, 2009 and other
advocators.
•slower expanders since they exert mild force of around 2N.
•slow expanders bring about skeletal expansion in these cases,
without causing undesired tissue reactions and allow physiologic
adjustments and reconstitution of the sutural elements over a
period of about 30 days
•Also, these appliances have fan type of expansion, i.e more
anterior and less posterior expansion, which is desirable in
bilateral cleft cases.
 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)
 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
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.
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
 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 after distraction
osteogenesis. improved position
of maxilla relative to mandible.
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.
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.
 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.
• 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 protocol

1. 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.
• Inpresence 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.
GOSLON Yardstick index is the most widely used to assess
the efficacy of treatment and treatment outcomes, which
in UCLP cases are closely linked to jaw growth.

It is a study model index

• A case of cleft lip and palate with severe maxillary retrognathism treated by distraction
osteogenesis and custom made intraoral rapid maxillary expansion appliance: A 2-year
follow-up of retention
• A female patient of age 12 years, presented with a chief complaint of impaired esthetics
due to non-syndromic, unilateral, incomplete cleft lip and palate extending posterior to
incisive foramen on the left side of the face.
• slightly concave profile with a class III skeletal pattern.
• Asymmetric ovoid upper arch and upper labial frenum deviated towards left
• oronasal fistula on left side
• class I molar relation on right and left side
• crossbite and Open bite in the region of 22, 23, upper dental midline deviated 2mm
towards right side, palatally positioned 12, partially erupted 22, incisors are in class III
relationship
Singaraju GS, Mandava P, Chirivella P, Kanabaddy SR. A case of cleft lip and
palate with severe maxillary retrognathism treated by distraction
osteogenesis and custom made intraoral rapid maxillary expansion appliance:
A 2-year follow-up of retention. Natl J Maxillofac Surg. 2018 Jan-Jun;9(1):69-
73. doi: 10.4103/njms.NJMS_14_18. PMID: 29937663; PMCID: PMC5996656
 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.
• REFERENCES:

1.CRANIOFACIAL DEVELOPMENT-  Sperber

2. Samuel Berkowitz-Cleft Lip and Palate: Diagnosis and management- 2nd
Edition
3.Thomas M. Graber, Katherine W. L. Vig, Robert L. Vanarsdall Jr. Orthodontics:
Current Principles and Techniques.
4.WR Profitt:Contemporary orthodontics-5th edition
5.Text book of orthodontics by Gowri Shankar.
6.OP Kharbanda; Orthodontics-Diagnosis and management of malocclusions and
dentofacial deformities;First edition
7. Cleft lip and palate, Seminars in Orthodontics
8.Singaraju GS, Mandava P, Chirivella P, Kanabaddy SR. A case of cleft lip and
palate with severe maxillary retrognathism treated by distraction osteogenesis and
custom made intraoral rapid maxillary expansion appliance: A 2-year follow-up of
retention. Natl J Maxillofac Surg. 2018 Jan-Jun;9(1):69-73. doi:
10.4103/njms.NJMS_14_18. PMID: 29937663; PMCID: PMC5996656
 9. Grayson et al, Pre surgical naso alveolar molding, cleftliip- craniofacial journal
1999:35
10. 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.
11.Advances in management of cleft palate: Edwards and Watson
12.Baik et al. surgical orthodontic treatment in patients with clcp: conventional surgery
v/s maxillary distraction, world J Orthod;2:331-40
13. Bhat N, et al. Cleft Lip and Palate: A Review.
Ann Med Health Sci Res. 2020;10: 927-930.
14.de Ladeira PR, Alonso N. Protocols in cleft lip and palate treatment: systematic
review. Plast Surg Int. 2012;2012:562892. doi: 10.1155/2 012/562892. Epub 2012 Nov 1.
PMID: 23213503; PMCID: PMC3503280.
15. MS Rani et al, CLASSIFICATION OF CLEFT LIP AND CLEFT
PALATE-A REVIEW doi:10.5368/aedj.2011.3.2.4.1
16. Sumitha et al , MAXILLARY EXPANSION IN CLEFT LIP AND
PALATE CASES- A REVIEW International Journal of Advanced Research
(2015), Volume 3, Issue 9, 1455- 1461